EXAMINATION 1 - Direct and Cross Exam of Expert Chiropractor Witness in car accident case

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DR. SUSAN M. STREET, called as a witness by the plaintiff, having been first duly sworn, was examined and testified as follows:
(Defendant's Group Exhibits Nos. 1 and 2 were marked for identification by the court reporter.)
MS. WHELAN: Let the record reflect that this is the evidence deposition of Dr. Susan Street taken pursuant to notice and that the evidence deposition will be conducted in accordance with the Illinois Supreme Court Rules and all applicable local court rules.

DIRECT EXAMINATION

BY MS. WHELAN:
Q. Dr. Street, can you state for the jury your full name, please?
A. Susan Marie Street.
Q. And you're a physician?
A. That's correct.
Q. What's your title?
A. Doctor of chiropractic.
Q. And where do you practice?
A. Midwest Chiropractic Clinic.
Q. How long have you practiced there?
A. Eight years.
Q. Are you licensed in the state of Illinois?
A. Yes.
Q. And in order to get that license, can you tell us about some of your qualifications? We'll start with your background and your education.
A. I attained a bachelor's of science degree from University of Wisconsin-Parkside in addition to a doctor of chiropractic degree from Palmer University, an accredited university from the Council on Chiropractic Education, where I completed over 4200 hours in anatomy, chemistry, diagnosis, microbiology, pathology, physiology, roentgenology, psychology, public health, chiropractic, chiropractic practice, nutrition, and dietetics, eye, ear, nose, throat, obstetrics, gynecology, pediatrics, geriatrics dermatology, contagious disease, physiological therapeutics, clinical neurology, first aids, and juris prudence.
Q. When did you graduate from Palmer?
A. October of 1992.
Q. And when were you licensed in the state of Illinois?
A. October of 1992.
Q. And you've been ??tinuously practicing since then?
A. That's correct.
Q. In order to be licensed under the State Practice Act, what requirements do you have to meet? Is there a test that you have to take?
A. Oh, absolutely.
Q. And that's a state test?
A. That's correct.
Q. And would that certify you then to --
A. There's actually three tests that you take. They are called boards. And in order to be qualified in the state of Illinois, you have to pass these three boards. They are national boards.
Q. What license or what act do you practice under? Are you licensed under the same Medical Practice Act as medical physicians?
A. That's absolutely correct. That's governed by the World Health Organization.
Q. Do you have any postgraduation or post-graduate classes or courses?
A. Yes.
Q. And what would those be in?
A. I have a certification in medical management consultant in the rating of physical impairment for disability evaluation. I've completed over 100 hours of post-graduate work in X-ray diagnosis in spinal and skeletal disorders from Palmer University. I have a diplomat from the National Board of Chiropractic Examiners.
Q. And what does that mean?
A. It's the highest degree that you can receive in your own field, recognition.
Q. Do you hold any other certificates?
A. Certificates of merit from my own university.
Q. Doctor, have you ever given a deposition before?
A. Yes.
Q. And under what circumstances?
A. Same; personal injury, workers' comp.
Q. Do you do any other type of work?
A. House cleaning.
Q. Do you do any independent reviews for --
A. Yes. I do.
Q. And --
A. I do peer review.
Q. And can you tell for the ladies and gentlemen of the jury what a peer review is?
A. Peer review is where I am sent a complete record of a physician in my field, a patient's file. And I am asked to examine that file and determine if the treatment was reasonable and customary. I then write my opinion on the case and present it to the company asking me to give my expert opinion. And they pay me for that service.
Q. And did you have an occasion to see Lisa Peck?
A. Yes.
Q. Can you tell me, when was the first time you had seen her?
A. November 17th, 1997.
Q. Do you have any independent recollection of Lisa or would you have to refer to your notes?
A. Both.
MS. WHELAN: Okay. If you can just let us know when you have an independent recollection or when you're referring to your notes so that we way keep it clear for the jurors and for the record.
THE WITNESS: Yes, ma'am.
BY MS. WHELAN:
Q. When you saw Lisa on November 17th, 1997, did she give you a history as to why she was in to see you?
A. Yes.
Q. And what did she state to you in her history?
A. I'm referring to the notes. Patient reports, quote, “I have left arm, shoulder, and neck pain. Weakness and tingling in my a??m.”
