Opinion ID: 2026576
Heading Depth: 1
Heading Rank: 8

Heading: Admissibility of Handke's Testimony

Text: Handke concluded that Epp's fibromyalgia was caused by the physical trauma of the accident after conducting a differential diagnosis. In Carlson v. Okerstrom, 267 Neb. 397, 675 N.W.2d 89 (2004), we addressed the reliability of a differential diagnosis. We stated that differential diagnosis is a technique which generally has widespread acceptance in the medical community, has been subjected to peer review, and does not frequently lead to incorrect results. We emphasized, however, that an expert's opinion is not admissible simply because he or she conducted a differential diagnosis. To the contrary, in order for an expert's opinion to be reliable, the court must determine whether the expert conducted a reliable differential diagnosis. Id. In Carlson, we set forth a two-step process for determining whether an expert conducted a reliable differential diagnosis. The first step in conducting a reliable differential diagnosis is to compile a comprehensive list of hypotheses that might explain the set of salient clinical findings under consideration. . . . If the expert rules in a potential cause that is not capable of causing the patient's symptoms, the expert's opinion is of questionable reliability. . . . Similarly, if the expert completely fails to consider a cause that could explain the patient's symptoms, the differential diagnosis is not reliable. . . . Once the expert has ruled in all plausible causes for the patient's condition, the next step is to engage in a process of elimination, eliminating hypotheses on the basis of a continuing examination of the evidence so as to reach a conclusion as to the most likely cause of the findings in that particular case. . . . In analyzing the second step of a differential diagnosis under the Daubert/Schafersman framework, the question is whether the expert had a reasonable basis for concluding that one of the plausible causative agents was the most likely culprit for the patient's symptoms. In other words, the expert must be able to show good grounds for eliminating other potential hypotheses. (Citations omitted.) (Emphasis in original.) Id. at 414, 675 N.W.2d at 105-06. In Carlson, the parties did not dispute that trauma was capable of causing the condition suffered by the plaintiff or whether the expert had properly ruled in potential causes of the plaintiff's injury. It was therefore unnecessary for us to determine whether the first step of the differential diagnosis was properly performed. Here, however, Epp's appeal concerns whether trauma can be a possible cause of fibromyalgia. We must therefore determine whether Handke properly ruled in trauma as a potential cause of Epp's fibromyalgia. [7] We have noted with approval nonexclusive criteria which the trial court may consider in evaluating the reliability of a particular theory. These include (1) whether the theory or technique can be, and has been, tested; (2) whether the theory or technique has been subjected to peer review and publication; (3) whether there is a known or potential rate of error; (4) whether there are standards controlling the technique's operation; and (5) whether the theory or technique enjoys general acceptance within the relevant scientific community. See, Carlson v. Okerstrom, 267 Neb. 397, 675 N.W.2d 89 (2004); Schafersman v. Agland Coop, 262 Neb. 215, 631 N.W.2d 862 (2001). These are, however, neither exclusive nor binding; different factors may prove more significant in different cases, and additional factors may prove relevant under particular circumstances. Id. The trial court was presented with voluminous materials to assist it in its determination of whether the theory underlying the opinions of Handke and Bennett was reliable. A review of these materials reveals the existence of a professional controversy regarding the causal relationship between physical trauma and fibromyalgia. A number of experts in the field of fibromyalgia believe that an association exists between physical trauma and the onset of fibromyalgia. See, e.g., A.W. Al-Allaf et al., A Case-Control Study Examining the Role of Physical Trauma in the Onset of Fibromyalgia Syndrome, 41 Rheumatology 450 (2002) (suggesting association between physical trauma and onset of fibromyalgia); Robert M. Bennett, A Multidisciplinary Approach to Treating Fibromyalgia, in Progress in Fibromyalgia and Myofascial Pain 393 (H. Vaeroy & H. Merskey eds., 1993) (stating musculoskeletal pain experienced by fibromyalgia patients arises as result of microtrauma); Dan Buskila et al., Increased Rates of Fibromyalgia Following Cervical Spine Injury, 40 Arthritis & Rheumatism 446 (1997) (noting association between diagnosis of fibromyalgia and cervical spine injury); Stuart Greenfield et al., Reactive Fibromyalgia Syndrome, 35 Arthritis & Rheumatism 678 (1992) (explaining that study to determine frequency of precipitating event occurring prior to onset of fibromyalgia revealed that 23 percent of patients with primary rheumatologic diagnosis of fibromyalgia reported having trauma, surgery, or other medical illness before onset of fibromyalgia); George W. Waylonis et al., A Profile of Fibromyalgia in Occupational Environments, 73 Am. J. Phys. Med. Rehab. 112 (1994) (noting association between onset of fibromyalgia symptoms and traumatic event); Muhammad B. Yunus et al., Fibromyalgia Consensus Report: Additional Comments, 3 J. Clinical Rheumatology 324, 325 (1997) (stating that [i]n the context of a legal setting (where the Consensus Report is likely to be used), causality entails only 51% certainty . . . it seems more than 51% likely that trauma does play a causative role in some [fibromyalgia] patients). This view is also held by Handke and Bennett, and was conceded by Lauby's expert, who stated that physical trauma may be a precipitating cause of fibromyalgia, though at present there is no way to determine the cause of fibromyalgia outside the clinical setting. Other experts, however, believe that the connection has not been sufficiently established and that additional studies are needed to confirm it. See, e.g., Al-Allaf et al., supra (concluding that further studies are needed to confirm association between trauma and