In the United States Court of Federal Claims
                        OFFICE OF SPECIAL MASTERS

*********************
DOUG PALUCK and RHONDA             *
PALUCK, as parents and natural     *        No. 07-889V
guardians on behalf of their minor *        Judge Charles F. Lettow
son, KARL PALUCK,                  *        Special Master Christian J. Moran
                                   *
                  Petitioners,     *        Filed: May 10, 2013
                                   *
v.                                 *        Entitlement; significant aggravation
                                   *        mitochondrial disorder; decision
SECRETARY OF HEALTH                *        on remand
AND HUMAN SERVICES,                *
                                   *
                  Respondent.      *
*********************

Sheila A. Bjorklund, Lommen Abdo Law Firm, Minneapolis, MN, for petitioners;
Chrysovalantis P. Kefalas, United States Dep’t of Justice, Washington, DC, for
respondent.

   PUBLISHED DECISION ON REMAND DENYING ENTITLEMENT1

      Doug and Rhonda Paluck request compensation on a claim that various
vaccines harmed their son, Karl. Their case is proceeding in the National
Childhood Vaccine Injury Compensation Program. 42 U.S.C. § 300aa–10 et seq.
(2006). The statute authorizes recovery when the petitioners establish that


      1
        The E-Government Act of 2002, Pub. L. No. 107-347, 116 Stat. 2899,
2913 (Dec. 17, 2002), requires that the Court post this decision on its website.
Pursuant to Vaccine Rule 18(b), the parties have 14 days to file a motion proposing
redaction of medical information or other information described in 42 U.S.C.
§ 300aa–12(d)(4). Any redactions ordered by the special master will appear in the
document posted on the website.
vaccines either caused a new illness or significantly aggravated a pre-existing
condition.

       A December 14, 2011 decision (“Entitlement Decision”) found that the
Palucks failed to establish that the measles, mumps, and rubella (“MMR”),
varicella, and pneumococcal vaccines caused Karl’s illness based upon a failure to
establish the factors set forth in Althen v. Secretary of Health & Human Servs.,
418 F.3d 1274 (Fed. Cir. 2005). This decision did not determine whether the
Palucks’ case should be categorized as either an initial causation claim or a
significant aggravation claim. See Decision, 2011 WL 6949326.

       The Palucks filed a motion for review. On April 18, 2012, the Court granted
this motion, vacated the December 14, 2011 decision, and remanded for additional
findings. Opinion and Order, 104 Fed. Cl. 457 (2012). The Court permitted, but
did not require, the submission of additional evidence. The Opinion and Order
specified that the decision on remand should determine whether “indicia of Karl’s
neurodegeneration manifested themselves prior to the vaccinations that occurred
January 19, 2005.” Id. at 469. The Opinion and Order also explicitly stated that
the Court was “mak[ing] no affirmative findings of its own.” Id. at 484.

      The parties were given an opportunity to present additional evidence on
remand. However, they did not and the evidentiary record has not changed after
the remand.

       Karl manifested problems traceable to his central nervous system before he
was vaccinated. Thus, the Palucks’ claim is treated as a claim that the vaccinations
significantly aggravated his underlying mitochondrial disorder. As discussed
extensively below in sections IV.B, IV.C and IV.D, the Palucks have not
established that Karl showed the rapid and drastic effects of a vaccination as the
theory of their expert, Dr. Frye, predicted. Notably (but not exclusively), Karl’s
dramatic decline did not happen until months after the vaccination.

      For these reasons, the Palucks have not demonstrated that they meet the
standards for entitlement. The Clerk’s Office is instructed to enter judgment in
accord with this decision unless a motion for review is filed.




                                         2
I.    Procedural History after Remand

       After the Opinion and Order remanded the case, the first action was the
submission of an order requesting status reports from each side, proposing the next
steps in the case. The parties were also instructed to address “the Court’s
comments regarding classifying Karl’s case as either a significant-aggravation
claim or new-injury claim.” Order, filed Apr. 24, 2012.

        The Palucks filed a status report containing four parts. First, the Palucks
argued that in the Opinion and Order, the Court “made specific findings as to each
Althen prong . . . . Upon his careful review of the record in this matter, [the Court]
concluded that Petitioners submitted sufficient evidence to meet their burden under
all of the three Althen prongs . . . . [The special master] needs only to adopt [the
Court’s] reasoning and conclusions.” Pet’r Status Rep’t, filed May 7, 2012, at 1.
Second, the Palucks argued that Karl’s neurodegeneration after January 19, 2005,
constituted a new injury and they were entitled to compensation on that claim. Id.
at 3-7. Third, and alternatively, the Palucks argued that even if Karl’s claim were
one for significant aggravation, they remain entitled to compensation. Id. at 7.
Fourth, the Palucks asserted that “[t]here is no need for additional testimony or
submission of evidence as to causation.” Id. at 8.

       After filing an unopposed motion for enlargement of time, the Secretary
presented her response to petitioners’ status report on June 8, 2012. First, the
Secretary summarized portions of the Opinion and Order. Resp’t Resp., filed June
8, 2012, at 1-3. Next, the Secretary contended that Karl’s case is properly
classified as a significant aggravation claim and argued that the Palucks have not
established that they are entitled to compensation. Id. at 3-8. The Secretary
responded to the alternative theory, the new injury claim, in a single sentence. Id.
at 8. Finally, the Secretary stated “should the special master decide that the record
is insufficient to fully consider petitioners’ claim as one of significant aggravation,
respondent does not object to the submission of additional evidence for that
purpose.” Id.

      An unrecorded status conference was held on June 27, 2012. As set forth in
the subsequent order, the parties were informed that their status reports did not
answer a question posed by the Court. The Opinion and Order expected resolution
of whether “Karl’s neurological, not mitochondrial, symptoms, however defined,
were manifested pre-vaccination.” The undersigned commented that the Secretary
appeared to have lumped Karl’s neurological problems with Karl’s mitochondrial
problems, which was contrary to how the Court framed the issue. The undersigned
                                           3
also requested that the Palucks explain how Karl’s gross motor delay that was
found in October 2004, differed from the chiropractor’s report of hypertonicity and
spasticity in February 2005. Consequently, both sides were ordered to file
supplemental briefs. Order, filed July 10, 2012.

       The Secretary filed a supplemental brief on August 21, 2012.2 Consistent
with her previous briefs, the Secretary continued to press the argument that, as a
legal matter, Karl’s claim should be analyzed as a significant aggravation claim. In
the Secretary’s view, Karl suffered one continuous process in which his
“neurodegeneration . . . developmental delays, and related symptoms are a sequela
of Karl’s pre-existing mitochondrial disorder.” Resp’t Br., filed Aug. 21, 2012, at
1. The Secretary asserted that neurological symptoms are not separate from
mitochondrial symptoms. Id. at 3. On the topic of mitochondrial disorders, the
Secretary stated that she had “no objection to re-opening the record to provide
additional evidence on mitochondrial disorders.” Id. at 3 n.1.

       The Palucks responded. The Palucks argued that “Karl had no
neurodegeneration prior to his receipt of vaccine on January 19, 2005.” Pet’r Br.,
filed Aug. 28, 2012, at 2 (capitalization changed without notation). The Palucks
reviewed some of the evidence showing Karl’s pre-vaccination history. Id. at 2-5.
The Palucks interpreted this evidence as consistent with their legal claim that the
January 19, 2005 vaccinations caused him a new injury. Id. at 5-7. In conclusion,
the Palucks argued against additional evidence. They stated:

       It would be a waste of resources in both time and money for this Court
       to open the record in this matter to receive additional evidence on
       mitochondrial disorders as suggested in a footnote by Respondent.
       See Respondent’s Suppl Brief, fn 1. There is more than sufficient
       testimony and medical literature as a matter of record to permit this
       court to make a determination if this is a cause-in-fact injury case or a
       significant aggravation injury case.

Id. at 7.



       2
         The Secretary had informally requested additional time to file this brief due
to an injury to her attorney. The Palucks did not oppose this request. See order,
filed July 30, 2012.

                                          4
       An August 30, 2012 order permitted the Palucks to identify evidence that
Karl’s gross motor delay was caused by a problem in his muscles, as opposed to
his central nervous system (“CNS”). The Palucks responded on September 4,
2012.

       An unrecorded status conference was held on September 11, 2012. A
primary purpose was to ascertain the Secretary’s position regarding the need for
additional evidence. In previous filings, the Secretary had stated that she did not
object, but the Secretary had not requested additional evidence. In the ensuing
status report, the Secretary stated that she “will not at this time move to present
additional evidence on the question of whether Karl’s pre-vaccination
mitochondrial symptoms were central nervous system or musculoskel[e]tal
problems.” Resp’t Status Rep’t, filed Sept. 18, 2012, at 2. The next day, the
Palucks stated that “[t]his matter is ripe for decision.” Pet’r Status Rep’t, filed
Sept. 19, 2012, at 2.

     At the oral argument on the second motion for review, which is discussed
below, the parties confirmed that they did not want to present additional evidence:

             THE COURT: Was there a consensus between the parties that
      no further evidentiary proceedings were to be conducted on remand
      before the Special Master?
             [PETITIONER’S COUNSEL]: Yes. Both sides were provided
      the opportunity to identify whether or not they believe[d] that further
      hearings were required or further evidence was required to be
      submitted into the record, and clearly Petitioners determined that there
      was sufficient evidence in the records to meet our burden of proof.

Oral. Arg. Tr., April 10, 2013, 9:1 to 10:3.3

       In combination, the Court’s Opinion and Order; the April 24, 2012 order,
requesting “next steps;” and the September 11, 2012 order, requesting statements
regarding the need for additional evidence presented the parties with several
opportunities to obtain additional evidence. The attorneys saw the Court’s
instructions about the need for the special master to consider, among other topics,

      3
        Later, on this point, the Court commented that he “has been a little
surprised that there weren’t further evidentiary proceedings conducted before the
Special Master, but I’ll leave that aside.” Id. at 24:6-8.

                                          5
the chiropractor’s records. The attorneys, presumably, reviewed those records and
the testimony from the experts about those records. This process “afford[ed] each
party a full and fair opportunity to present its case.” Vaccine Rule 3(b)(2). After
an opportunity to consider whether additional information would be helpful, each
party submitted status reports declaring that additional evidence was not needed.
The parties submitted the case for adjudication.4

      4
         Conceivably, the undersigned could have exercised his authority to
“require the testimony of any person,” 42 U.S.C. § 300aa – 12(d)(3)(B)(iii), sua
sponte. As a matter of discretion, the undersigned refrained for several reasons.
First, the attorneys of record are experienced and competent counsel. They are
able to analyze the law and the facts. The attorneys also have access to doctors
who can informally advise them as to whether additional evidence may help (or
hurt) their cases. Thus, there is little reason for this special master to second-guess
the informed decision of the parties not to submit additional evidence, especially
because special masters have been cautioned not to interfere with counsel’s
development of the case. See Boley v. Sec’y of Health & Human Servs., 82 Fed.
Cl. 407, 414 (2008), mot. for rev. denied after remand, 86 Fed. Cl. 294 (2009).
        Second, as a practical matter, a sua sponte order requiring the testimony of a
medical doctor would be difficult to implement. A basic question is who would
pay for the doctor’s time? In this time of budget austerity, this question matters.
This issue alone may account for why special masters have not issued any sua
sponte orders compelling unrequested testimony during the undersigned’s tenure as
a special master.
        Third, the compelled testimony of a witness implicates other relationships.
For example, the Palucks may have a continuing relationship with Karl’s primary
pediatrician, Dr. Stephen McDonough, who may wish not to become involved in
litigation. Thus, the Federal Circuit has warned that “the specter of a subpoena”
could be “a disincentive” for doctors “to treat a vaccine-injured patient.” Andreu
v. Sec’y of Health & Human Servs., 569 F.3d 1367, 1383 (Fed. Cir. 2009).
        For these reasons, special masters guide parties in presenting their cases and
are willing, when the circumstances justify an order, to compel the production of
evidence that a party has requested. See, e.g. Doe 34 v. Sec’y of Health & Human
Servs., 87 Fed. Cl. 758, 765 (2009) (ruling that special master did not err in
securing participation of a doctor whose testimony the Secretary “had always
requested”). After the parties present all their evidence, the special master
functions as a finder of fact, albeit one with expertise in the subject. See Hodges v.
Sec’y of Health & Human Servs., 9 F.3d 958, 961 (Fed. Cir. 1993). One party’s
disappointment over the outcome of a hearing does not entitle that party another
                                                                         (. . . continued)
                                             6
       On October 8, 2012, the Palucks filed a second motion for an award of
attorneys’ fees on an interim basis. After the parties discussed the request, the
Palucks filed a stipulation on October 22, 2012. The next day, a decision awarding
additional attorneys’ fees was entered.

