Med-Legal Services at PPWG
Pacific Pain & Wellness is a one-stop-shop providing cutting edge science driven medical psychological expertise as applied to legal issues. Grounded in formal education, training, certifications and clinical experience, qualified forensic scientist clinicians translate the complex language of medicine, psychiatry, and psychology to educate fact finders. Winning legal professionals are keenly aware that the right expert can have a major impact on verdicts and settlements. Our team of medical experts include:
Kartik Ananth MD, MBA
Board Certified Psychiatry (ABPN) & Pain Medicine
Board Certified Pain Medicine /Interventional Pain Medicine
Mohan Nair MD
Board Certified in Brain Injury Medicine (ABPN) Psychiatry (ABPN) & Pain Medicine
How can we help?
Pacific Pain & Wellness Group's Med-Legal team is committed to providing the legal community comprehensive and accurate forensic medical and mental health examinations. In depth peer reviewed assessments combined with cutting edge technology and tools assists our experts to help present your case to the fact finder for optimal outcomes. Our experts have provided extensive trial testimony in defense and plaintiffs cases. We are familiar with the milieu of the courtroom and its adversarial nature that can be intimidating for non-forensic experienced and trained clinicians. We will provide timely and jargon free IME reports when needed; prepare for and withstand forceful cross examinations.
We provide (1) Full spectrum expert witness services for personal injury/civil litigation, criminal cases, private disability, medical board investigations, and employment litigation. (2) Confidential consultations, record reviews, litigation support for IME depositions, witness preparation, and trial testimony (3) Provide and coordinate medical, psychological, neuropsychological, toxicological, and imaging experts for complex civil litigation.
Pacific Pain & Wellness Group’s Med-Legal team will provide clinical and med-legal consultations on complex cases involving brain injury, chronic pain and psychological trauma (PTSD) in adults and children of all ages. Trained at Harvard and the University of California with multiple ACGME board certifications, Dr. Nair provides IMEs, confidential consultations and litigation support on med-legal cases involving brain injury and psychological trauma (PTSD) in both adults and children of all ages. Dr Nair has extensive experience in testifying with the ability to explain complex science and statistical data in a non-alienating jargon free manner to juries and the Court. Dr. Nair, working as a team with neurologists, neuroradiologists, physical medicine/neuro rehab specialists, internists, and medical toxicologists, will provide in depth analysis on med-legal issues. We can provide consultations to help determine if a case has merit and potential financial outlays and outcomes.
WE KNOW HEAD TRAUMA AND BRAIN INJURY
Brain injury medicine is a specialty that emerged from the common interests of neurologists, rehab medicine doctors and some psychiatrist who recognized that those with subtle brain injuries having significant life impact were not being addressed by most neurologists and psychiatrists.
Head / brain injuries, even seemingly minor, can result in a lifetime of pain and suffering. TBI, including mild TBI, can result in problems in functioning and long-term outcome. The presence of co-occurring conditions such as chronic pain and PTSD can amplify these concerns to catastrophic levels.
Concussion / mild traumatic brain injury may take many forms and recovery trajectories. Unlike focal injury, diffuse axonal injury from shear forces from traumatic brain injury cause neurological impairment by disconnecting cortical and subcortical brain networks. (Sharp 2014 , Borich 2014, Newsome 2016, Wolf 2016)
Post TBI hormonal problems (pituitary, thyroid, testosterone) can affect patients physically, psychologically, emotionally and in social interpersonal functioning affecting work and family life. In a recent metanalysis, 1 out of 8 mild TBI subjects had pituitary dysfunction.
20-40% of patients with moderate and severe traumatic brain injury result in growth hormone deficiency, hypogonadism, hypothyroidism, hypocortisolism, and central diabetes insipidus.
Emotional explosiveness, impulse control problems, violent outbursts, depression, and suicidal feelings are often more prominent and may last longer than cognitive impairment. Imaging and neuropsychological testing when positive may identify the “low hanging fruits” in TBI litigation. A thorough brain injury evaluation looks at multiple domains of pathology and functioning beyond those reflected in neuropsychological and brain imaging findings or their absence.