Q. Did she say when that pain started in those different areas?
A. Yes.
Q. And when was that?
A. 11/6/97.
Q. Did she say what caused her pain or what caused the pain to start?
A. Yes.
Q. What was that?
A. Patient reports, quote, “I was at a complete stop and was rear ended,” period.
Q. So 11/17/97 would have been the first time that she came to you for any treatment, correct?
A. That's correct.
Q. Do you know if she had been to treatment any time prior to coming to see you?
A. Yes.
Q. And where did she go?
A. She saw Dr. Man- -- I'm going to spell this. M-a-n-n-s-c-h-r-e-c-k. That is her spelling of the physician's name so ...
Q. Do you know if she had ever gone to a hospital?
A. No, I don't know. She reports that she was taken to Swede's after the accident.
Q. And then Dr. Mannschreck was another doctor she said she had seen prior to coming to see you?
A. Yes, ma'am.
Q. Did she tell you any history about her vi?? with or treatment with Dr. Mannschreck?
A. Yes.
Q. And what was that?
A. She reported that he gave her a diagnosis o?? a sprain/strain in the cervical spine, gave her muscle relaxers and painkillers, asked her to follow up with him in one week.
Q. Do you know how many times she saw Dr. Mannschreck?
A. No.
Q. Do you know if her conditions from the time that she had seen Dr. M??k to the time she saw you had continued to be the same, gotten better, or worse?
A. Patient reported that she was not better and that she was worse.
Q. Do you know whether Lisa had suffered any left arm pain, shoulder pain, and neck pain prior to this accident?
A. I have no knowledge of that.
BY MS. WHELAN:
Q. Did you perform an examination on Lisa whe?? she first saw you?
A. Yes, orthopedic and neurologic examination. And a radiographic examination was performed.
Q. Can you tell us -- explain for the jury an orthopedic examination?
A. Orthopedic examination is an examination in which you attempt to duplicate the patient's pain in order to determine the cause of the pain. You perform one diagnostic test after another. It's usually a stress on the muscle, tendon, ligament, and bone.
Q. Do other physicians other than chiropractors perform orthopedic tests?
A. Yes, orthopedic surgeons would be the only other field qualified to perform orthopedic tests.
Q. What were your findings on the orthopedic tests?
A. Patient had extension of pain on the left with compression of the cervical spine in an ??ial position, which exacerbated the numbness and tingling I need to back up a second and add that we also did ??n MRI for diagnostic reasons.
Q. Okay. Just going back to the orthopedic findings, you said that there was an extension of ?? on the left?
A. Uh-huh.
Q. Can you explain for us, what does that mean?
A. Extension means the pain radiates from one point to the other, particularly in this case from the cervical spine down the left arm. Another definition or diagnosis for the same condition would be radiculopathy. It stems from the word “radiating.”
Q. And the numbness and tingling, where was that found?
A. Into the arm ??e hand.
Q. Was that the left arm, also?
A. That's correct, always the left.
Q. Were there any other findings?
A. Particular positive findings were the scenario that accompanies radiculopathy, always you have muscle spasm, edema. Deep tendon reflexes were in??act and bilateral. Patient was able to draw a line ?? ween the C5-C6 dermatome on the left. Dermatome is the pattern in which a ne??ve will travel. And it is associated with the area of skin, muscle, that the nerve services.
Q. Now, when you say the patient was able ??o draw a line, are you saying that she was able to ?? you directly the pain paths?
A. Exactly. By using her finger on her ?? hand, she was able to point to it, which helps a physician to know exactly where the impingement occurs. Her explanation of her pain was very clinical.
Q. You mean it was consistent with some of your findings?
A. Consistent with all of my findings, yes.
Q. As far as the neurological tests that were performed, can you expl?? us what those are?
A. Neurological tests are performed in order to determine if there is any neurological deficit that would require the patient to see a neurosurgeon prior to me performing conservative care.
Q. Did you have any findings, positive findings, with the neurological tests?
A. No.
Q. So basically her neurological system was intact, there weren't any nerve damage -- there wasn't any nerve damage?
A. I could not detect nerve damage, that's correct.
Q. What about the radiographical examination?? was that just X-rays and MRI?
A. MRI is a magnetic resonance imaging, which does not include radiographs. The MRI of the cervical spine summarized that there was a minimal disk bulge located at C6-C7, reported that there was no focal disk herniation or significant compromise of the canal or the foramina.
Q. And in translation that would mean what?
A. That means that the patient had soft tissue pushing on the nerve, loss of ligament integrity.
Q. Now, we hear ?? “soft tissue” used a lot. Can you explain for us, what does that entail?
A. Soft tissue is all the substances in the body that are made of protein that are not bone with the exception of blood. So that would be ligament, tendon, muscle, and its variations, which would include disk material.