      On January 30, 2013, the Palucks filed a motion for review with the Court,
arguing that the undersigned’s time for issuing a decision expired 90 days after the
April 18, 2012 Opinion and Order. After additional briefing and argument, the
Court denied the motion for review, finding that the amount of time that case was
pending on remand did not constitute “such a passage of time as undue delay
tantamount to a failure to exercise jurisdiction on the part of the special master.”
The Court mandated a decision within 120 days of its May 3, 2013 Opinion and
Order.

II.   Background of Karl’s Medical History

       Although the parties draw different conclusions from the facts, there is a
basic agreement about them. These facts were detailed in the December 14, 2011
decision and the April 18, 2012 Opinion and Order. The following summary is
presented for context. More detailed findings of fact are made throughout sections
III. and IV. below.

       Karl was born on January 15, 2004. His development appeared to be normal
for the first six months or so. During this time, Karl received typical vaccinations
at two, four, and six months, without any apparent ill effects from them. See
exhibit 5 at 12.

      Karl’s pediatrician, Dr. McDonough, noticed that Karl was developmentally
delayed during an examination when he was eight months old. Exhibit 5 at 111.
The doctor referred Karl to a program for children with developmental delays,
K.I.D.S. The staff at K.I.D.S. assessed Karl. The ensuing report stated:

      Karl’s gross motor delays are impacting his ability to achieve age-
      level skills in other areas of development. Karl has difficulty moving
      against gravity, which is an important gross motor foundational skill.

opportunity to present further evidence. Sword v. United States, 44 Fed. Cl. 183,
190-91 (1999) (ruling that the special master did not abuse her discretion in
denying the respondent’s motion to submit additional expert testimony).

                                         7
       . . . When evaluating Karl’s muscle tone the passivity in his arms is
      greater than normal. His arm’s consistency is softer than normal and
      his extensibility provides no resistance to passive movement. . . . Karl
      has difficulty bringing his hands together to clap or bang cubes
      together. He does not yet participate in turn-taking games such as pat
      a cake and peek-a-boo. . . . In order to provide stability in his arms
      and trunk, Karl fixes his legs. By fixing his legs, Karl presents with
      slight elevated tone.

Exhibit 15 at 4.5

      Additionally, the evaluators observed that “Karl is not using many gestures,”
and “is not approximating sounds made by another person. He tends to produce
sounds spontaneously, but does not imitate when a model is provided him.”
Exhibit 15 at 4-5. The evaluators also noted that “Karl does not respond to specific
words or phrases such as ‘no, no, Karl.’” Id. at 5. The report recommended that
Karl “receive infant development services . . . targeting his speech/language, gross
motor, and the delays in fine motor related to low muscle tone.” Id.

        In this proceeding, the Palucks and the Secretary draw very different
conclusions from the K.I.D.S. report. The Palucks interpreted the report as
showing that Karl’s cognition and language abilities were “absolutely normal,” and
that any developmental delays “were most prominently gross motor delays, maybe
a little bit of fine motor delays.” Tr. 101:9-11. The Secretary, on the other hand,
saw the report as supporting her view that Karl’s cognition and language were
below average. To the Secretary, Karl’s inability to respond to “no no,” for
example, was not a “minor trivial thing.” Tr. 787:11-13.



      5
        The report’s authors define the following three terms: “Passivity refers to
the amount of flapping of the child’s hand or foot when the evaluator shakes an
extremity, thereby imposing multiple quick stretches. Normally the extremity
tightens at the wrist or ankle after a few excursions of the hand or foot.” Exhibit
15 at 4 n.1. “Consistency refers to the relative firmness of muscle tissue, which is
evaluated by palpation. Normally the muscle feels sturdy but there is some
yielding to pressure.” Id. at 4 n.2. “Extensibility refers to the capacity of a muscle
to elongate when a quick stretch is imposed on it. . . . Typically a normal, graded
resistance is felt throughout the range of motion.” Id. at 4 n.3

                                          8
      Around this same time, Karl was having two other problems. He was having
recurrent otitis media and recurrent erythema multiforme.6 These problems
continued to afflict Karl periodically from approximately October 2004 to April
2005. Karl was seen by his doctors for these two problems as necessary.

      On December 27, 2004, Dr. McDonough saw Karl. Dr. McDonough
recorded that “[n]eurologic examination reveals normal muscle tone. There is no
ankle clonus. Deep tendon reflexes appear to be symmetrical. He has good head
control and fairly good truncal control but is not pulling himself to stand or
crawling yet.” Exhibit 3 at 5. His assessment of Karl was “[b]ilateral serous otitis
media; rash, possible erythema multiforme, . . . and possible mild gross motor
delay.” Id. at 5-6.

       Karl’s next appointment with Dr. McDonough was on January 19, 2005,
which was his one-year well-baby appointment. Karl received doses of the
measles, mumps, and rubella vaccine, the pneumococcal vaccine, and the varicella
vaccine. Dr. McDonough recorded a history about Karl’s current functioning. At
this appointment, Dr. McDonough referred Karl to physical and occupational
therapy. Exhibit 3 at 3. Instead of taking Karl to a therapist as their pediatrician
recommended, the Palucks brought him to a chiropractor. Exhibit 12.

       On March 24, 2005, Dr. McDonough referred Karl, then 14 months of age,
to a pediatric neurologist, Dr. Siriwan Kriengkrairut, “for gross motor delay, global
developmental delay, and hypertonicity.” Exhibit 3 at 7. In his referral, Dr.
McDonough also noted that Karl “has had recurrent erythema multiforme.” Karl
saw both Dr. McDonough and Dr. Kriengkrairut in April. See Exhibit 3 at 9-11
(Dr. McDonough), 83-85 (Dr. Kriengkrairut).

      Karl had relatively little interaction with health care providers in May and
June 2005. On July 12, 2005, Karl had a series of seizures. He was hospitalized
for approximately three weeks. Despite investigation, the doctors did not identify
the cause of Karl’s seizures.



      6
        Erythema multiforme is “an acute eruption of macules, papules, or
subepidermal vesicles presenting a multiform appearance.” Stedman’s Medical
Dictionary 667 (28th ed. 2006). While “the eruption is usually self-limited . . . ,
[it] may be recurrent or may run a severe course.” Id.

                                          9
       After the July 2005 hospitalizations, Karl was tested extensively.
Eventually, samples obtained from Karl were sent to Baylor College of Medicine
for mitochondrial diagnostic testing. Exhibit 18 at 60-61. The electron transport
chain enzymes test conducted on muscle tissue by Baylor showed increased citrate
synthetase activity, “suggesting mitochondrial proliferation, which can be an
adaptive response to mitochondrial function.” These results, while “not
reflect[ing] any specific diagnostic pattern,” do “fulfill a minor diagnostic criterion
for a mitochondrial disorder,” id. at 60, indicating that Karl most likely suffered
from a disorder in his mitochondria. The precise nature of Karl’s mitochondrial
problem, however, is not known. See Tr. 503:22-25 (Dr. Snodgrass: “I think he
has a progressive disease and that it’s probably a primary mitochondrial disease,
but it might be a progressive disease that is not a primary mitochondrial disease.”);
Tr. 88:24-25 (Dr. Frye: “Using the modified Walker criteria or the Morava criteria,
he meets criteria for a probable mitochondrial disorder . . . he is rated as probable
by both criteria.”).

       Mitochondria are organelles (parts of cells) that supply energy to cells.
“Mitochondrial disease is not a single entity but, rather a heterogenous group of
disorders characterized by impaired energy production due to genetically based
oxidative phosphorylation dysfunction. Together, these disorders constitute the
most common neurometabolic disease of childhood.” Opinion and Order, 104 Fed.
Cl. at 463 n.8, quoting Entitlement Decision, at *1, quoting exhibit E (Richard H.
Haas et al., Mitochondrial Disease: A Practical Approach for Primary Care
Physicians, 120 Pediatrics 1326, 1327 (2007)) (internal quotation marks omitted).
“Mitochondrial diseases are usually progressive and multisystemic. Typically
affected organs are those with a high energy demand, including skeletal and
cardiac muscle, . . . and the central nervous system.” Exhibit E (Haas) at 1327.

      Although Karl’s treating doctors have not identified the exact error in Karl’s
mitochondria, both testifying experts agree that Karl suffers from a mitochondrial
disease. Tr. 88:23-89:2 (Dr. Frye), 413:1-20 (Dr. Snodgrass); see also Tr. 27:10-
11 (Petitioners’ attorney: “[a]n undisputed fact from both experts is that Karl has a
mitochondrial dysfunction”). Additionally, and importantly, the experts also agree
that Karl was born with his mitochondrial defect. Tr. 80:24-81:8 (Dr. Frye), 260:5-
10, 377:7-11 (Dr. Snodgrass). The fact that Karl was born with the mitochondrial
disorder means that the Palucks cannot claim (and do not claim) that any
vaccination caused Karl’s mitochondrial disorder.

      Instead, the Palucks argue that “Karl’s devastating neurological regression
following receipt of five vaccines on January 19, 2005 is a new injury.” The basis
                                          10
for this argument is that, to the Palucks, Karl “exhibited no signs of central nervous
system damage, with resultant neurodegeneration, until after receipt of the January
2005 vaccines.” Pet’r Status Rep’t, filed May 7, 2012, at 2.

       The Secretary disagrees. The Secretary argues that the Palucks’ “claim is
best analyzed as a significant aggravation claim.” For the Secretary, Karl’s
“neurodegeneration, developmental delays, and related symptoms are a sequela of
Karl’s pre-existing mitochondrial disorder.” Resp’t Resp., filed June 8, 2012, at 4.
This is the first issue requiring resolution.

III.   Initial Causation or Significant Aggravation

       The Court’s framing of this issue controls the analytical structure on remand.
See 42 U.S.C. § 300aa–12(e)(2)(c) (empowering the Court of Federal Claims to
remand “to the special master for further action in accordance with the court’s
direction”); Hanlon v. Sec’y of Health & Human Servs., 40 Fed. Cl. 625, 630
(1998) (a decision from the Court of Federal Claims is binding on a special master
in the same case on remand), aff’d, 191 F.3d 1344 (Fed. Cir. 1999). In its Opinion
and Order, the Court stated:

       A related second issue [7] is whether indicia of Karl’s
       neurodegeneration manifested themselves prior to the vaccinations


       7
         The Court’s initial issue was “the precise definition of Karl’s injury.” The
Court, as set forth in the text, queried whether “neurodegeneration” is the
appropriate metric. Both before and after remand, the parties have presented
evidence and argument based upon a claim of “neurodegeneration.” For examples
of pre-remand arguments, see Pet’r Posthr’g Br., filed Feb. 18, 2011, at 28
(sequence of medical events “support [petitioners’] contention that [Karl’s]
vaccines cause[d] [his] neurodegeneration”); Resp’t Posthr’g Br., filed Feb. 18,
2011, at 43 (arguing petitioners’ evidence “is irrelevant to a hypothesis that posits
a relationship between vaccinations and neurodegeneration”). For examples of
post-remand arguments, see Pet’r Status Rep’t., filed May 7, 2012, at 7 (all the
evidence “clearly demonstrates that Karl Paluck suffered a new injury –
devastating neurodegeneration – following receipt of his . . . vaccines”); Pet’r Br.,
filed Aug. 28, 2012, at 7 (“[Karl] had neurogeneration after receipt of the . . .
vaccines.”); Resp’t Br., filed Aug. 21, 2012 (“There is no reliable evidence . . . that
neurodegeneration . . . represent[s] distinct, new injuries from [Karl’s]
                                                                       (. . . continued)
                                           11
      that occurred January 19, 2005. The parties have framed these issues
      in simplified terms, i.e., whether Karl was progressing or regressing
      developmentally prior to his vaccinations. With a genetic abnormality
      of the type inhering in Karl, this may not be the proper focus for
      determination. Rather, based on the record as it stands, voluminous as
      it may be, it is medically and scientifically uncertain whether
      developmental progress or regress is a valid measure to assess the pre-
      vaccination condition of a very young child with Karl’s type of
      mitochondrial defect, or whether another indicator should be
      employed. If Karl’s neurological, not mitochondrial, symptoms,
      however defined, were manifested pre-vaccination, then Karl’s case
      involves a significant-aggravation claim. See [Shalala v.]
      Whitecotton, 514 U.S. [268,] 274 [(1995)]. If not, then Karl’s case
      concerns a new-injury claim.