fibromyalgia and to determine whether trauma has causal role); Buskila et al., supra (noting that data from literature is insufficient to indicate whether causal relationships exist between trauma and fibromyalgia); Frederick Wolfe et al., The Fibromyalgia Syndrome: A Consensus Report on Fibromyalgia and Disability, 23 J. Rheumatology 534 (1996) (noting that epidemiologic studies of trauma and fibromyalgia needed to address potential or predictive causality are currently not available). After reviewing the evidence and applying the Daubert/Schafersman standards, the trial court found that the theory of a causal link between physical trauma and fibromyalgia has not been verified by sufficient testing, has not been subject to peer review, and does not enjoy general acceptance within the medical community. Consequently, the court excluded Handke's testimony on the cause of Epp's fibromyalgia. Upon our review, we determine that the court abused its discretion by excluding Handke's testimony. Although important, general acceptance of the causal link between physical trauma and fibromyalgia is not determinative of the admissibility of expert testimony under Daubert/Schafersman standards. See Carlson v. Okerstrom, 267 Neb. 397, 675 N.W.2d 89 (2004). So long as the expert's opinion is based on reliable methodology, his or her opinion is admissible, whether or not the court agrees with the expert's conclusion. Reichert v. Phipps, 84 P.3d 353 (Wyo. 2004). In the instant case, Handke arrived at the conclusion that Epp's fibromyalgia was caused by physical trauma after conducting a reliable differential diagnosis, as we will determine later in this opinion. Handke's conclusion is supported by medical literature in evidence which supports the theory that fibromyalgia may be caused by physical trauma. The Daubert test does not stand for the proposition that scientific knowledge must be absolute or irrefutable. See State v. Dahood, 148 N.H. 723, 814 A.2d 159 (2002). [I]t would be unreasonable to conclude that the subject of scientific testimony must be 'known' to a certainty; arguably, there are no certainties in science. Daubert v. Merrell Dow Pharmaceuticals, Inc., 509 U.S. 579, 590, 113 S. Ct. 2786, 125 L. Ed. 2d 469 (1993). While a theory or technique that has attracted only 'minimal support' within the relevant scientific community may properly be viewed with skepticism, a reliability assessment does not require an express determination of a particular degree of acceptance within the scientific community. See 509 U.S. at 594. Thus, '[c]ontroversy within the scientific community is not necessarily a ground for exclusion of scientific evidence. In deciding whether to admit scientific evidence, a court need not resolve disputes between reputable experts; the evidence may be admissible even though a dispute exists. . . . [T]he witness who testifies to an expert opinion is subject to cross-examination concerning how he or she arrived at that opinion, and . . . in eliciting testimony to vitiate the opinion.' State v. Sampson, 167 Or. App. 489, 502-03, 6 P.3d 543, 553 (2000), quoting State v. Lyons, 324 Or. 256, 924 P.2d 802 (1996). Although the issue is disputed, there is support in the medical literature for the theory that physical trauma can cause fibromyalgia. That support, while controverted, is the result of peer-reviewed research conducted pursuant to appropriate methods of scientific inquiry. While there is not a sufficient scientific consensus to say that the theory is generally accepted, nor has a rate of error been established, the theory that trauma can cause fibromyalgia has been the subject of empirical research, the results of which have been subjected to peer review and publication. See Daubert v. Merrell Dow Pharmaceuticals, Inc., supra . We cannot conclude that Handke and Bennett's reliance on this research, instead of literature to the contrary, was methodologically unreliable. If proffered scientific evidence rests on sound scientific reasoning or methodology and properly can be applied to the facts in issue, it meets the Daubert requirements for admissibility, even if the conclusion is novel or controversial. See State v. Dahood, supra . Despite the existence of spirited dissent, see State v. Sampson, 167 Or. App. at 503, 6 P.3d at 553, the lack of a scientific consensus on the link between trauma and fibromyalgia was not sufficient to render reliance upon that literature methodologically unreliable. We, therefore, conclude that the evidence was sufficient to support the theory of a causal relationship between physical trauma and fibromyalgia and that the trial court abused its discretion in concluding otherwise. Having determined that Handke properly ruled in physical trauma as a cause of Epp's fibromyalgia, we must next determine whether Handke properly ruled in and ruled out other causes. Because there appears to be no disagreement between the parties regarding whether Handke properly ruled in other potential causes of Epp's fibromyalgia, we determine that Handke correctly conducted the first part of his differential diagnosis. We similarly conclude that Handke properly ruled out other potential causes of Epp's fibromyalgia. Handke testified that known causes of fibromyalgia include trauma, infection, stress, idiopathy, chronic pain diagnosis, and diseases such as degenerative arthritis and rheumatoid arthritis. Handke further testified that he eliminated causes other than trauma. Handke based this elimination upon repeated clinical examinations; the fact that Epp did not suffer from any of the other known causes of fibromyalgia prior to the accident, and soon thereafter developed symptoms of fibromyalgia. Ruling out decisions based on the results of physical examinations provides a well-accepted diagnostic technique which generally provides a valid basis for discarding hypotheses during the ruling out portion of a differential diagnosis. See Carlson v. Okerstrom, 267 Neb. 397, 675 N.W.2d 89 (2004). Under these circumstances, we cannot say that Handke's differential diagnosis was unreliable. Consequently, we conclude that the trial court abused its discretion in not allowing the jury to determine the weight given to Handke's opinion testimony on the cause of Epp's fibromyalgia.