Q. Okay. Your findings then for ??isa based in your examinations, what were your -- excuse me; what was your diagnosis?
A. Lisa was diagnosed with segmental dysfunction of the cervical spine, laxity of ligament myalgia secondary to a motor vehicle accident with another vehicle.
Q. Segmental dysfunction; can you describe for us, what does that mean?
A. Segments refer to the vertebral bodies found in the spine. And the word dysfunction in this case refers to the misalignment, a/k/a juxtaposition, a/k/a subluxation of the spine.
Q. And the spine, was there any certain part of the spine that there was any segmental dysfunction that you were able to diagnose?
A. Yes.
Q. Where would th???
A. C5, C6, and C7 were visibly posterior and a direct cause of her pain.
Q. When you say they were “visibly posterior,” what are you basing that on?
A. My eyes.
Q. Okay. I mean, I didn't know if it was something visible just through X-ray or if it was something that you were able to --
A. Both.
Q. Both. Okay. Myalgia, can you describe for us what that is?
A. My refers to muscle, algia refers to pain. It simply means pain in the muscle.
Q. What was your course of treatment then for Lisa?
A. Patient was placed on a treatment plan, standard treatment plan, for a cervical sprain/strain, four to six weeks, in which she was given adjustments, physical therapy, exercises. Her spine was supported.
A. Patient was recommended to use ice.
BY MS. WHELAN:
Q. When you said that she was recommended a course of treatment for four to six weeks, what ?? that -- what does that -- excuse me; what is the significance of that?
A. The chiropractic profession has certain protocols, a/k/a standards of practice. And in?? diagnosis of cervical sprain/strain, the standard protocol is a four- to six-week treatment plan. ?? know that soft tissue heals within a four- to six-week period. And if addressed during that time, the ??ing should be completed at the end of the six-week period given no exacerbations.
Q. And how many times would Lisa come to see you in a given week over the four to six weeks?
A. The treatment plan was three times a week for two weeks, two times a week for two weeks, reassess. But in Lisa Peck's case and in my case, I was unable to accommodate her on some of those dates. It was near the holiday and I had a vaca?? planned. She was seen by one of the physicians for one visit. And I believe there was another time I was unable to see her.
Q. Can you explain to: the Ladies and gentlemen of the jury why it would take frequent visits over a period of time to treat a soft tissue injury?
A. Absolutely. This is the most misunderstood concept I believe in chiropractic. When you first adjust the bone and move it ?? Point A to Point ?? what you have is basically a space where the bone was, which was the wrong place. So the spine has no support where you just put it. It has no ligament, mus?? of tendon support. So by nature of physics -- you ?? change the laws of physics -- everything goes to the path of least resistance. Therefore, any stress placed on the spine is naturally going to put it back into a position where it was supported somewhat, even though that position of the bone was wrong.
Q. And is this done in like increments?
A. That's correct. Naturally it would follow that the patient would come back in and you would adjust. Some of the bone position would stay and some would not. We're actually talking about millimeters or even sometimes half a millimeter. Positions would stay. Your goal is to -- the end goal is to line up the spine such that there's no neurological or orthopedic findings and such that the patient has no subjective complaints.
Q. So are you physically moving the bone?
A. Yes, ma'am.
Q. Into a certain alignment then?
A. Yes, ma'am. And then attending the ligaments, tendons, and the muscles to support that position through exercise and physical therapy.
Q. What kind of physical therapy was Lisa ??ven?
A. Ultrasound and electrical muscle stem.
Q. What's the benefits of those two moda??es?
A. Ultrasound delivers a sound wave through the skin in order to relieve -- remove the toxins. No?? relieve, remove.
Q. When you say “remove toxins,” can you explain for us, how do toxins actually get into the system and how are they removed and why is that important?
A. When a tissue is injured, it naturally secretes fluids. Excuse me; I'm just trying to determine how technical to get. Just give me a second.
These fluids ?? in the way of cellular function and prevent the muscles from performing their God-given ability. Therefore, when you remove the fluids from the interstitial tissue and the muscle, it enables the muscle cell to smoothly contract. The electrical muscle stem has multiple functions but overall is used to force contraction of the muscle to fatigue the muscle initially in acute phases in order ?? prevent muscle spasm from pulling the bone back into ?? position that causes the ?? pain. And in the last stages it is used to rehabilitate the muscle, a/k/a train the muscle to support its new position.
Q. How did Lisa respond to treatment?
A. Very well.
Q. And when did you start noticing some improvement in her condition?
A. I'm referring to the notes. 11/19/97.
Q. That would be two days after she first saw you?
A. That's correct.
Q. And what were you able to notice on that date?
A. Decreased frequency and decreased intensity of pain.
Q. So at that point she wasn't completely healed, it was just a -- ?? beginning process of the healing, correct?
A. That's correct.
During Lisa's recovery, what were some of the things that you were able to notice as she progressed in her treatment?