Opinion and Order, 104 Fed. Cl. at 469. The critical portion of this passage is the
Court’s statement that “If Karl’s neurological, not mitochondrial, symptoms,
however defined, were manifested pre-vaccination, then Karl’s case involves a
significant-aggravation claim.” This statement directs an examination of Karl’s
health before vaccination, looking for evidence of “neurological, not
mitochondrial, symptoms.”8

mitochondrial disorder.”). Thus, this decision will continue to use the parties’
characterization of Karl’s injury as one of “neurodegeneration.”
      8
        The Court’s phrase “neurological, not mitochondrial, symptoms, however
defined” seems to distinguish neurological symptoms from mitochondrial
symptoms. See orders, filed July 20, 2012 and July 30, 2012 (requesting
supplemental briefs on this topic).
      The Secretary stated that differentiating between neurological symptoms and
mitochondrial symptoms “is contrary to the medical understanding of
mitochondrial disorders, as well as contrary to the testimony of both parties’
experts.” According to this argument, “one cannot separate ‘mitochondrial
symptoms’ from the symptoms related to the mitochondrial disorder-affected
organs, including the central nervous system.” Resp’t Br., filed Aug. 21, 2012,
at 3.
      The undersigned cannot entertain the Secretary’s argument. The Court’s
Opinion and Order has presented the issue as whether “Karl’s neurological . . .
symptoms . . . were manifested pre-vaccination, then Karl’s case involves a
                                                                     (. . . continued)
                                         12
       The Court’s framing of the issue, however, is not how the parties presented
their cases before the remand. Consequently, there is relatively little evidence
directly responsive to the Court’s issue. From a transcript that runs more than 800
pages, each party identified only one passage in which an expert opines whether
Karl was displaying neurological symptoms before vaccination.

      The Secretary points to the following portion of cross-examination
testimony as evidence in which Dr. Snodgrass opined about Karl’s pre-vaccination
neurological problems:

             Q: . . . And in fact I believe you testified that his developmental
      delay began sometime in the fall of 2004. That would be – the
      neurologic system is a system of the body, correct?
             A: It is.
             Q: And the fact that he had developmental delay would indicate
      that he has some type of involvement of his neurologic symptoms – or
      his neurologic system.
             A: His nervous system is abnormal, we can all agree on that.
                                          ***
             Q: Well, he also has his muscle – musculoskeletal system
      involved, does he not?
             A: I believe that is secondary to the central nervous system
      problem.

Tr. 416:10 to 417:22 (cited in Resp’t Br., filed Aug. 21, 2012, at 3-4).

        In contrast, the Palucks cited to this excerpt from Dr. Frye’s testimony.
With reference to the K.I.D.S. evaluation of Karl in October 2004, Dr. Frye
testified:

             A: . . . And the Vineland was used to look at his overall
      development, it can be used as an IQ, and we see that he actually was
      absolutely normal on the Vineland also without any delays. So really
      this points to the specific delays in gross motor, probably due to
      problems with muscle development, and the energy that the muscle
      needs, because of his mitochondrial disorder.

significant aggravation claim. . . . If not, then Karl’s case involves a new-injury
claim.” This instruction is binding on remand. See Hanlon, 40 Fed. Cl. at 630.

                                          13
Tr. 636:5-12 (cited in Pet’r Br., filed Aug. 28, 2012, at 3, and Pet’r Status Rep’t,
filed Sept. 4, 2012, at 1).

        In sum, the basic dispute over whether Karl had symptoms of a neurological
problem before vaccination is captured in those two passages. Dr. Snodgrass
testified the Karl’s gross motor delays identified in the fall of 2004 were
“secondary to the central nervous system problem.” Tr. 417:21-22. Dr. Frye’s
different view is that the gross motor delays were because of a problem “with
muscle development, and the energy that the muscle needs, because of his
mitochondrial disorder.” Tr. 636:10-12.

       These are the only passages in which the experts touch upon whether Karl
displayed signs or symptoms of a disorder in his central nervous system before the
vaccinations, although the record contains other relevant evidence, discussed
below. After the parties filed briefs that were intended to identify evidence
supporting their position regarding the onset of Karl’s neurological problems, a
status conference was held. The parties were informed that the quantum of
evidence on this particular topic was relatively sparse. Thus, consistent with the
Court’s statement that the case was “remanded to the special master for further
proceedings,” the parties were invited to consider whether they wished to present
additional evidence. Both parties declined. The Palucks stated “It would be a
waste of resources in both time and money for this Court to open the record in the
matter to receive additional evidence on mitochondrial disorders. . . . There is more
than sufficient testimony and medical literature as a matter of record to permit this
court to make a determination if this is a cause-in-fact injury case or significant
aggravation injury case.” Pet’r Br., filed Aug. 28, 2012, at 7.

        As explained in the September 11, 2012 status conference, special masters
may decide an issue even when there is relatively little evidence (or even no
evidence) on the topic. King v. Sec’y of Health & Human Servs., No. 03-584V,
2008 WL 1994968, at *3 (Fed. Cl. Spec. Mstr. Feb. 7, 2008) (special masters “can
always rule on a factual issue no matter how scanty the evidence is, even in the
absence of any evidence. . . if there is no evidence, the factual issue simply is
resolved against the party having the ‘burden of proof’”). The special master’s
responsibility is to make findings of fact based upon the evidence and weighing
that evidence. The evidence of record need only preponderate in one party’s favor.
It is not necessary for a party to submit a certain quantum of evidence to prevail.
Under the preponderance of evidence standard, it is enough that the special master,
as trier of fact, simply “‘believe that the existence of a fact is more probable than
its nonexistence before [he] may find in favor of the party who has the burden to
                                          14
persuade the [judge] of the fact’s existence.’” Moberly v. Sec’y of Health &
Human Servs., 592 F.3d 1315, 1322 n.2 (Fed. Cir. 2010) (quoting Concrete Pipe &
Prods. of Cal., Inc. v. Constr. Laborers Pension Trust for S. Cal., 508 U.S. 602,
622, 113 S.Ct. 2264, 124 L.Ed.2d 539 (1993)) (alterations in Moberly, further
citations omitted).

       Here, the evidence preponderates in the Secretary’s favor. Before
explaining why it is more probable that Karl displayed problems in his central
nervous system before the January 2005 vaccinations, the undersigned must
acknowledge that the Palucks could be correct. It is certainly possible that Karl’s
problem in gross motor skills was purely a problem in his muscles and not at all in
his CNS. Based on this record, no one can say for sure. But, even in the absence
of certainty, the evidence must preponderate one way or the other–either Karl’s
gross motor problems originated with his CNS or they did not.9

      Three reasons support a finding that Karl was manifesting problems with his
CNS before 2005. First, indisputably, Karl was displaying poor muscle tone. The
connection between CNS and muscle tone appears not to be particularly
controversial, as Dr. Frye testified, in the context of explaining what tone is, “[t]he
nervous system helps maintain tone.” Tr. 111:19-2010; see also Tr. 109:6-7 (Dr.


      9
         The outcome of this issue does not depend on how the burden of proof is
allocated. The burden of proof determines which party prevails when the evidence
is in equipoise. See Andrew Corp. v. Gabriel Electronics, Inc., 847 F.2d 819, 824
(Fed. Cir. 1988); Cook v. United States, 46 Fed. Cl. 110, 113 n.5 (2000); see also
Director, OWCP v. Greenwich Collieries, 512 U.S. 267, 272-76 (1994) (discussing
difference between burden of persuasion and burden of producing evidence).
Here, the evidence is not in equipoise. The evidence preponderates in favor of the
Secretary’s position.
      10
         At this point in his testimony, Dr. Frye had been asked to explain the
significance of “truncal hypotonia,” a symptom that a neurologist detected in Karl
in April 2005, months after the vaccination. Dr. Frye stated that truncal hypotonia
“is suggesting that we have brain damage that is going on, or it also could be
muscular damage, too. . . . It would be more damage to the nervous system.” Tr.
111:16-20.
       Given this context, Dr. Frye’s testimony that “[t]he nervous system helps
maintain tone” is viewed as supporting the limited proposition that problems in
                                                                      (. . . continued)
                                          15
Frye: “with increased tone, you think that there’s damage to the cortex of the brain
or the white matter”).

      Dr. Frye’s acknowledgement of a connection between low muscle tone and
dysfunction in the CNS tends to make it more likely that Karl’s tone was due to a
CNS disease. But, this general likelihood is not the only reason for finding that
Karl exhibited neurological symptoms before his January 2005 vaccinations.

      The second reason supporting a finding that Karl was displaying problems
originating in his central nervous system in the fall 2004 was that Karl was having
trouble with functions other than just his gross motor skills. According to the
K.I.D.S. report that assessed Karl’s functioning, Karl had a problem with his
expressive language. Exhibit 15 at 2-3.

      While the Palucks steadfastly argue that before the January 2005
vaccinations, Karl “had normal central nervous system functioning,” Pet. Br., filed
Aug. 28, 2012, at 7, this argument is not persuasive. The Palucks are overlooking
the portion of the K.I.D.S. report that recommended Karl should receive
developmental services “targeting his speech/language.” Exhibit 15 at 5.11

       A problem in expressive language tends, at least in the absence of other
identified causes, to be considered a CNS problem.12 Dr. Snodgrass’s testimony

tone sometimes originate in the nervous system. Tr. 111:19-20. Dr. Frye did not
say all problems in muscle tone come from the nervous system.
      11
         When questioned about this referral, Dr. Frye stated that the K.I.D.S.
evaluators’ referral for speech therapy was “probably [a] more protective
prophylactic measure[].” Tr. 722:14-15. However, there is no evidence—other
than Dr. Frye’s opinion—to support the assertion that the K.I.D.S. evaluators were
not proposing a therapy intended to help Karl. The recommendation that Karl
receive speech therapy is in line with his performance on the PLS-3 and Vineland,
showing that Karl was 22 percent delayed in communication skills. A more
detailed discussion of Karl’s expressive language in October 2004 is found in
section IV.A.2 below.
      12
        In one unrecorded status conference, the Palucks’ attorney suggested that
Karl may have had a problem with his expressive language because he could have
had a misshapen tongue. The Palucks have not offered this explanation in any of
                                                                    (. . . continued)
                                       16
alludes to this connection between expressive language and CNS. On direct
examination, Dr. Snodgrass testified that prior to Karl’s vaccination – in
September and October of 2004 – his “development was abnormal in speech and
language and both gross and fine motor function were impaired.” Tr. 328:5-6. On
cross examination, Dr. Snodgrass testified that Karl’s “nervous system is
abnormal” and that his pre-vaccination developmental delays indicated the
involvement of his neurologic systems. Tr. 416:15-19.

       Again, it should be pointed out that, as a matter of logic, it is possible that
(a) Karl had gross motor delays exclusively because the mitochondria in his
muscles (and only in his muscles) were not functioning, and (b) Karl had delays in
his expressive language for unidentified reasons unrelated to his CNS.
Conceivably, there could be two (or more) unrelated processes preventing Karl
from developing normally in the domains of gross motor and express language.
However, the question is what is more likely? It seems much more likely that
Karl’s mitochondrial defect was already starting to affect his central nervous
system before the January 2005 vaccinations. Mitochondrial defects can impair
the functioning of organs with a high need for energy, such as the central nervous
system. Exhibit E (Haas) at 1327.