As we begun to understand TBI as a network disruption disorder, subtypes of concussion/mild traumatic brain are recognized. These include cognitive, ocular-motor (visual), headache/migraine, vestibular(balance), and anxiety/mood predominant variants and associated conditions such cervical strain and sleep disturbance (Lumba-Brown 2019). TBI related hormonal problems (pituitary, thyroid, testosterone) can affect patients physically, psychologically, emotionally and in social interpersonal, sexual functioning affecting work and family life. In a recent meta-analysis one out of 8 mild TBI, or mTBI, subjects had pituitary dysfunction (Tan 2017).
These symptoms of mTBI can occur in the absence of relevant findings on the CT or the MRI and neuropsychological testing. In a sense, imaging and neuropsychological testing, when positive, identify the low hanging fruits of mTBI. A thorough brain injury evaluation looks at multiple domains of pathology and functioning beyond those reflected in neuropsychological testing and brain imaging findings or their absence.
The 1.5 billion dollar settlement that the NLF provided former players consisted of neuropsychological testing and a neurological exam. These exams looked for overt neurological deficits and cognitive impairment, but fail to recognize and often downplay subjective complaints of vison, balance, chronic pain, chronic headaches, ringing in the ears, sensitivity to light and noise, trouble sleeping, aggression, restlessness, impulsivity, suicidality and difficulty expressing, and controlling emotions. Subjective complaints may be seen as less than genuine. These subjective complaints are more frequent, more disruptive and may last longer than overt neurological problems or cognitive impairment in TBI. Without obvious imaging abnormalities, individuals with TBI frequently fail to recognize the connection between the symptoms and the brain injury and may not bring it to the attention of doctors.
What is a Post-Concussion Syndrome /Traumatic Brain Injury?
A general disturbance of cerebral function seen after head trauma include the following:
- Activity influenced more by external stimuli.
- Impaired ability to use abstract concepts.
- Disturbed attention and concentration.
- Disturbed spontaneity.
- Poverty of ideas.
- Post-traumatic orderliness.
- Post-traumatic slovenliness.
- Disturbed and labile affect.
- Psychomotor slowing.
- Memory complaints.
- Diminished social awareness.
- Loss of intellectual flexibility.
Brain injuries resulting from serious motor vehicle accidents (MVA) may result in obvious neurological deficits and seizures. In less severe cases, there are subtle behavior affective changes. The individual may fail to associate the head injury with subsequent symptoms. Confusion, intellectual changes, affective lability, or psychosis may occur directly after the trauma or as long as many years afterwards.
Injury to the prefrontal and frontal regions of the cortex regions are common in serious MVA and may give rise to personality change described as the frontal lobe syndrome. Premorbid personality problems may be worsened. Personality changes may occur even in the absence of severe cognitive impairment. These changes may include impaired social judgment, labile, affect, uncharacteristic lewdness, inability to appreciate the affect of one’s behavior, diminishing of attention to personal appearance and hygiene and boisterousness. Impaired judgment may take the form of diminished concern for the future, with increased risk taking. Others may present with blunted affect, emotional withdrawal, social withdrawal, and lack of spontaneity. This may be the result of disordered functioning of the dorsolateral frontal cortex. The patient may also develop changes in sexual behavior including decreased sex drive, erectile dysfunction, and decreased frequency of intercourse.
Generalized deficits plus frontal lobe injury may lead to symptoms that are often subtle and at first may not be attributed to the underlying brain damage. For example, the person may show poor tolerance of environmental change. The patient becomes more dependent on external cues for action, becomes more concrete, and loses mental flexibility. Affective (emotional) change may manifest i.e., becoming more irritable, labile, and explosive. In more serious cases, social disorganization, loss of interest in the self, explosive irritability, and a shallow, labile, blunted affect may be seen. These personality changes may be intertwined with focal damage and PTSD.