A. The patient's progress was typical in that she continued to report decreased intensity and tingling and pain into the arm. Gradually the pain came out of the arm, up into the shoulder, and into the neck where she began to get stiffness into her cervical spine, which is typical for these types of injuries. She then regained range of motion in the cervical spine and at the time of release had no ??tive orthopedic or neurological exams with full range of motion.
Q. Did Lisa at any time tell you that there were certain restrictions that she had in moving either her arm or her neck?
A. That's correct.
Q. And were these findings that you had also displayed?
A. That's correct. I apologize for not mentioning that. It is in my notes.
Q. Can you tell us what those restrictions were.
A. Decreased range of motion is all quadrants
Q. And “in all quadrants” meaning?
A. Bending to the left, bending to the right, bending forward, extending, rotating to the left, rotating to the right.
Q. That would be for her neck?
A. That's correct.
Q. Any other areas of her body that had decreased range of motion?
A. She reported stiffness ?? her lumbar.
Q. The numbness and tingling that she had in her left arm, do you know how that affected her on a daily basis?
A. The numbness was a subjective numbness, not objective numbness.
Q. If you can just explain to the jury the difference between subjective and objective.
A. Subjective is when the patient feels a sensation of numbness. That is a typical response of nerve compression. But when tested either with a pinprick and cotton ball, which I do both, it cannot b?? confirmed.
Q. Was there any weakness in any of Lisa's extremities?
A. Yes, in grip.
Q. That would be on the left, left arm?
A. That would be on the left by comparison to the right, which is difficult to ascertain in regards to impairment because the patient is right dominant. Therefore, you expect the right to be somewhat stronger than the left.
Q. Do you know how long the weakness existed for?
A. The patient reports that the weakness was gone at the end of the reassessment.
Q. And is that the same day as discharge or --
A. Yes, ma'am.
Q. Okay. Do you know how long she experienced the reported numbness?
A. The patient was experiencing an intermittent numbness up to 12/15. And then I explained to the patient on that date that what she had was subjective numbness secondary to nerve trauma, which is not uncommon. If I could elaborate a bit, this is the s??e as phantom pain. This is why you can amputate a person's leg and their toes will itch. Even though the toes aren't there, the nerve remembers.
Q. That nerve, is that the same nerve that you were referring to earlier as being -- following the ?? of C5?
A. It's actually C6.
Q. C6?
A. That's correct.
Q. According to the history that was given to you and your examination and findings, were Lisa's complaints consistent with her history?
A. Very.
Q. And were you able to form an opinion based upon a reasonable degree of chiropractic certainty as to whether her injuries were a result of the automobile accident that she was invo, a in on November 7th, 1997?
A. Yes. It is my determination that there is a direct correlation between the injury that Lisa received in the car accident and the diagnosis that I treated.
BY MS. WHELAN:
Q. Do you have an opinion based upon a reasonable degree of chiropractic certainty as to whether the injuries that Lisa received were a result of the automobile accident she was involved in on November 6th, 1997?
A. Yes. I believe there to be a direct correlation between the injuries she received and the automobile accident on November the 6th to be related to the condition that she presented to me with.
Q. Do you believe your treatment was helpful in rehabilitating the patient?
A. Yes.
Q. Do you believe your treatment was necessary?
A. Yes.
Q. And do you believe that your bills incurred were reasonable?
A. Yes.
MS. WHELAN: I'm done.
MR. GOFF: Dr. Street, I'm Bill Goff. And I represent Rudy Henderson. He's the defendant in this case.

CROSS-EXAMINATION

BY MR. GOFF:
Q. When this particular patient came to your office on November 17th, 1997, she did report to you that she had been involved in a motor vehicle accident on November 6th, 1997, correct??
A. Correct.
Q. And she told you that it was a rear-end accident, correct?
A. Correct.
Q. And in fact, did she fill out a form called “Automobile Accident History”?
A. Correct.
Do you have any other knowledge or information about how this accident occurred other than it was a rear-end motor ?? accident that occurred on November 6th, 1997?
A. Yes.
Q. What other knowledge do you have?
A. I have knowledge contained that the patient wrote to me on a form. I give to my patients an automobile accident?? form. It's ca??led “Automobile Accident History” and “Auto Accident,” two forms.
Q. Anywhere in either one of those forms, Dr. Street, is there any indication as to the speed of the vehicle that rear ended the patient's vehicle?