        Finally, and least importantly, the Palucks and Dr. Frye made evidentiary
admissions that are consistent with a finding that Karl’s case is one for significant
aggravation. For example, the Palucks’ October 17, 2008 Amended Petition stated
that they allege that the “vaccines given on January 19, 2005 caused a significant
aggravation of Karl’s underlying mitochondrial disorder, leading to alterations in
his brain development and subsequent neurodevelopmental regression.” Amended
Pet., filed Oct. 17, 2008, at 2. The Secretary’s post-remand brief specifically cited
this pleading, Resp’t Resp., filed June 8, 2012, at 4-5, and the Palucks have not
explained why they should not be held to their attorney’s statements. See Pet’r Br.,
filed Aug. 28, 2012.

       Similarly, the Secretary cited a portion of Dr. Frye’s testimony that supports
the Secretary’s view that Karl’s case is one of significant aggravation. Dr. Frye
stated: “I believe that [it] is more likely than not that the vaccines received on
January 19, 2005, significantly changed the course of Karl’s development by

their written briefs and the Palucks have not identified any evidence that supports a
finding that Karl’s developmental delay in regard to expressive language was
based upon a structural problem.

                                          17
significantly exacerbating an underl[y]ing mitochondrial disorder.” Resp’t Br.,
filed Aug. 21, 2012, at 2 (citing Tr. 53:9-12).13

       Dr. Frye’s use of the term “significantly exacerbating” in his testimony and
the Palucks’ use of the term “significant aggravation” in their amended petition
further support a finding that Karl’s case should be characterized as one of
significant aggravation, although these comments are not dispositive by
themselves. In the Vaccine Program, special masters typically do not strictly hold
petitioners to their pleading.14 Similarly, not too much weight is given to Dr.
Frye’s isolated statement referring to “significantly exacerbating.” On the other
hand, to the extent that the amended petition and Dr. Frye’s testimony have
relevance, they weigh, slightly, on the side of significant aggravation.

      For these reasons, the preponderant weight of the evidence favors finding
that Karl was displaying neurological problems before vaccination.15 Thus,
according to the structure set by the Court’s Opinion and Order, Karl’s case is
properly analyzed as presenting a claim for significant aggravation.


      13
         In the same paragraph of the Secretary’s brief, she cites other portions of
Dr. Frye’s testimony for the proposition that “Dr. Frye often characterized Karl’s
post-January 2005 condition in terms that suggested a connection to all his
symptoms.” Resp’t Br., filed Aug. 21, 2012, at 2. However, in the cited portions
of Dr. Frye’s testimony, he seems to be comparing Karl’s condition in April or
June 2005 to Karl’s condition in January 2005, not Karl’s condition in October
2004.
      14
          In traditional litigation, parties are bound by their pleadings. See, e.g.,
Best Canvas Prods. & Supplies, Inc. v. Ploof Truck Lines, Inc., 713 F.2d 618, 621
(11th Cir. 1983) (stating that as a general rule “a party is bound by the admissions
in his pleadings”) (citations omitted).
      15
         The undersigned has also considered the relative experience of Dr. Frye
and Dr. Snodgrass. Both have some experience with mitochondrial disorders, but
neither has extensive experience. For Dr. Frye’s background in mitochondrial
disorders, see Tr. 42:25 to 46:20, 210:16 to 213:2. For Dr. Snodgrass’s experience,
see Tr. 250:11-14, 396:4 to 400:12, 495:2-4, 554:13-55:7. Thus, this factor does
not contribute to accepting or to rejecting either Dr. Frye’s opinion or Dr.
Snodgrass’s opinion.

                                         18
IV.   Significant Aggravation

        The elements of an off-Table significant aggravation case were stated in
Loving v. Secretary of Health & Human Servs., 86 Fed. Cl. 135 (2009).16 There,
the Court blended the Althen test, which defines off-Table causation cases, with a
test from Whitecotton, which concerns on-Table significant aggravation cases.
The resultant test has six components. These are:

      (1) the person’s condition prior to administration of the vaccine, (2)
      the person’s current condition (or the condition following the
      vaccination if that is also pertinent), (3) whether the person’s current
      condition constitutes a ‘significant aggravation’ of the person’s
      condition prior to vaccination, (4) a medical theory causally
      connecting such a significant worsened condition to the vaccination,
      (5) a logical sequence of cause and effect showing that the vaccination
      was the reason for the significant aggravation, and (6) a showing of a
      proximate temporal relationship between the vaccination and the
      significant aggravation.

Loving, 86 Fed. Cl. at 144; see also Opinion and Order, 104 Fed. Cl. at 468, n.14
(citing and quoting the Loving test).

       Since Loving was decided, the Federal Circuit has explained that possible
alternative causes may be considered as part of a petitioner’s prima facie case. See
Stone v. Secretary of Health & Human Servs., 676 F.3d 1373, 1380 (Fed. Cir.
2012). To maintain clarity in parts of the analysis, the possibility of alternative
causes is set out in a separate section below. See section V.

       Of the six parts to the Loving test, the December 14, 2011 decision
addressed factors four through six because those elements overlap with the Althen
test. Although the Court accepted this method of analysis, the Court vacated the
decision with respect to each of the Althen elements. The Court’s analysis of
factors four through six is discussed extensively in the context of the particular
element. However, factors one through three have not been specifically analyzed


      16
        After remand, the Federal Circuit approved the Loving six-prong test as
accurately setting forth the elements of petitioners’ case. W.C. v. Sec’y of Health
& Human Servs., 704 F.3d 1352, 1357 (Fed. Cir. 2013).

                                         19
in either the December 14, 2011 decision or the Court’s Opinion and Order. Hence
Loving factors one through three begin the analysis.
      A.  Loving Prong 1: What was Karl’s Condition Prior to
      Administration of the Vaccine?

      The first step in the Loving test is to define Karl’s condition before he
received the vaccinations at issue. An overarching problem is that Karl was born
with a mitochondrial defect, although the doctors treating Karl before the
vaccinations did not know of this defect.

       The parties agree that Karl’s mitochondrial defect was affecting his
development before vaccination. The Palucks maintain that the mitochondrial
defect was isolated to Karl’s muscles and this mitochondrial defect caused Karl to
have delays in his gross motor development that was recognized in October 2004.
See Pet’r Br., filed Aug. 28, 2012, at 3 (“Dr. Frye explained that the delays noted
in this October 2004 evaluation [referring to the K.I.D.S. assessment] were
secondary to problems with Karl’s muscle development and energy needs because
of his undiagnosed medical disorder.”). Thus, the Palucks recognized that the
mitochondrial disorder was impairing Karl’s health, but disputed linking the
mitochondrial disorder to Karl’s CNS.

      The Secretary agreed that Karl’s mitochondrial disorder was already being
manifested in the fall 2004. Resp’t Br., filed Aug. 21, 2012, at 1 (“Karl’s
mitochondrial symptoms, including neurological symptoms, manifested before his
receipt of his January 2005 vaccinations.”). As discussed in the preceding section,
a preponderance of evidence supports the finding that the mitochondrial problem
impaired the functioning of Karl’s CNS.

      To determine the state of Karl’s condition prior to vaccination, it is
necessary to examine his medical records and the experts’ testimony on various
aspects of his health and development. The following sections discuss his illnesses
and immunologic responses, expressive language skills, and the extent of his gross
motor problems. On the second and third topics, the experts have some
disagreements.

            1.     Illnesses and Karl’s Immunologic Responses

      As the Court stated “[d]uring this same time period [before vaccination],
Karl began manifesting two medical problems that would appear repeatedly from

                                        20
October 2004 to July 2005: otitis media and erythema multiforme.” Opinion and
Order, 104 Fed. Cl. at 462 (footnotes deleted without notation). Exhibit 3 at 38,
57-62. The erythema multiforme indicates that Karl’s immune system was
activated. Tr. 98:8-12, 295:2-14.

      On October 14, 2004, Karl was examined by Dr. Amy E. Oksa, who
recorded an impression of bilateral otitis media, viral exanthema, and left
conjunctivitis. Dr. Oksa prescribed Amoxicillin for the ear infection, Gentamicin
ophthalmic solution for the conjunctivitis, but no specific treatment for the rash.
The Palucks were encouraged to return to the clinic in “two to three weeks for
recheck [of the rash] and sooner if needed.” Exhibit 3 at 57.

       On November 8, 2004, Karl was seen by Dr. Donna J. Mumert at the
Dickinson Clinic. The physician reported that Karl “has a history of otitis media.
Mom states that she’s not sure that he’s getting better and would like to have his
ears rechecked.” Karl’s mother also reported that he had been “fussy over the past
couple of days.” Dr. Mumert recorded an impression of left otitis media and
prescribed Zithromax to be administered daily for five days. She recommended
that Karl be rechecked in one week or sooner. Exhibit 3 at 58.

      On November 15, 2004, Karl returned to the Dickinson Clinic and was
examined by Dr. Oksa, who recorded that Karl presented for an ear recheck,
having “had bilateral otitis media initially treated with amoxicillin one month ago
and then treated with Zithromax one week ago. He currently seems to be doing
well.” Ms. Paluck also recounted that Karl “still has been fussy and irritable.” Dr.
Oksa’s impression was that the otitis media had resolved. Under “Plan,” the report
notes “Flu shot today.” Exhibit 3 at 59.

      On December 4, 2004, Karl visited the Dickinson Clinic for a recheck and
was examined by Dr. Mumert. The report states that Karl

      was on Zithromax two weeks ago for an ear infection. He did have an
      ear recheck following this. His ears were clear. However, mom states
      he has been fussy over the past couple of days. . . . Mom states that for
      the last week he has been irritable and not his usual self. He has not
      had any fevers. No diarrhea. He is otherwise healthy and well.

Exhibit 3 at 60. After examining Karl, Dr. Mumert recorded an impression of
bilateral otitis media. She also noted that Karl’s skin was “[n]ormal with no

                                         21
exanthem.” Id. She prescribed Omnicef for 10 days and recommended that Karl
be rechecked in two weeks or sooner. Id.

       Karl returned two weeks later, on December 11, 2004, to be examined by
Dr. Oksa. In her report, Dr. Oksa wrote that “Karl presents today for evaluation of
skin lesions on his arms and legs. Patient has had these for greater than one week.
Of note, he had a similar type rash October 14, 2004, when evaluated for bilateral
otitis media and conjunctivitis.” Exhibit 3 at 61. Dr. Oksa continued:

      Mother states that this rash went away, but developed again about a
      week ago. . . . The fussiness was better, but now has worsened over
      the last couple of days. He also developed a very slight papular rash
      on trunk earlier this week, but it was much different than the
      extremity rash and has pretty much gone away. It was not urticarial.
      Mother could barely perceive it. It had been noticed by the day care
      provider. The Omnicef was stopped . . . three days ago, secondary to
      more of the rashes.

Id. Dr. Oksa’s examination revealed “several 0.5 to 1.0 centimeter areas of
erythema which are slightly raised, but nontender. These are present mostly
on the distal extremities, but there are also a couple of lesions on the
proximal upper extremities.” Id. She observed that “[s]ome are more
purplish in appearance. No petechiae or purura noted.” Id. Dr. Oksa
recorded an impression of “[r]esolved otitis media” and “[p]robable
erythema multiforme secondary to viral illness.” She prescribed Orapred
and recommended a return to the clinic if the symptom persisted or
worsened. Id.

       On December 22, 2004, Karl presented at the Dickinson Clinic for a recheck
of his rash. Dr. Oksa recorded that Karl’s “[m]other states that the spots almost
totally resolved. The only lesions that were left were slightly bluish resolving
lesions. After the Orapred was finished the red spots came back and now . . . are
worse than . . . before.” Exhibit 3 at 62. Dr. Oksa reported “[a]pproximately 1.0
centimeter erythematous, slightly raised vesicular lesions on extremities, more on
the distal lower extremities than proximal and mostly on the distal upper
extremities. The rest of the skin is spared.” Id. Her impression was a recurrent,
nonspecific rash. Dr. Oksa’s plan was to “discuss patient with Dr. Cornatzer,
Dermatology, and proceed with whatever recommendations he has.” Id.