Problems with intellectual functions may be among the most subtle manifestations of brain injury. Changes occur in the capacity to concentrate, use language, abstract, calculate, remember plans, and process information. Problems with arousal can take the form of inattention, distractibility, and difficulty switching and dividing attention. Mental sluggishness, poor concentration, memory problems are common complaints. High-level cognitive functioning in terms of executive functions are frequently impaired, although such impairment is difficult to detect and diagnose with cursory cognitive testing. Only specific tests that mimic real life decision-making situations can objectively demonstrate the problems encountered in daily life. Executive functions include setting goals, assessing strengths and weaknesses, planning and directing activity, initiating and inhibiting behavior, monitoring current activity, and evaluating results.
Other neuropsychiatric consequences, cognitive changes may be both generalized and focal. There may be blunting of overall performance on standardized IQ test with decline from estimated premorbid levels. Focal deficits reflect areas of cortex damage. Memory disturbances are common with impaired learning of new material and slow retrieval. Psychomotor slowing is common with more severe injury.
Affective changes often occur after a traumatic brain injury. Patients often describe mourning as a loss of their former selves, often a reflection of deficits in intellectual and motor abilities. The severity of depression and mood disturbances may be related to the extent of neuropsychological impairment as documented by neuropsychological testing Apathy secondary to brain injury, which includes decreased motivation and pursuit of pleasurable activities or schizoid behavior and complaints of slowness in thought and cognitive processing may resemble depression. Depression is common in up to 20 to 50%. Among causes of death, suicide is over-represented leading to 14% of all deaths.
Most individuals with mild TBI recover quickly with significant and progressive reduction of complaints in cognitive, somatic, and behavioral domains. The research suggests that there may be two groups of mild TBI, those who recover in three months and those who have persistent symptoms. Individuals more likely to develop prolonged Post-concussion Syndromes include:
1) Those under stress at the time of the accident.
2) Those that develop depression and anxiety soon after the accident.
3) Those that have extensive social disruption after the accident.
4) Those that have problems with physical symptoms.
Traumatic brain injury (including concussions) has a widespread impact on the body and mind:
Disruptions of brain network can result in disturbances where some symptoms/disturbances are more intense than others -- i.e., clarity of thinking and memory, vision, balance, pain in the head and neck as well as widespread pain, sleep, fatigue, autonomic nervous system, and hormonal disturbances Emotional instability including suicidality and explosiveness are often more prominent and may last longer than cognitive impairment. Growth hormone, thyroid, sex hormones and cortisol disturbances can cause secondary medical problems like muscle loss, fat accumulation, bone weakening, cardiac fatigue, cognitive impairment, and sexual dysfunction with diminished quality of life. These conditions are frequent, even in seemingly mild TBI and can have devastating consequences to a person’s life.
Standard neurological exams, imaging, and neuropsychological testing may not capture the complex interplay of social, emotional, behavioral, and bodily disturbances seen in a significant number of individuals that sustain concussions and seemingly mild traumatic brain injury. Investigative work up may include neuropsychological testing, CT/MRI, PET/SPECT, scans Diffusion Tensor Imaging (DTI), EEG and sleep studies and laboratory testing for hormonal and metabolic imbalances.
A thorough brain injury evaluation conducted and coordinated by a brain injury medicine specialist looks at multiple domains of pathology and functioning to ensure optimal outcomes.
The Pacific Pain & Wellness Group team will help patients recover with coordinated neuro rehab, PT, pain management, cognitive behavioral therapy and pharmacological management of pain, sleep, fatigue, mood, and anxiety Pacific Pain & Wellness Group will provide individually tailored multimodal interventions that resolve symptoms and enhances wellbeing.
Cutting edge interventions provided at PPWG including ketamine infusion (for TBI, PTSD, chronic pain, and depression; Botox (for depression), transcranial magnetic stimulation, hyperbaric oxygen (for TBI) will be provided when appropriate.
Individuals suffering from brain injury are often struggling with severe psychological trauma, chronic pain, and sleep disturbances. At PPWG we have the experts that can flesh out the complexity of widespread disruption of body mind work, family, and the capacity to enjoy life in the aftermath of TBI.
All that being said, TBI is also often accompanied by PTSD and chronic pain…
WE KNOW PSYCHOLGICAL TRAUMA (PTSD)
PPWG Med-Legal team has decades long experience in the med-legal assessment of trauma in adults and children. Dr. Nair has conducted research on PTSD while at the Veterans Administration/University of California, Irvine and continued this work with children and adolescents during his formal training at Harvard.
Posttraumatic Stress Disorder is a psychiatric disorder that develops in a significant minority of subjects exposed to serious and life-threatening events. However the majority of subjects do not develop PTSD even in the face of serious traumatic exposure and many individual will become emotionally stronger and grow from the experience.
Those who develop PTSD go on to have a variety of symptoms intense fear, helplessness, horror; re-experiencing the traumatic event, avoiding trauma reminders, feeling numb to the world around them, feeling on edge and not being able to sleep. PTSD can be a chronic and relapsing condition that can mimic many physical and mental disorders because of the waxing-waning nature of PTSD. Hyperarousal (feeling on edge) can look like anxiety, avoidance can be mistaken for depression. Somatization (preoccupation with physical illness complaints) is a common PTSD presentation.
There has been growing recognition about the relationship between pain and PTSD, and the increased risk of chronic pain in PTSD patients. A breakdown of the symptoms commonly associated with both these disorders demonstrates large overlap. For example, both are characterized with anxiety, avoidance, and increased preoccupation with bodily illness. This symptom overlap is important to the understanding of the overall clinical picture of a patient who presents with both PTSD and chronic pain.
WE KNOW CHRONIC PAIN
“Our understanding brains steadily combine all the available information from the outside world and within our own bodies with our personal and genetic histories. The outcomes are decisions of the tactics and strategies that could be appropriate to respond to the situation. We used the word pain as shorthand for one of these groupings of relevant response tactics and strategies. Pain is not just a sensation but, like hunger and thirst, is an awareness of an action plan to be rid of it.” Patrick Wall, Pioneer Pain Neuroscientist (Pain: The Science of Suffering 2002)
We at PPWG know how those injured and suffering from pain are frequently unable to both access meaningful medical treatment while also balancing school, work, family commitment, and sleep.
Fibromyalgia syndrome is one chronic pain condition that is often seen after injuries Fibromyalgia syndrome (FMS) is a crippling chronic pain syndrome. As many as 60% of fibromyalgia patients experience anxiety and depression, among several other challenges including chronic fatigue and non-restorative sleep.
Recent evidence shows abnormalities in functioning both in the brain and in the small nerve ending (SFPN small-fiber polyneuropathy) associated with chronic pain as well. It is important to screen for SFPN because it can often be identified and treated directly or cured.
Chronic Regional Pain Syndrome starts out with a minor injury with no discernible cause but can later have catastrophic consequences to those affected. One out of every five CRPS patients may endure a lifetime of pain with few treatment options available. Individuals suffering from CRPS face increased depression, anxiety and cognitive impairment which contributes to impaired occupational functioning and quality of life.
In employment litigation, expert witnesses are often brought in to access factors related to certain types of injury in a work environment PPWG provides professional consultation and forensic assessments in matters of employment litigation.
Our team members specialize in multiple board-certified disciplines and cover various aspects of civil litigation and expert witness testimony. Operating with a highly skilled team of professionals and years of combined experience we are a proven reliable source for impartial evaluation and reporting.
Our expert witnesses are conversant with and current in all med legal issues and the dispute resolution process having served as experts both at trial and arbitration, and having participated in depositions. Services include providing consultation, forensic analysis, case evaluation, and expert testimony in a broad range of disciplines.
- Hostile Work Environment
- Emotional Distress
- Anxiety Disorders
- Depressive Disorders
- Wage and Hour
- Accountability of employer
- Class action
- Co-workers receiving same treatment
- Hour issues in relation to company standards
- Workplace Discrimination/Harassment
- National Origin
- Workplace Retaliation
- Emotional Distress
- Facing retaliation for reported discrimination
- Facing retaliation for reported harassment
- Whistleblower retaliation
- Wrongful Termination
- Toxic Exposure
- Environmental exposure (lead, carbon monoxide, solvents)
- Hypoxic Anoxic Brain Injury
- Workers’ Compensation
- AME/PQME Psychiatry
- Fitness for Duty
- Workplace Negligence
- Workplace Accidents
Physicians and MHPs (Mental Health Professionals) are often brought in to assess factors related to certain types of injury or injustice. PPWG provides professional consultation and assessment in many matters of civil litigation. Operating with a highly skilled team of professionals and decades long experience PPWG is a reliable source for impartial evaluation and reporting.
In the areas of his expertise, Dr. Nair is conversant with and current in med legal issues and the dispute resolution process having served as an expert witness both at trial and arbitration, and having participated in depositions. His services include providing consultation, forensic analysis, case evaluation, and expert testimony.
- Standard of care
- Neurocognitive Assessments
- Neuropsychological Testing
- Psychosomatic Disorders
- Borderline Personality Disorder (BPD)
- Traumatic Brain Injury (TBI)
- Dementia Evaluation
- Post-Traumatic Stress Disorder (PTSD)
- Police Brutality Insanity Defense/Criminal Responsibility
- Risk Assessments of violence, sexual violence
- Fitness to Stand Trial
- Fitness for Duty
- Psychiatric Disability Evaluations
- Psychiatric Malpractice
- Testamentary Capacity
- Psychological/Emotional Injury
- Other Legal Evaluations (Parole, Probation, Drug Court/Diversion)
- Civil Capacity Assessment
- Testamentary Capacity
- Contractual Capacity
- Medical Toxicology
- Adverse drug reactions
- Drug toxicology
- Forensic toxicology
- Psychiatric Emergency Room
- Standard of Care
- Psychiatric E.R. Procedures
- Etiology Exclusion
- Coercion Avoidance
- Setting Evaluation (i.e., Least Restrictive)
- Time Evaluation (i.e., Timelines of patient being attended to)
- Psychopharmacology (i.e., Unforeseen Side Effects)
- Patient Disposition and Premature Discharge
- Suicide /Suicide Risk Evaluation
- Ambulatory Care
- Aftercare Plan
- Telepsychiatry in E.R.
- Mental Health Malpractice
- Violence Risk Assessment
- School Districts
- Breach of Contract
- Failure to protect a child or report abuse
- Sexual Misconduct and other abuse
- Personal Injury
- Improper Expulsion
- Gross Negligence
- Willful Misconduct
- Opposing Counsel Misconduct
- Child Psychiatry
- Neurocognitive Assessments
- Neuropsychological Testing
- Child Custody Evaluations
- Child Sexual Abuse Evaluations
- Child Trauma Evaluations
- Child Traumatic Injury Evaluations
- Post-Traumatic Stress Disorder (PTSD)
- Elder Matters
- Cognitive Impairment
- Conservatorship and Victimization
- Contractual Capacity
- Dementia Expert
- Diminished Capacity at the time of event
- Financial Abuse
- Medication Side Effects
- Mental State
- Physical Problems in Relation to event
- Psychological Stress
- Testamentary Capacity
- Undue influence
- Wrongful death from prescribing psychiatric medication
- Post Traumatic Stress Disorder (PTSD)
- Claims of PTSD from accidents
- Claims of PTSD from first responders
- Claims of PTSD from natural disasters
- Claims of PTSD from man-made catastrophes
- Claims of PTSD from war
- Negligence in prescribing
- Negligence in administration
- Negligence in monitoring
- Negligence in obtaining adequate informed consent
- Tardive Dyskinesia
- Neuroleptic Malignant Syndrome
- Serotonin Syndrome
- Metabolic Syndrome
- Problems related to benzodiazepines
- Psychiatric medication withdrawal issues