A. Patient reports that she was uncertain in regards to the speed.
Q. Do you have any knowledge as to the for??, involved in this accident?
A. Yes.
Q. And what knowledge do you have in that regard?
A. My knowledge is related to Foreman & Croft's Second Edition on whiplash injuries. it's called The Cervical Acceleration/Deceleration Syndrome. It reports that the force of impact is equal to 2.5 times that the acceleration.
Q. I'm talking about specifically the accident that this patient was ?? you have any knowledge as to the velocities involved?
A. I know that the patient was reported to be stopped.
Q. All right. And do you have any indication as to the speed of the vehicle that ??eat ended the patient's vehicle?
A. The patient reported -- I only know what the patient reported. And the patient reported that she did not know the speed of the vehicle.
Q. Therefore, you don't know the speed of the vehicle, either; is that correct?
A. That's right.
Q. Would it be correct to assume that the greater the speed, the higher likelihood of a type of whiplash injury to the neck?
A. No.
Q. Would it be accurate to state that the higher the speed, the more likely someone could be injured?
A. There are other variables other than speed, Mr. Goff, in relationship to the type of injury received.
Q. Well, i?? someone is stopped and is rear ended by a vehicle going 60 miles an hour, would that person be more likely to be injured than one rear ended by a vehicle going 5 miles per hour?
A. More likely, yes.
Q. That's just the laws of simple physics, correct?
A. There's other lows.
Q. But the laws of physics say that if it's hyperflexion/hyperextension injury that's caused by acceleration/deceleration, the body is going forward, the neck is going forward, and then stops, correct?
A. Can I explain something?
Q. No. I'd like you to answer my question.
Is that correct?
A. I don't agree.
Q. You don't agree with what?
A. The simplicity of the question. There is not a direct correlation to speed and injury.
Q. Do you know what happened to your patient's body upon impact?
A. Based on the injury that she presented with I can assume.
Q. No. Do you know what happened to her without making assumptions? Do you know what happened to her body?
A. In regards to ?? position, you mean?
Q. No. As to how her body moved during the accident. Did she tell you that?
A. Yes.
Q. Is that documented in your records somewhere that you can show me?
A. No.
Q. Well, then how do you know that?
A. She told me.
Q. Okay. So you have to go on what she told you and believe what she told you, correct?
A. That's called subjective.
Q. Okay. What did she tell you in terms ?? how her body moved during this accident?
A. She told me that her head was rotated slightly to the right and that upon impact her neck extended -- not using that terminology -- and then flexed.
Q. Please tell the jury as best you can recall if it's not documented in your records in language they would understand what she told you what happened to her body during the impact.
A. Patient report that she was sitting in her seat with her head slightly rotated to the right approximately 40 degrees and upon impact her head moved backwards and then forward.
Q. So would you agree that for an injury to occur there has to be movement such as that to the body of a patient?
A. Yes.
Q. And would you ?? that the greater the impact, the more likely there would be greater amounts of movement to that body?
A. Yes.
Q. Now, as a chiropractic physician or as a??y physician, you have to assume or believe the histor??y that the patient gives you in terms of their comp??s, the history of how the accident happened, correct??
A. No.
Q. In this case you related your opinion that the complaints she was making to you were related to the motor vehicle accident on November 6th, 1997, correct?
A. That was based on objective findings, not on what the patient said.
Q. If the patient had come in and given you a different history and had the same findings, would you still think that her findings were caused by a motor vehicle accident of November 6th of 1997?
A. No.
Q. So it was the patient telling you that she was in a motor vehicle accident and that it was her opinion that that's when her complaints started?
A. That's called subjective.
Q. And that's something you took her word ?? correct?
A. It is.
Q. Because you didn't have any other knowledge. You have no wa?? of knowing if she might have had there symptoms from some other cause, correct?
A. Not correct.
Q. Well, if the patient doesn't tell you if she had already been having these symptoms from other causes, how would you know?
A. Patient did report that she had previously had other symptoms.
Q. Immediately prior to the accident?
A. No.
Q. But if she did and she didn't report that to you, you would have no way of knowing, correct?
A. Right.
Q. So that's ju?? the point I'm trying to get at.
A. I see.
Q. You're believing her history when she comes in and says, “My neck hurts and it's hurt since I was in an accident on November 6th, 1997,” correct?
A. I believed her, yes.
Q. And that's the basis of you also giving your opinion that the symptoms of which she presented were caused by a motor vehicle accident on November 6th, 1997 because that's the only history you have, correct
A. That's not correct.
Q. You have a different history than she ?? injured on November 6th of 1997?
A. Nope. That is the history I have. But that is not -- the first part of your question does not follow. The second part does. You cannot throw that all into one, Mr. Goff, and expect me to answer it all yes. I can't. I want to help you out here. But I can't.
BY MR. GOFF:
Q. Have you seen -- ever seen any photographs of the vehicles that were involved in this accident?
A. No.
Q. You have no knowledge of what damage, if any, was done to either vehicle, do you?
A. I'm referring to my notes. I don't believe I do. That's usually a question I ask but ...
Q. And why do you usually ask that question?
A. Because it ?? me to determine the validity of the patient.
Q. How so?
A. The more accurate a patient is able to report findings that are documented, the more I feel personally I can trust the patient, what they say.
Q. In this case do you see any indication that the patient ever told you or gave you any information as to the amount of damage done to either vehicle involved in this accident?
A. No.
Q. Now, plaintiff's counsel asked you if you had any knowledge of whether this particular patient ?? had any left arm pain, shoulder pain, or neck pain pr?? to the accident. I believe you answered that you did not have any such knowledge; is that correct?
A. The question was stated such that -- I can't remember the exact question, Mr. Goff. But it was stated such that I had to answer no. But it was not directed toward recollection, if I recall. And my recollection is that the patient did tell me in 1994 she had received some -- she had similar symptoms. But during the course of examination, I determined that the patient was incorrect in her perception.
Q. Incorrect th?? did have some prior neck pain in 1994?
A. It wasn't the neck pain. The question on my automobile accident form stated, “Have you previously been injured in a similar manner?” And she reports, “Yes. Before in 1994.” When -- according to my recollection, when I spoke with the patient on this, this was not a correlation. In other words, this was not the same injury. Patient had neck pain. But the?? was no radiculopathy involved and no C6 ne??ve impingement.
Q. Is that what she told you, there wasn't any such involvement in her prior --
A. No. ?? questioned the patient and that was my conclusion.
Q. Now, I also want to show you what's been marked as Group Exhibit No. 2.
BY MR. GOFF:
Q. And I would represent to you that these are also records from Med-Plus. And this is an Accidental Injury Report signed by Lisa Peck on December 8th, 1995 indicating that she was in a November 29th, 1995 rear-end motor vehicle accident, would you agree?
A. I would agree.
Q. And would it appea?? from looking at these records marked as Group Exhibit No. 2 that her present complaints at that time as of December 8th, 1995 were neck pain, headache, neck/low back pain and stiffness upon rising, neck stiffness, limited range of motion of the neck; is that correct?
A. That's correct.
Q. Did she give you a history of this prior motor vehicle accident when she saw you?
A. No.
Q. This is the first time you've become ?? of it?
A. Yes.
Q. Would you know whether she had continued to suffer from neck symptoms and symptoms into her left shoulder between December of 1995 and when she ca??e to see you in November of 1997?
A. I have no record of her reporting that she had pain during that time.
Q. Assuming that her signed Accident Injury Reports are accurate as of December 8th, 1995, might or could the complaints that she made to you in November of 1997 still have been related to her prior motor vehicle accident which occurred in November of 1995?
A. Some could have, yes.
Q. And is that opinion within a reasonable degree of chiropractic certainty?
A. Yes.
Q. Now, the patient did tell you that she ??d been seen by Dr. Mannschreck at least on one occasion before she came to see you, correct?
A. Correct.
Q. And Dr. Mannschreck, do you have any familiarity with him?
A. No. I just know that he's a medical physician.
Q. Okay. And medical physicians are different from chiropractic physicians?
A. Yes.
Q. The two of you have different forms of training?
A. No. Some.
Q. Different forms of philosophy for sure?
A. Yes.
Q. And apparently she told you that Dr. Mannschreck prescribe?? some medication for her condition, correct?
A. Yes.
Q. Dr. Mannschreck did not refer her to you, did he?
A. No, not that I know. She's referred by a massage therapist.
BY MR. GOFF:
Q. No matter the cause of this particular patient's complaints when she came to see you, you ?? believe that your course of treatment for her was ?? successful, correct?
A. Yes.
Q. And in fact, when was the last time you examined her or treated her?
A. 12/22.
Q. Of 1997?
A. That would be correct.
Q. And on that date did she have any more symptoms?
A. None.
Q. And in your opinion, had she made a complete recovery?
A. That's correct.
Q. And in your opinion, did she sustain any type of permanent injury or have any type of permanent injury that you could de??ect?
A. Always.
Q. And how so?
A. Always in ligamentous involvement there ?? an element of permanent damage.
Q. Would I be correct in assuming then th?? the injury to her neck that she sustained in the motor vehicle accident of November 29th, 1995 also would have resulted in a permanent injury?
A. I can't draw that conclusion.
Q. Did you see the diagnosis that was made --
A. No.
Q. -- by Med-Plus back in November -- in December of 1995 following that November of '95 accident?
A. No. What was the diagnosis?
Q. I'm not sure. I'm going to let you determine that, Doctor, since you can read these records far better than I.
A. Were mine better??
MR. GOFF: Let the record reflect that I am again showing Dr. Street Group Exhibit No. 2, which are the Med-Plus records following the November of 1995 accident.
A. He has strained muscles is what he said. A?? the answer would be yes.
BY MR. GOFF:
Q. The answer is yes, that because the diagnosis was strained muscles back in 1995 that she would have some degree of permanent injury from that?
A. Right.
Q. And is that why you previously testified ?? when she came to see you in 1997, she still may have been suffering from symptoms from that 1995 accident?
A. Did I say that?
Q. Well, maybe I misinterpreted your answer. But I believe I asked you whether you knew whether she had continued or -- whether the symptoms she had when she came to see you in 1997 still would have been -- could have been from the 1995 accident.
A. And I said that I didn't have any information in regards to whether she ?? mptoms at the time that she presented to me with the 1997 accident.
Q. But they might or could have been a continuation of the symptoms?
A. I can't determine that. Let me clarify something for you. The diagnosis in --
MR. GOFF: That's okay. Doctor, let me ask you questions.
THE WITNESS: All right; sorry.
BY MR. GOFF:
Q. Is a strain necessarily involving a ligament?
A. A strain is referring directly to a ligament. A sprain is referring directly to a muscle, which is ?? dichotomy on Dr. Girgenti's notes because it says “strained muscles.”
Q. Okay. But in any event, assuming that the Med-Plus records from 1995 were correct, it is your opinion she would be expected to have some degree of permanent injury from that, correct?
A. Yes.
Q. And might or could that degree of permanent injury from that 1995 accident cause her to have continued symptoms?
A. Oh, yes.
Q. Into the neck and left arm?
A. That's correct.
Q. And when you last saw this particular patient on December 22nd of 1997, did you feel she needed any restrictions on her work --
A. No.
Q. -- or physical activities?
A. No.
Q. Any restrictions on her recreational activities?
A. No.
MR. GOFF: I have no further questions. Thank you, Doctor.
THE WITNESS: Yes.
MS. WHELAN: Doctor, I have a couple follow-up questions with you.
THE WITNESS: Okay.

REDIRECT EXAMINATION

BY MS. WHELAN:
Q. With respect to the rear-end accident, you had previously testified that there are a number of variables that can be incorporated into an accident and into whether a patient is injured, correct?
A. Correct.
Q. If a patient came to you and said that they were involved in a low-speed rear-end collision, would that make a difference in your treatment to a patient versus someone that said they were involved in a high-speed collision?
A. No. Treatment plan is going to be based ?? objective findings at the time of the examination.
BY MS. WHELAN:
Q. So when a patient presents to you with a history of trauma, you are looking at -- are you looking at the patient and the patient's symptoms and your findings and diagnosis or are you looking at the history of how this trauma looked -- how the trauma occurred before you try to treat a patient?
A. There are four elements in determining the treatment plan. The patient's history is important but it does not determine the ??ment plan. Objective and subjective findings, which we defined earlier. The patient tells me how they feel. I determine if that is true with the neurological and orthopedic tests. And then the radiographic and MRI diagnostics. All of those incorporated bring about a treatment plan.
Q. So you more or less treat the patient wi?? their findings irregardless of the history that was given to you --
A. That's correct.
Q. -- as to how the accident occurred?
A. That is correct. And in the case of Lisa Peck, there was an acute injury present at the time ?? examination, which would be consistent with an automobile accident that occurred on November 6th.
Q. There was some discussion of physics. Is it also true that if -- in physics if you have a stationary object and it's hit by a moving object, that the forces are also absorbed into the occupants of that stationary object?
A. That would be correct. Another example of that would be an analogy of using a ship inside of a glass container. You drop the glass container on the carpet and the glass doesn't break but the ship will.
Q. Can that be app?? then -- in your experience and knowledge of physics, is that the same principle that applies to occupants in motor vehicle accidents?
A. That is correct.
Are you familiar with -- are you familiar with low-impact injuries -- low-impact injuries?
A. Are you referencing velocity?
Q. Correct.
A. Yes. There are several factors that determine the extent of injury in a patient. Velocity, again, is one of them. Other factors would be the size of the car she was in, the size of the car she was hit with, the amount of skidding that occurred. The position of her neck upon impact is one of the most strongest factors of injury. And in Ms. Peck's case, rotation of the neck in a 40-degree position is correlated with our research to cause extensive damage at any velocity.
Q. And the velocity that's involved in motor vehicle accidents, does that also include something called G forces?
A. That would be correct. G forces is a measure of velocity.
You had indicated that you don't have any information in any ?? your notes pertaining to the property damage that was sustained by Lisa Peck or the other vehicle, correct?
A. Correct.
Q. And that's because that wasn't asked, correct?
A. Correct.
Q. It wasn't that Lisa was trying to with?? any information from you or anything like that?
A. It actually could have been asked. I just don't recall. And it's not in the notes. It usually is. I'm surprised it's not there.
Q. If Lisa came into you and showed you pictures of either no damage or lots of damage, would that have changed your treatment plan of Lisa?
A. No.
BY MS. WHELAN:
Q. And again, the ??on why your treatment plan wouldn't change is --
A. Because the treatment plan is based on the objective findings at the time of the examination.
Q. MS. WHELAN: I'm going to ask you a couple of questions pertaining to the 1995 accident that Lisa had.
BY MS. WHELAN:
Q. And since she was ??so involved in an automobile collision in 1995, since that came after 1994 and some time prior to your treatment of her in ??, when she indicated that she had no problems since, ?? we assume it was since 1994 to the present time --
A. Yes.
Q. -- when you treated her in 1997?
A. Yes, that's what I would assume.
Q. You had indicated that with a ligamentous strain --
A. Correct.
Q. -- that there's an element of permanent damage?
A. That's correct.
Q. But you had also indicated with doctor's records from Med-Plus in ?? there was some dichotomy in his notes?
A. Correct.
Q. Can you explain what that is?
A. It sounds like the patient had muscle spasm. And I see no other documentation that supports anything other than that as she had reduced range of motion. And in addition, she had no ??gical findings and ?? orthopedic findings other than reduced restriction of motion. I'm assuming that he was treating the patient for muscle spasm, as there is extensive therapy that was performed. Muscle spasm does not necessarily have ?? large component for chronic or permanent injury. ?? he used the word “muscle sprain.” Sptain is in refe?? to a ligament. And you do not sprain a muscle.
Q. So from his notes you're unable to determine whether or not there was -- or can you determine from his notes whether there was any ligamentous injury to Lisa Peck back in 1995?
A. No, I cannot.
Q. In the 1995 accident there was also no reference to any arm weakness, correct?
A. No. There was.
Q. There was?
A. Uh-huh. (Per?? documents.) I guess I saw the hand. She just had a report of hand coldness. But you are correct, I don't see weakness. There was I believe a grip test strength. Did he do a grip test? (Peruses documents.) Yes, they were consistent with -- they were within ??mal limits.
Q. -- no left arm weakness, which was a sym??om that she was complaining of in the 1997 accident, correct?
A. Correct.
Q. Again, would that be something that would correlate with your review of doctor's records, that it was more muscle spasm versus ligamentous?
A. Right.
MS. WHELAN: ?? nothing further. Thank you.
MR. GOFF: We're almost done.

RECROSS-EXAMINATION

BY MR. GOFF:
Q. Doctor, it's my understanding that you do acknowledge that ??ity and the amount of skiddi?? are factors in determining the likelihood of injury?
A. Correct.
Q. And referring to the Automobile Accident History form that the patient filled out when she came to see you and where she indicated that she had not had any problems since before 1994, that would be inconsistent with the records that I showed you the were Group Exhibit 2, correct?
Stipulated Supplied Answer: Correct
Q. And we also know that, in fact, she was involved in a motor vehicle accident in late November of 1995 that she didn't tell you about, correct?
A. Right.
Q. And that would be -- her answer to your Automobile Accident History form would be inconsistent with what was marked as Defendant's Group Exhibit 2, which were the Med-Plus records for treatment she received following that November 1995 accident , correct?
A. Correct.
MR. GOFF: I have no further questions.

FURTHER REDIRECT EXAMINATION

BY MS. WHELAN:
Q. And your treatment -- whether or not ?? had referred to an automobile accident or forgot to r??r to an automobileaccident in 1995, would your treatment have changed at all with Lisa Peck?
A. No.
MS. WHELAN: I have nothing further.
THE WITNESS: Okay.
MR. GOFF: Thank you, Doctor.

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