                                        22
      The Palucks brought Karl to Dr. Cornatzer, a dermatologist, on December
27, 2004. Dr. Cornatzer obtained a biopsy from Karl’s left arm. The results of the
biopsy were consistent with the diagnosis of erythema multiforme. See exhibit 9 at
1-3.

       Karl’s erythema multiforme presents a potential alternative cause for Karl’s
neurodegeneration (as the Palucks have defined Karl’s neurodegeneration).
Although Dr. Frye acknowledged that Karl suffered from erythema multiforme
before vaccination, this condition did not affect Dr. Frye’s opinion. See Tr. 626:19
to 628:6 (redirect). However, Dr. Snodgrass questioned the consistency of Dr.
Frye’s position. Dr. Snodgrass queried if Dr. Frye were correct that Karl’s
neurodegeneration started when Karl’s immune system was activated, why didn’t
the erythema multiforme start that process? In Dr. Snodgrass’s view, if Dr. Frye
were correct on his theory, the erythema multiforme (and not the vaccinations)
could have caused the aggravation. See Tr. 357:16 to 358:17 (direct examination);
see also Tr. 443:16-19 (cross examination). Resolution of this question is not
necessary because, as explained below, Karl did not significantly decline in the
weeks immediately following January 19, 2005, when he both received a set of
vaccinations and suffered another bout of erythema multiforme.

            2.     Expressive Language

      One point of departure between the experts regarding Karl’s pre-vaccination
condition is his expressive language. The primary source of information about
Karl’s ability to use language is the K.I.D.S. evaluation in October 2004.17 Karl’s
language was evaluated using three tests, the Bayley Scales of Infant Development
2nd Edition, the Preschool Language Scale-3 (“PLS-3”), and the Vineland
Adaptive Behavior Scales. Exhibit 15 at 2.

      Bayley. On this test, Karl’s “MDI” was 91.18 An MDI score of 91 is the
age equivalent of eight months. Since Karl was a few days past nine months old at

      17
         Dr. McDonough’s January 19, 2005 evaluation adds additional
information about Karl’s language. This report is discussed in the following
section.
      18
        In this context, “MDI” probably means “mental development index.”
Medical Abbreviations (15th ed. 2011) at 204.


                                        23
the time of the evaluation, this represented a delay of 11 percent. Nevertheless, he
was classified as “Within Normal Limits.” Exhibit 15 at 2.

      Vineland. In the “Communication Domain” of the “Adaptive Behavior
Composite” for the Vineland, Karl’s standard score was 94. This placed Karl in
the 34th percentile with an age equivalency of 7 months. The amount of his delay
in communication was 22 percent. Exhibit 15 at 3.

       PLS-3. Karl’s performance on the Vineland’s Communication Domain was
quite similar to his score on another standardized test the K.I.D.S. evaluators gave
to him, the Preschool Language Scale-3. “The PLS-3 evaluated Karl’s ability to
use language (language expression) and understand language (auditory
comprehension).” Exhibit 15 at 2. For “Expressive Communication,” Karl’s
standard score was 101, which placed him in the 53rd percentile. His age
equivalent was “7 months,” again making him 22 percent delayed. Id. at 3. Dr.
Snodgrass briefly addressed the PLS-3, agreeing with petitioners’ counsel that it
placed Karl at the seven month level. Tr. 459:20 to 460:1.

      In Dr. Frye’s opinion, Karl’s “language was right at the average.” Tr. 100:5.
Dr. Frye based his opinion on the PLS-3. Dr. Frye stated that Karl’s “total
language standardized score was 96. The average is 100, but 96 is very close to
100 on these scales, and so he was very close to normal as far as his language.” Tr.
100:5-8.

      In this context, Dr. Frye also discussed the result of Karl’s performance on
the Vineland Adaptive Behavior Scales. Dr. Frye stated, “As far as what normal
development would be considered, that his delays were most prominently gross
motor delays, maybe a little bit of fine motor delays, but cognition, language was
absolutely normal.” Tr. 101:8-11; see also exhibit 15 at 3 (reporting results of
Vineland).

       Additionally, Dr. Frye testified that he viewed the PLS-3 as unnecessary
because Karl passed the Denver II test19 at one year of age. Dr. Frye explained that
the Denver test “is a screening test . . . to tell you to go for more specific tools such
as the PLS or the PDMS. And really more specific tools like [these] shouldn’t
really necessarily be used unless you fail some screening tests.” In this case Karl

      19
         See sub-section IV.A.3.b., below, for a description of the Denver II and
Karl’s results on the test.

                                           24
“actually passed the Denver[,]” which “suggests that he doesn’t need any of those
tests at one year of age.” Tr. 822:17 to 823:4.

      When asked whether Dr. Frye was correct in assessing Karl as “right at the
average” in his language, Dr. Snodgrass said that Dr. Frye was not correct. Dr.
Snodgrass explained why he thinks that Karl’s language was not at the average.
Dr. Snodgrass testified that

      the evaluation included a number of things and it included the fact that
      Karl did not seem to respond to ‘no’. Now no is a pretty elementary
      communication. And he did not mime or copy sounds made by
      others. Before we can speak normally, small babies will make noises
      similar to a noise which their caretaker is making.

Tr. 329:5-12. Dr. Snodgrass did acknowledge that Karl scored within
normal limits on the Bayley test. Tr. 459:16-19.

       When Dr. Snodgrass was asked whether Dr. Frye’s statement from transcript
page 101 that “cognition language was absolutely normal” was true, Dr. Snodgrass
said, “I think if we refer to Exhibit 15 we’d have to say no that’s not correct.” Tr.
329:16-17.

      During redirect, Dr. Frye essentially repeated his opinion that the October
2004 K.I.D.S. evaluation showed that Karl’s “language was completely normal.”
Tr. 636:1-2. Dr. Frye also stated that “he actually was absolutely normal on the
Vineland also without any delays.” Tr. 636:7-8. The Palucks’ attorney did not ask
Dr. Frye to address Dr. Snodgrass’s testimony on page 329 of the transcript.

       The undersigned, however, requested that Dr. Frye address the difference in
his opinion expressed on page 99 of the transcript and Dr. Snodgrass’s opinion
from page 329. Dr. Frye was referred to four skills relating to language that the
K.I.D.S. evaluators said that Karl could not perform. Dr. Frye was told that Dr.
Snodgrass pointed to some of these deficiencies as supporting Dr. Snodgrass’s
opinion that Karl was delayed in language. Dr. Frye responded: “But I don’t think
that’s correct because . . . the objective standardized test put him absolutely in the
average range.” Tr. 722:9-11.

      Dr. Frye also questioned the consistency of the K.I.D.S. evaluation. Dr.
Frye noted that one of Karl’s listed weaknesses was not communicating with

                                         25
gestures. However, one of Karl’s identified strengths was “gestur[ing] for ‘I
want.’” See Tr. 723:9-25; see also exhibit 15 at 3, 5.

       There was a brief rejoinder from Dr. Snodgrass when he testified later that
day. Dr. Snodgrass stated that “things like not responding to no no was significant,
it was more than just a minor trivial thing.” Tr. 787:11-13.

       When the K.I.D.S. evaluators identified problems with Karl’s gross motor
skills and expressive language, they referred him for therapy “targeting his
speech/language, gross motor, and the delays in fine motor related to low muscle
tone.” Exhibit 15 at 5. If the Palucks accepted this referral for treatment, then the
notes are not contained within exhibit 15.

      While the Palucks argue that Karl’s language development was normal, as
measured by the various tests performed in October 2004, it seems unlikely that
the evaluators would have referred Karl to therapy targeting his speech and
language if this were the case. Accordingly, the preponderant weight of the
evidence favors finding that Karl’s language development was delayed prior to his
vaccination.

             3.    Extent of Gross Motor Problems before Vaccination

      Another area of difference between Dr. Frye and Dr. Snodgrass concerns
Karl’s physical function on the day he received his vaccinations, January 19, 2005.
In short, Dr. Frye saw Karl as relatively well, except for some motor delay. In
contrast, Dr. Snodgrass’s viewed Karl as worsening.

       Dr. Snodgrass’s opinion rests upon Dr. McDonough’s records from
appointments on December 27, 2004, and January 19, 2005. Thus, those two notes
are detailed below. Following those summaries, the competing perspectives of the
experts are set forth.
                   a)     Developmental Status on December 27, 2004

      During the appointment during which Dr. Cornatzer biopsied Karl’s rash,
Dr. Cornatzer recommended that Dr. McDonough see Karl because Karl had been
pulling on his ears. See exhibit 3 at 5. This was on December 27, 2004, 23 days
before the date of vaccination. See exhibit 23 at 7-8. Dr. McDonough recorded a
developmental history that “Karl is rolling over. He tries to crawl, he has several
words that he says.” In Dr. McDonough’s assessment of Karl’s neurologic system,

                                         26
he records the following good traits about Karl: “normal muscle tone. There is no
ankle clonus. Deep tendon reflexes appear to be symmetrical. He has good head
control and fairly good truncal control.” On the other hand, Dr. McDonough also
states Karl “is not pulling himself to stand or crawling yet.” Dr. McDonough
assessed Karl as having “possible mild gross motor delay,” but did not refer Karl
for therapy or otherwise mention whether Karl was receiving services through the
K.I.D.S. program. Dr. McDonough intended to check Karl at his next visit in one
month. Exhibit 3 at 5-6.
                   b)     Developmental Status on January 19, 2005

       The next appointment, a well-baby visit to assess Karl at one year of age,
occurred on January 19, 2005. In the history of present illness section, there is a
notation that Karl is not standing. The HPI section also states “recheck rash.”
Exhibit 5 at 62.

       For the “Growth & Development” section, there is a circle around “Roll
Over” and “Babbles,” skills associated with a six month old. Next to the words
“Sit well” and “Pull to Stand,” abilities associated with an eight month old, is the
hand-written notation “not.” For nine months category, the form lists “Crawl”
“Wave bye” “Dada-Mama.” Of these three, only “Crawl” is circled with
handwriting saying “4 point.” For the 11-12 months category, the form lists
“Cruise / Roll Ball,” “Use cup / Pincer” and “1-3 words.” None of these items is
circled. Beside the “Use cup / Pincer” skill is handwriting noting “not yet.” An
additional handwritten note in another portion of the form states “doesn’t hold cup
well.” Handwriting next to “1-3 words” is difficult to decipher, but appears to say
“no words.” Exhibit 5 at 62.

       Another assessment of Karl’s abilities is presented on a Denver II
(“Denver”) screening form. Exhibit 5 at 35. (The Palucks and Dr. Frye filed a
blank Denver screening form to assist in understanding the typical development,
because Karl’s form is faded, making it difficult to read. See exhibit 38.) The
Denver evaluates four different domains (personal/social, fine motor adaptive,
language, and gross motor), which are distributed along the screening form’s
vertical axis. Across the form’s horizontal axis, top and bottom, are marks
designating the age of the child, from birth to 6 years of age. During an evaluation,
the evaluator aligns a ruler with the marks printed on the top and bottom of the
form corresponding to the child’s age and draws a vertical line through the form.
This line intersects with specified age-appropriate skills printed on the form in
each of the four domains. Dr. Frye explained how the form is used.

                                         27
      If you look in the upper left hand corner you see what seems to be a
      scale, it says percentage of children passing and it goes from 25 to 50
      to 75 to 90. . . .
             This is important because as long as this line that’s drawn . . . is
      within that shaded bar we know that it’s within normal limits. . . .
      [T]he way we use the Denver . . . we go through the four different
      areas, that is personal/social, fine motor adaptive, language, and gross
      motor, and we ask whether a child can do these skills or can’t do these
      skills. And if th[e] line that we’ve drawn is outside one of those
      boxes and the child can’t do that [skill], we get concerned.
             . . . the way we notate this usually is if the child can do an
      activity we put P for pass, if they can’t we put F for fail. . . .
                                           ***
             . . . if their chronological age passes through that box that
      means they should have developed or be developing that skill. It’s not
      until their chronological age actually passes the box that you say that
      they should have done it and they’re not or that they’ve actually failed
      that developmental milestone.

Tr. 631:10 to 633:22.20

       Within the personal - social domain, Dr. McDonough assigned Karl three
“P’s” (for passing) and two “F’s” (for failing). The passing abilities were “initiate
activities,” “play ball with examiner,” and “indicate wants.” The failing skills
were “wave bye-bye” and “play pat a cake.” For both these activities, more than
75 percent of children can do them by 12 months. On the other hand, “initiate
activities” and “play ball with examiner” seem to be activities performed by less
than 75 percent of children.

       Within the domain of “fine motor - adaptive,” there is one “P” that is near
two different skills, “bang 2 cubes held by hands” and “thumb finger grasp.” Both
of these activities can be accomplished by 99 percent of children at 11 months.

      The next domain is “language.” Dr. McDonough has an “F” for “one word”
and a “P” for “dada-mama specific.” The “dada-mama specific” skill is something

      20
        Dr. Snodgrass did not disagree with Dr. Frye’s explanation. See Tr.
799:11-17 (“Well I think he is reiterating what the developers of the Denver would
say.”).

                                          28
approximately 75 percent of children can accomplish by approximately 11 months.
For the “one word” skill, about 50 percent of children can do this by 12 months,
with 75 percent of children speaking one word at 14 months.21

       The final domain is “gross motor.” There are two “P’s” for “stand holding
on” and “pull to stand.” Approximately 75 percent of children can pull to stand at
approximately 9 months and approximately 99 percent can pull to stand at
approximately 10 months. Karl’s form also has three “F’s” in gross motor. Of
these three skills that Karl was not displaying, the most basic step is “get to
sitting.” The normal values for “get to sitting” is about the same as “pull to stand,”
with about 75 percent of children getting to sitting at nine months and 99 percent
getting to sitting at 10 and 1/2 months. The other two skills in the gross motor
domain marked with F’s are “stand 2 secs,” and “stand alone.” There was no mark
for two skills that fewer than 50 percent of children can do at 12 months: “stoop
and recover” and “walk well.”

       There are some slight inconsistencies in the recording of Karl’s abilities
between the two forms. For example, on the form from Dr. McDonough’s office,
the entry for “Dada-Mama” around 9-10 months is not circled. Exhibit 3 at 3. Yet,
on the Denver form, Karl got a “P” for “dada-mama specific.” Similarly, Dr.
McDonough did not circle, but wrote the word “not” next to “Pull to stand” under
7-8 months, whereas there is a P on the Denver form next to “pull to stand.”

      Dr. McDonough’s office form also has a section in which the pediatrician
can report the results of a physical examination. Most systems were “WNL”
(within normal limits). There are two exceptions. First, the entry for “Hips” is
checked WNL, but there is a handwritten notation saying “got [illegible] ↓ROM.”
See Tr. 825:9-19, 829:12 to 831:6, 331:6 (interpreting notation to indicate a
decreased range of motion). Second, the entry for “Neuromuscular” is checked as
ABN (abnormal). The handwriting says “muscle tone ↑+ upper.” The entry
appears to continue on the next line, saying “lower extremities.” A third line reads
“2 Beats clonus R [illegible]. A fourth line reads, perhaps, “inconsistent.”

      Dr. McDonough’s assessment includes “gross motor delay” and “recurrent
erythema multiforme.” The plan was an “early development referral [to]
Dickinson.” The Dickinson Clinic offered “> [greater] available PT OT [physical

      21
        Dr. Frye explained that doctors usually do not count a child’s speaking
“dada” or “mama” as a spoken word. Tr. 748:4-13.

                                         29
therapy and occupational therapy] services.”22 Dr. McDonough also prescribed
Zithromax. He wanted Karl to return in 3 months. Exhibit 3 at 3.
                   c)     Testimony

       The testifying experts came to different conclusions about Karl’s functioning
as of January 19, 2005. Dr. Frye’s initial direct testimony discussed Karl’s status
on the date of vaccination relatively cursorily. The extent of the dialog between
the Palucks’ attorney and Dr. Frye was:

             Q: Then if we move to January of 2005 at his 12-month and
      four days past his 12-month birthday, he received the MMR, PCV7,
      and Varicella. At that evaluation for those – and at the receipt of
      those vaccines, his pediatrician did note that he was going to refer
      Karl for possible, again, motor delay.[23]
             A: Right.
             Q: And specifically those gross motor delays were as you were
      just describing. He wasn’t able to sit totally unsupported, and he was
      not yet crawling or pulling himself to a stand.
             A: Exactly.

Tr. 102:16 to 103:4. At this point, the Palucks’ attorney begins questioning Dr.
Frye about Karl’s fevers following the vaccinations.

      In Dr. Snodgrass’s preliminary24 direct testimony, he also briefly discussed
Karl’s status in January 2005. Dr. Snodgrass stated that Karl worsened between

      22
         In a later record, Dr. McDonough specified that on January 19, 2005, he
referred Karl for “physical and occupational therapy in Dickinson” and
recommended a “stimulation program and ongoing tracking” with “Badland
Human Services.” Exhibit 3 at 7.
      23
         Although counsel’s question says that Dr. McDonough was referring Karl
for “possible” motor delay, Dr. McDonough referred Karl for motor delay. Exhibit
3 at 3. Unlike Dr. McDonough’s December 27, 2004 report, the January 19, 2005
report does not characterize Karl’s gross motor delay as “possible.”
      24
        The first day of the hearing was March 22, 2010. During that session, the
Palucks’ attorney requested that Dr. Snodgrass testify on direct examination before
                                                                     (. . . continued)
                                        30
his visits with Dr. McDonough on December 27, 2004, and January 19, 2005. In
the earlier appointment, Dr. McDonough recorded that Karl “‘says words.’” Tr.
257:14 (quoting exhibit 3 at 5). However, in the next month, Dr. McDonough
“says, ‘No words, doesn’t sit well.’” Tr. 257:14-15 (quoting exhibit 5 at 62). To
Dr. Snodgrass, “something was changing in that relatively short interval, a bit less
than a month.” Tr. 257:18-19.

       When the hearing resumed, Dr. Snodgrass returned to the differences in Karl
between December 2004 and January 2005. Dr. Snodgrass commented that in
December 2004, Dr. McDonough said that “Karl doesn’t pull to stand or crawl.
That his development is abnormal but that his tone, muscle tone, is normal.” Tr.
330:22-24; accord exhibit 3 at 5. To Dr. Snodgrass, Dr. McDonough’s finding that
Karl has normal muscle tone in December 2004 is important because on January
19, 2005, Dr. McDonough found that “Muscle tone of the extremities and the back
is up or increased and there’s ankle clonus on one side.” Tr. 331:7-9.25 In Dr.
Snodgrass’s view, Karl was worse in January than he was in December: “These
are new findings which were not present in December. This [ankle clonus] is a
positive finding if you have abnormal tone, whereas beforehand, the findings were
simply that Karl could not do things which the average child would do at that age.”
Tr. 331:10-14.

       Dr. Frye did not rebut Dr. Snodgrass’s opinion that between December 2004
and January 2005, Karl worsened. Dr. Snodgrass pointed to two deteriorations.
First, Karl went from “says words” to “no words.” Second, Karl went from
“normal muscle tone. . . . [with] no ankle clonus,” exhibit 3 at 5, to “muscle tone
[increased]” with “2 beats clonus” on his right side, exhibit 5 at 62. Thus, there is
preponderant evidence that in two areas of development – gross motor and


the Secretary cross-examined Dr. Frye. This request was denied and the hearing
proceeded in a more traditional format with cross-examination of Dr. Frye
immediately following his direct examination. See Tr. 134:1 to 141:2. The
duration of Dr. Frye’s testimony and Dr. Snodgrass’s travel commitments limited
Dr. Snodgrass’s direct testimony on March 22, 2010, to a short amount of time.
      25
         Dr. Snodgrass also interpreted Dr. McDonough’s handwriting as saying
that Karl had a “decreased range of hip motion.” Tr. 331:6. This portion of Dr.
McDonough’s record is not easily deciphered.


                                         31
expressive language – Karl was worse in January than he was the previous
month.26

      Dr. Snodgrass’s opinion that Karl was deteriorating in December 2004
accords with statements made by Ms. Paluck during Karl’s hospitalization in July
2005. When Karl was hospitalized, Ms. Paluck told four people (Dr. Oska (a
physician at St. Joseph’s Hospital); Molly Eastman (a nurse practitioner, working

      26
          Some testimony compared Karl’s gross motor ability in January 2005 to
his gross motor ability in October 2004. Dr. Frye stated that Karl’s gross motor
ability in October 2004 was the equivalent of a four month old. Since Karl was
nine months old in October 2004, the amount of delay was five months. Tr. 639:6-
9. In January 2005, Karl’s gross motor development was between nine and ten
months, making his delay two to three months. Tr. 639:13 to 640:6. So, in Dr.
Frye’s opinion, Karl’s gross motor functioning had improved between October and
January because “he was a little bit less delayed.” Tr. 638:24.
       Dr. Snodgrass stated that attempting to give Karl an overall level of
functioning was not helpful.

      I’ve got a problem with the whole Denver concept of reducing gross motor
      to X months. Karl had asymetrical motor performance. There were a
      number of areas where his performance was quite bad. . . .
             So the problem is you can take a thing he does badly and a
      thing he does well and average them, but that doesn’t really give you a
      useful answer. In other words I wouldn’t want to reduce his gross
      motor impairment to a single area[,] but I would say his gross motor
      performance was bad, I’d certainly say that.

Tr. 802:18 to 803:6; see also Tr. 458:21-24 (Dr. Snodgrass: “What we have for
Karl is that in some areas his problem was greater than in others. So trying to
reduce him to a single age equivalent of eight months is, I believe, misleading.”).
       Comparing Karl in October 2004 to Karl in January 2005, while interesting,
is not very illuminating. The K.I.D.S. testing was a “very good and extensive
evaluation.” Tr. 99:2 (Dr. Frye); accord Tr. 328:20-24 (Dr. Snodgrass agreeing
with Dr. Frye’s testimony on transcript page 99). Training is required to
administer the standardized tests given to Karl as part of the K.I.D.S. testing. Tr.
821:17-21 (Dr. Frye); see also Tr. 786:10-15 (Dr. Snodgrass). In contrast, the
Denver screening test “is a quick screening test, it’s not a detailed evaluation.” Tr.
786:8-9.

                                          32
with Dr. Frost); Dr. Pierpont (a geneticist); and Dr. Moertel (a hematologist)) that
Karl’s problems started in the fall 2004. See Tr. 360:3 to 367:2 (Dr. Snodgrass)
(citing exhibit 6 at 62-65; exhibit 11 at 225, 229-32, 234; and exhibit 11 at 46).
Two of those reports say that Karl began to lose milestones at 11 months.

       Since Ms. Paluck was recounting in July 2005 Karl’s status in December
2004, her recollection is not truly contemporaneous. See Shapiro v. Sec’y of
Health & Human Servs., 101 Fed. Cl. 532, 539 (2011) (discussing
“contemporaneous”), aff’d without opinion, No. 12-5152 (Fed. Cir. May 7, 2013).
On the other hand, Ms. Paluck was providing her statement when she was seeking
treatment to solve Karl’s medical problem and her statement was not made when
she was anticipating litigation. Furthermore, as Dr. Snodgrass testified without
any contradiction, the medical personnel who created these records obtained the
history from Ms. Paluck independent of each other and they are consistent with
each other. Thus, these histories are entitled to some consideration, see Cucuras v.
Sec’y of Health & Human Servs., 993 F.2d 1525, 1528 (Fed. Cir. 1993), even if
they are not dispositive by themselves. See Tr. 646:6-7 (Dr. Frye stating that he
“rel[ies] very heavily on care giver information”).

      Overall, by January 19, 2005, Karl had problems in his CNS. His
pediatrician diagnosed him with gross motor delays, which had worsened in the
preceding three weeks. Karl was also having problems with his language. Finally,
Karl was recovering from the most recent episode of erythema multiforme.
      B.     Loving Prong 2: What is Karl’s Current Condition (or His
             Condition Following the Vaccination, if Also Pertinent)?

      The second part of the Loving test is to discuss “the person’s current
condition (or the condition following the vaccination if that is also pertinent).”
While both periods are included in the Court’s test, an analysis of Karl’s most
current condition is not possible, as the Palucks have not filed recent medical
records.27 Accordingly, the analysis under this prong will focus solely on Karl’s
health in the months following his vaccination.

      27
         The Palucks’ counsel, without submitting any medical records, presented
some information about Karl’s health during the April 10, 2013 oral argument on
the second motion for review. She stated that Karl was recently hospitalized but
has returned home. He requires a ventilator to breathe and his parents have
implemented a do not resuscitate order. He remains unable to perform basic life
                                                                    (. . . continued)
                                        33
       The December 14, 2011 decision discussed Karl’s post-vaccination status as
part of the second Althen prong. That decision concluded that between September
2004 and July 2005, Karl’s developmental progress was “not linear.” Decision,
2011 WL 6949326, at *23. The Court’s Opinion and Order vacated this aspect of
the December 14, 2011 decision primarily because it failed to discuss records of a
chiropractor whom Karl was seeing. Opinion and Order, 104 Fed. Cl. at 480.

      For ease of organization, Karl’s history is divided into periods, roughly
corresponding to the source of information about Karl.

             1.    Daycare Records

        The first post-vaccination record created contemporaneously with the events
being described in it is a record from Karl’s daycare.28 For January 21, 2005, there
is an entry stating that “Deb [presumably a staff member at FunShine Express] talk
[sic] to Rhonda [Karl’s mother] about chiropractor.” The daycare record also
states that Karl had a temperature of 101.5 degrees. Exhibit 22 at 1.

       A daycare staffer made additional entries on January 24, 25, and 26, 2005.
On these three days, Karl was recorded as being “fussy.” However, there is no
notation or other indication that Karl had a fever on any of those days. On January
28, 2005, Karl is again recorded as being “very fussy,” but the caregiver also states
that Karl had a fever of 101.3. Exhibit 22 at 2.




sustaining activities such as eating and swallowing. He receives nutrition through
a feeding tube. See Oral Arg. Tr., April 10, 2013, at 34:16 to 35:20.
      28
        The Palucks filed two pages of records from Karl’s daycare provider,
FunShine Express. These two pages contain entries beginning on January 6, 2005
and ending on February 8, 2005. Exhibit 22.
      During the earlier phase of the case, the undersigned ordered the Palucks to
produce other records from Karl’s daycare. Order, filed July 22, 2011. The
Palucks filed a status report, stating “there are no other daycare records to be
obtained and, therefore, none to be submitted.” Pet’r Status Rep’t., filed Aug. 22,
2011.

                                         34
       The experts discussed the significance of the fever on these two days and the
other symptoms, such as tiredness, that the daycare providers recorded.29 Dr. Frye

      29
         The Court questioned whether it was appropriate to find that Karl had
fever only on these two days. The Court stated “[r]easoning from . . . omissions to
a positive postulate is always questionable.” Opinion and Order, 104 Fed. Cl. at
476, n.27 (citations and quotation marks omitted).
       The finding that Karl did not have a fever on days other than January 21 and
January 28, however, is consistent with how the parties presented their cases. In an
October 27, 2009 status conference, the parties discussed the extent of Karl’s
fevers. The undersigned had inquired if a hearing to determine facts about Karl’s
condition were needed. The Palucks’ attorney represented that the presence of a
fever does not make a difference to Dr. Frye’s opinion because he saw evidence of
an encephalopathic process whether or not Karl had a fever. Ultimately, in the
October 27, 2009 status conference, the parties agreed that although there may be a
genuine dispute about whether Karl’s fevers were “high,” this was a non-material
fact. In light of this agreement, the undersigned did not order a fact hearing.
       Although the October 27, 2009 status conference was not recorded, the
extent of the agreement was memorialized at the beginning of the hearing. Tr.
8:18-25. Although both counsel commented upon the undersigned’s description of
the fever issue, the attorneys did not argue that Karl had a fever on days other than
January 21 and January 28. Tr. 11:19 to 12:18.
       In their post-hearing brief, the Palucks referred to Karl as having a fever on
January 21 and January 28. Their recitation of facts included:

      Karl developed a fever of 101.5°F. on January 21, 2005. From
      January 21st through 28th, his day care providers noted Karl to be
      lethargic, irritable, tired, and to have a decreased appetite. They
      recorded a fever of 101.3°F on January 28, 2005. There was no
      indication that Karl was ill prior to receiving his vaccines on the 19th
      or was otherwise ill during the January 21-28 time frame.

Pet’r Posthr’g Br., filed Feb. 18, 2011, at 6 (citations omitted and emphasis added).
       If the Palucks intended to contend that Karl had a fever on days other than
January 21 and January 28, it was incumbent on them to offer persuasive evidence
supporting this contention. See Walther v. Sec’y of Health & Human Servs., 485
F.3d 1146, 1150 (Fed. Cir. 2007) (“[I]t would be unusual to require a party to
prove that ‘there is not a preponderance of evidence,’ as our legal system rarely
requires a party to prove a negative.”). In absence of this showing, the undersigned
                                                                       (. . . continued)
                                          35
testified “He was lethargic. He was irritable. He was tired, had a decreased
appetite, so he had systemic signs of being sick or of, as we had talked about,
immune activation, these immune mediators actually being increased, and possibly
this process already going on of this cascade of metabolic decompensation.” Tr.
103:23 to 104:3. To Dr. Frye, Karl’s irritability and lethargy was a manifestation
of an encephalopathic process. Tr. 193:10-25. As part of cross-examination, Dr.
Frye explained that the vaccines activated Karl’s immune system and the activated
immune system produced a fever. Tr. 196:25 to 197:3.

       Dr. Snodgrass agreed that Karl’s daycare reported a fever on two days. Dr.
Snodgrass testified that the varicella and MMR vaccines, which contain live
viruses, “do cause a fever in some children, but it takes time to appear. And it
usually will not appear until the seventh or eighth day.” Tr. 338:23 to 339:1. Dr.
Snodgrass disagreed with Dr. Frye’s causal connection of Karl’s January 2005
vaccinations and his subsequent fever. Dr. Snodgrass stated that “a fever two days
after immunization is unlikely to be due to those immunizations.” Tr. 339:1-2.30

       Even though Karl had a fever on two days in January, Dr. Snodgrass stated
that Karl was, overall, healthier than he was a few months earlier. Dr. Snodgrass
stated “there is a contrast between November and December 2004 when there were
many doctor visits and phone calls and January and February when there were
not.” Tr. 336:19-22. In this same portion Dr. Snodgrass reiterated:

      [W]e have this marked contrast between November and December
      when he was often seeing the doctors, either in Bismarck or at the
      Dickinson Clinic or his parents were telephoning them.
             So I have every reason to believe that his parents are attentive
      to his needs, so I have to conclude that he was more sick in November
      and December than he was in January or February.

Tr. 341:22 to 342:5. More evidence of Karl’s relatively improved state of health is
that the rash, which had been episodically recurring in Karl throughout the fall

finds that in the two weeks following vaccine, Karl had a fever only on those two
dates.
      30
         On cross-examination, Dr. Snodgrass elaborated about the basis for his
opinion that fevers occurring shortly after an MMR or varicella vaccination are not
caused by the vaccine. See Tr. 570:20 to 576:20.

                                        36
2004, was better on January 19, 2005. Tr. 445:9-10.31 Karl also did not stay home
from daycare. Exhibit 22 at 1-2; see also Tr. 565:21-22 (Dr. Snodgrass’s
testimony that one reason that he thinks the vaccinations did not significantly
aggravate Karl’s condition was the lack of evidence showing “significant
regression, being sick, calling the doctors, staying home from day care, et cetera”).
Concisely stated, Dr. Snodgrass’s opinion is that “Karl was not seriously ill in
January.” Tr. 558:8.

        On January 31, 2005, Karl’s daycare provider reported that Karl was acting
“very tired fussy.” It also says “He has spots all over his arms & legs again.”
Exhibit 22 at 2. Dr. Snodgrass stated that “I think that [report of more spots] is
more of the erythema multiforme. . . . And that could be associated with fever and
irritability.” Tr. 339:20-25. In the rebuttal phase of the hearing, Dr. Snodgrass
testified that “the simplest explanation” for the January 31, 2005 incidence of red
spots “is that the erythema multiforme waxes and wanes and that was a period
when it was more evident.” Tr. 804:9-11.32

      There are additional reports from the daycare provider for each day between
February 1, 2005, and February 4, 2005, inclusive. For two days, Karl was
reported as being “tired.” On an intervening day, Karl “did very good today.”
Exhibit 22 at 2.

      On February 7, 2005, the daycare notes state that Karl went to a
chiropractor, and the details of this appointment are provided below. On February
8, 2005, the daycare record says: “Karl not very content not sleeping very long 1/2
[hour] at a time[,] tries to crawl pulling his body.” Exhibit 22 at 2.33

      31
         In the history of present illness section of Dr. McDonough’s form, the
note says “Recheck rash – better [with] Desonide.” Dr. McDonough’s assessment
includes “recurrent erthythema multiforme.” Exhibit 5 at 62.
      32
         Dr. Frye also viewed the presence of red spots as an indication that Karl’s
erythema multiforme had recurred. Dr. Frye connected the erythema multiforme
with an activation of Karl’s immune system that was, in turn, caused by the
vaccinations. Tr. 645:2-14.
      33
           This is the final daily entry from the daycare record. See footnote 28,
above.


                                           37
             2.    Chiropractic Records

        On February 7, 2005, Ms. Paluck brought Karl to his first appointment at the
Pokorny Chiropractic Clinic.34 The “present complaint” was that Karl was “Not
crawling / walking.” On the intake form in the blank associated with the typed text
“pain described,” there is handwriting saying that “ear infections – w/ red spots on
extrem[ities].” Exhibit 12 at 1.35 (This handwriting is probably the handwriting of
a person from the chiropractic clinic.) Another part of the intake form has different
handwriting, which is probably from Karl’s mother, saying that the reason for
Karl’s visit was “infant – not crawling, walking, problems sitting – sometimes.”
Id. at 2.

       On another form, which the chiropractor used to record the treatment
provided at each visit, there is a series of boxes adjacent to the letter “O,” which
presumably stands for “objective.” The boxes are labeled Progress, NCM, Palp,
MP, Antalgia, Spasm, Edema, Pain/Tender, ROM C/S, ROM L/S. Some boxes
contain handwritten dashes, letters, or arrows, pointing either upward or
downward. The significance of these entries is not clear. Neither Dr. Frye nor Dr.
Snodgrass discussed these boxes in their testimony. Similarly, neither the Palucks
nor the Secretary referred to these boxes in their recitation of Karl’s medical
history in the briefs filed after the hearing.



      34
          Although Dr. McDonough had referred Karl for physical therapy and
occupational therapy following the January 19, 2005 appointment, the Palucks
were not taking Karl for therapy. One of Dr. McDonough’s later records explains
that the Palucks thought that Karl’s problem was a “pinched nerve which is
interfering with his development.” Exhibit 3 at 7.
      35
         When the Secretary’s counsel asked Dr. Snodgrass about whether this
report of pain meant that Karl had otitis media, the Palucks’ attorney objected due
to lack of foundation. Dr. Snodgrass agreed with the Palucks’ attorney, saying that
chiropractors “would not try to decide whether a person has an ear infection or
not.” Tr. 341:13-14.
       On the other hand, Dr. Snodgrass testified—without any objection—that a
chiropractor could report the presence of a rash accurately. Tr. 340:9, 341:7-8.


                                         38
       For Karl’s first visit, the chiropractor’s notes, which are difficult to decipher,
has in the “comment section,” the following:
       Dr. [Steven] McDonough / Bismarck / MedCenter 1 Clinic
       X Pt. tenderness sub occip (R) ↓ ROM / head / Pot

Exhibit 12 at 4. The chiropractor’s assessment was “C-Seg. Dys.” Id. at 5.36

       Two days later, Karl returned. He was described as “irritable.” There is also
a notation, perhaps preceded by an asterisk, saying “Pt hip [after] cross crawl.”
Id.37 After two more days (February 11, 2005), he was described as “spastic.” Id.

       In his rebuttal testimony,38 Dr. Frye saw “irritable” as a presentation that was
“somewhat unlike Karl because he’s been described as being a very happy child
until the January 19th.” Tr. 647:1-3. Dr. Frye then discussed why the report of
spasticity was “interesting” to him. He saw “spasticity” as marking a significant
change in Karl’s status:

      [A]s I mentioned before[,] changes in tone sometimes are very subtle
      things. Spasticity though suggests a very severe neurological event,
      . . . and [for] spasticity to actually develop within the time frame that
      we see, within a month, suggests that there was very rapid change in
      his central nervous system. So whereas tone is something that you
      feel as far as the resistance to passive flexion, spasticity actually
      suggests that there’s actually significant damage where the muscles

      36
         Neither party asked Dr. Frye or Dr. Snodgrass to interpret this note. It
might mean that the chiropractor assessed Karl as having a dysfunction in the
cervical segment of his spine.
      37
         With reference to this visit, Dr. Frye said that the chiropractor “makes a
note of some abnormalities of his of [sic] bilateral hips with cross crawl.” Tr.
647:4-5.
      38
         Dr. Frye did not mention Karl’s visits to the chiropractor in his reports of
March 30, 2009 (exhibit 16), July 17, 2009 (exhibit 21), or January 11, 2011
(exhibit 40). Dr. Frye also did not discuss the chiropractor’s records in his
testimony during the first day of hearing. See Tr. 32-242. Similarly, when the
Palucks prepared a demonstrative exhibit presenting a “Time Line” for Karl, the
Palucks did not include any entries from the chiropractor. See exhibit 24.

                                           39
      are being contracted forcefully because they have actually lost control
      from the brain.

Tr. 647:12-23. Dr. Frye stated that in his review of Karl’s records prior to
February 11, 2005, he did not discover any caregiver noting spasticity during an
examination. In Dr. Frye’s view,

      this suggests that there is significant damage to the brain, what we call
      an upper motor neuron lesion, and that the neurons in the motor cortex
      are severely damaged and are no longer controlling the neurons in the
      spinal cord. And within that time period to go from maybe some
      increased tone to becoming spastic suggests a very quick and fast
      regression.

Tr. 648:7-14.

       The next entry from the chiropractor is three days later, February 14, 2005.
Karl is reported as being in a “better mood.” Exhibit 12 at 5. Karl returned on
February 16, 2005, and the chiropractor described Karl as “less rigid – more
comfortable on all 4’s.” Id. On February 18, 2005, the notation is “less rigid –
‘happier.’” Id.

      The Palucks did not elicit any testimony from Dr. Frye about the February
14, February 16, or February 18, 2005 records. See Tr. 648:20 to 649:1 (Dr. Frye’s
testimony describing visits on February 11, 2005 and March 30, 2005); see also Tr.
649:20 to 650:6 (the Palucks’ attorney drawing Dr. Frye’s attention to a visit on
March 17, 2005).

       In his direct testimony, Dr. Snodgrass referred to the chiropractor’s records
as not showing a change in Karl.39 He stated that the records from the Pokorny
Chiropractic Clinic “talk about problems. In fact, they use the word spastic in
various places[.] . . . They often say spastic, stiff, et cetera. So they are reporting
on the same general phenomenon which first became evident to Dr. McDonough in
January.” Tr. 336:24 to 337:4.


      39
         Dr. Snodgrass’s expert reports also did not discuss Karl’s experience at
the chiropractor. See exhibits A, N, and BB.


                                          40
       Karl continued to go to the chiropractor every few days from February 20,
2005 to March 10, 2005, inclusive. The portion of the form labeled “S,” which
presumably stands for symptoms, contains different handwritten notations, of
which some are difficult to read. Entries include “stiff,” “irritable,” “less fussy” in
association with increased bowel movements, “less hypertonicity,” and “irritable”
in association with not sleeping well. Exhibit 12 at 6-7. Neither Dr. Frye nor Dr.
Snodgrass commented on these particular records.

       In the middle of this period, Ms. Paluck brought Karl to the pediatrician’s
office because Karl’s mom thought he might have an “ear infection.” In addition,
Karl “has been a little bit fussy. Also has been coughing some and has had a bit of
rhinorrhea for the past couple weeks.” Karl was, at this time, “eating and drinking
fair. Making urine.” The doctor’s objective examination of Karl included that his
head, eyes, ears, nose and throat were “normocephalic and atraumatic.” The
doctor assessed Karl as having “Bronchitis with irritability. No current evidence of
otitis media.” Exhibit 3 at 63.

      From this information, the doctor planned that Karl should receive
“[s]ymptomatic cares [sic].” The doctor recommended maintaining the routine
checkups with Karl’s pediatrician. Id.40

       On March 17, 2005, Karl saw the chiropractor for the fourteenth time since
February 7, 2005. For “S,” the handwriting states “upper [illegible, perhaps “ext”
for extremities] skin blotches – back pain.” (This handwriting is not the same as
the previous entries.) For “A,” which presumably stands for “assessment,” the
record says “palpation of spine painfull [sic] Baby cries loud when touched.” Dr.
Frye commented that the report of back pain and loud crying when touched “is
suggesting that [Karl’s] starting to have spasticity of some of the axial musculature
and back pain, which would again suggest that he has some abnormal control of
those muscles.” Tr. 650:1-4. In Dr. Frye’s view, “this is something that is
progressive because we know previously he was a very happy child without any
pain.” Tr. 650:4-6.

      The sequence of visits to the Pokorny Chiropractic Clinic is interrupted by a
development at Dr. McDonough’s office.


      40
        In his initial testimony, Dr. Frye described this visit but did not add any
additional meaningful information. See Tr. 105:9-106:4.

                                          41
             3.   Social Services’ Involvement and Dr. McDonough’s
             Referral to Dr. Kriengkrairut

       On March 22, 2005, Ms. Paluck returned a call from Dr. McDonough. This
led to a joint phone call among Dr. McDonough, Karl’s mom, and Karl’s dad. Dr.
McDonough records the following information:

      Some brief crawling
      Not sitting on his own
      Leans to one side
      Babbling more
      Rash – comes + goes
      [Illegible] testing CT scan

Exhibit 5 at 72. Dr. McDonough’s plan is to refer Karl to a neurologist.

       The Palucks’ attorney drew Dr. Frye’s attention to this record. Their
attorney stated:

            Q: . . . That’s the first indication that we have that the
      pediatrician is now concerned such to a level that Karl needs to see a
      neurologist.
            A: That’s true. And it looks like something about testing with a
      CT scan.
                                          ***
            A: . . . [Dr. McDonough] believes that some medical testing
      needs to be done[.]

Tr. 107:4-13.41

      On March 23, 2005, Brenda Erie from Stark County Social Services called
Dr. McDonough. The message was “Please call ASAP. Emerg[e]nt.” While the
reason for the call is “emerg[e]nt,” the details that prompted the call were not


      41
          Much later in Dr. Frye’s testimony, he stated “[i]f you look through the
record, . . .the pediatrician’s record, . . . after the vaccine there is no mention of
him making any babbling sounds.” Tr. 702:9-12. Dr. Frye was not asked about
the March 22, 2005 phone call.

                                           42
provided. Dr. McDonough returned this call approximately two hours later. His
note states “Discussed peds neuro evaluation.” Exhibit 5 at 73.

       Dr. McDonough completed a “Consultation Request Summary” on March
24, 2005. Dr. McDonough stated, “I have been contacted by a chiropractor in
Dickinson who is providing care for Karl. I also received contact by Stark County
Social Services regarding Karl’s lack of participation in physical and occupational
therapy.” Exhibit 3 at 7. (Dr. McDonough’s referral does not explain how the
Stark County Social Services learned that Karl was not attending therapy, as Dr.
McDonough had recommended.) Dr. McDonough said that he has “talked to the
parents and recommended a CT scan and medical evaluation for congenital
infection and inborn areas of metabolism.” Karl’s parents, however, were
“reluctant to do any medical evaluation” due to their belief that Karl’s
developmental problems were caused by a pinched nerve. Dr. McDonough
requested that Dr. Siriwan Kriengkrairut, a neurologist, conduct an “evaluation and
medical investigation[] into the etiology of his developmental delay and
hypertonicity.” Id.

      Karl returned to his regular chiropractor on March 27, 2005. For the
symptoms, Karl is reported to have “Rigid lower extrem[ities]. . . . ‘Doing well ‘til
yesterday.’” The assessment is “same” and also says “‘took a few crawl steps.’”
Exhibit 12 at 7.

       Although the March 27, 2005 chiropractor’s treatment record does not
explain precisely how Karl changed after “doing well” until March 26, 2005, some
additional information may be found for a visit on March 28, 2005. On that day,
Ms. Paluck brought Karl to his pediatrician’s office in Dickinson.42 Dr. Gary
Peterson, not Dr. McDonough, saw Karl for this appointment.

       Ms. Paluck reported that Karl had “four days of wheezy cough, runny nose
for two weeks.” Ms. Paluck also informed Dr. Peterson that Karl had been
“[f]ussy, not eating well,” although no duration was specifically noted. Karl was
reported not to be having any ear pain, diarrhea, or nausea. Exhibit 3 at 64.



      42
        Ms. Paluck originally called the clinic in Bismarck, but a nurse directed
Ms. Paluck to make an appointment at Dickinson. Exhibit 5 at 74.


                                         43
       Dr. Peterson examined Karl, focusing on Karl’s breathing. There is no
mention of developmental milestones, such as crawling, speaking, or walking. Dr.
Peterson diagnosed Karl as having “1. Early bilateral otitis media. 2. Bronchiolitis,
suspect RSV.” Id. Dr. Peterson treated Karl with SVN (small volume nebulizer)
and prescribed an SVN for use at home. He did not prescribe any antibiotics,
noting that “Mother has preferred no antibiotics be written as yet since he has had
the trouble with erythema multiforme in the past.” Dr. Peterson’s note states
“Recheck tomorrow morning to ascertain improvement. See sooner for shortness
of breath.” Id.

       There is no information in the record indicating that the Palucks brought
Karl in for medical treatment in the immediate days following his March 28, 2005
appointment with Dr. Peterson. The next visit was with the Pokorny Chiropractic
Clinic on April 2, 2005. See exhibit 24 (Pet’r Timeline) at 3; exhibit H (Resp’t
Summary of Medical Records) at 10.

       However, before Karl returned to the chiropractor, the chiropractor
memorialized a “Phone convers[ation]” with a person whose name is difficult to
decipher but was affiliated with “SCSS.”43 The caller was inquiring about a
possible adverse vaccine reaction to which the chiropractor responded “No.” The
chiropractor also discussed “CP, cerebellar tumor.” The people also discussed
“P.T. / O.T. in conjun[ction] [with] chiro[practic] care.” Exhibit 12 at 7.

      In connection with this report, Dr. Frye testified that the chiropractor “also
discusses . . . a possible adverse reaction to the vaccine.” Tr. 649:16-17. Dr. Frye,
however, failed to note that the chiropractor’s opinion was that Karl did not have
an adverse reaction to the vaccine. See id.; see also exhibit 12 at 7.

       Dr. Frye interpreted “CP” as meaning cerebral palsy. To Dr. Frye, the
reference to cerebral palsy was significant because “those children with cerebral
palsy do have spasticity, but for here this is pretty significant that he has cerebral
palsy which probably affects, which affects the limbs and the motor system to a
significant extent, he actually puts in here that maybe he has a cerebellar tumor,
suggesting that he has some ataxia or some inability to control his movements very
well.” Tr. 649:4-11.

      43
        Given the information in Dr. McDonough’s request for a consultation,
SCSS probably refers to “Stark County Social Services” and the caller was
probably Brenda Erie. See exhibit 5 at 73.

                                         44
       Dr. Frye continued his interpretation of the chiropractor’s memorialization
of a phone conversation. Dr. Frye stated that “this is more of what we would think
of as a fine motor problem than a gross motor problem. So it seemed like he was
suggesting that there was actually something more and progressive.” Tr. 649:12-
15. Unfortunately, Dr. