Page 14 - GP Spring 2019

without discomfort, is another unexpected symptoms of TMJ and TMD. I test areas distracted function differs from the tested
outcome. In this case the claimant is scored inside and outside the known envelope function. This is scored as an inconsistent
as implausible results on testing because the of symptoms and create a mix of muscle effort during distraction. Furthermore,
claimed symptoms are not being supported and joint testing. The composite of testing throughout the interview the claimant is
by the physical test. 4 includes areas with and without expected asked to place their tongue into the left,
nociceptive features. A claimant who right and anterior maxillary vestibule. This
While symptoms can be very undependable provides a positive response to areas maneuver causes lateral and protrusive
for medico-legal cases because they can without known nociceptive characteristics excursions while distracted. Success in
be difficult to independently verify the may be scored as an implausible response. this maneuver while failing to achieve an
consistency of symptoms, they can be Or a claimant who is unsure of discomfort excursion, while directed, is scored as an
important for teasing out the veracity of in a series may be scored as an ambiguous inconsistent effort during distraction.
a claim. For example, have the claimant’s response. In either case the result may
symptoms as reported to various providers be used to consolidated with other tests However, not all instances of insufficient
and agencies changed in a way that cannot to determine the potential for symptom effort lead to a conclusion of malingering. A
be explained? Has the physical therapist magnification or malingering. single instance of insufficient effort within
(PT) noted that the symptoms got better a series of tests could be scored as an outlier
and then worse, while the primary care Determining the veracity of symptoms is and would be considered a transient event.
physician (PCP) noted no change over the a very difficult exercise and often requires
same time period? Is the claimant trying to a deft and deliberate approach. Claimants In claimants with a jaw pain related dis-
game the system and manage the providers? are often not aware of the full clinical ability, where the pain is unconfirmed by
Is the claimant altering their condition picture of injuries that they report. Finding objective evidence, I cannot rule out a
to each provider? The claimant may see where a claimant’s symptoms deviate from non-organic component to the claim. This
the PT weekly and feel that they have to expected findings can shed some light may include symptom magnification or
report some progress, even though it may on whether a claimant is catastrophizing submaximal effort when a claimant has
be episodic, while reporting no change to to maximize the claim. Inexorably a the following pattern: no radiographic ev-
the PCP, who they may see quarterly. Also deviation from expected findings might idence of jaw or joint dyscrasia (either hard
when did the symptoms start- right away or lead an investigating clinician to suspect or connective tissue), ambiguous or im-
after the legal consult? As the investigator an extension of the symptoms, whereas a plausible findings on pain testing, is a con-
I have the benefit of seeing the complete treating clinician may not be so critical and fused pain historian often giving differing
history for the claimant as recorded in the is obliged to ‘take a patient at their word’ accounts of the injury or the symptoms and
entire collected record. and seeks to help where they can. Testing has inconsistent or implausible changes in
areas known to be outside the envelope of test scores (jaw movements) across repeat-
Symptoms Validity Testing classical signs and symptoms serves as a ed examinations (submaximal effort).
To be sure, there are true accidents which control for gauging other responses.
cause injury. The problem becomes To be sure, CT and MRI imaging are essen-
determining when symptom magnification Effort Testing tial for diagnosing TMJ claims. The reports
has occurred. How does one independently I evaluate the effort made by the claimant given by radiologists serve to guide our un-
corroborate claimant symptoms? In many throughout the entire IME. I am testing derstanding of the claimed injuries and are
cases there can be soft tissue injuries the effort made by the claimant in two part of the body of evidence for conducting
that are not visible by means of imaging conditions. First, are the movements made IME’s.
modalities. And, on occasion, there can in line with the expected limitations of the
be visible hard tissue changes that are injury. For example, in a TMJ case in which However, as difficult as it may be to veri-
the normal part of everyday life and can the claimant reports an injury to the left fy the TMJ status from a claimant with no
result from normal activities. Symptoms joint, it is found that the claimant cannot special training in dentistry or orthopedics,
validity testing (SVT) is our best attempt do a left lateral excursion, but can move the quintessential task is to determine the
to determine the veracity of injury claims into protrusive and right lateral excursion. veracity of claims made by a dental HCP
when there are no clinical signs to guide us. Further, the imaging studies or joint who has seen TMJ cases and understands
In fairness to both the claimant and the third testing don’t reveal a capsular discrepancy. the envelope of symptoms. Here the abili-
party, which may be indemnifying a claim, This may be scored as problematic or ty to corroborate signs and symptoms is a
the opinion of the examining clinician must submaximal effort, which while standing challenge for even master diagnosticians.
be based on some acceptable criterion. alone may not mean much, but when taken I recommend a choreographed exam. I
with the whole of the exam, can reveal a weave in and out of the interview through-
To test the validity of a claim I provide non-organic cause for the examination out the exam. I carefully tease out the vec-
a series of tests that I score according to results. tor and cause of the injury multiple times to
expected results. For example pressure gather more details about the event. It is not
against a given muscle of mastication can Secondly, during a twenty minute surprising that for injuries, when someone
be very variable, however, pressure against interview the claimant has been observed has not lost consciousness, the event slows
the retromolar pad should not. The expected for maximum opening and any signs down and they can remember the injury in
results from pressure against the retromolar of deviation. The claimant is observed detail. I use the discussion to distract and
pad, or say the attached buccal gingiva opening to 20 mm or wider, having no corroborate information given to me and to
anywhere in the mouth can be considered deviation or sign of discomfort when other HCP’s in the past. I do rapid sensi-
as a control. A claimant stating that those speaking. However, when asked to tivity and range of motion testing in a se-
areas are involved in the envelope of demonstrate maximum opening, the quence called out by my assistant, ofter re-
symptoms can be scored as an implausible claimant reluctantly opens with a deviation peating a test in a slightly different manner.
response given the know presentation of and only to 10 or 15 mm. In this case the

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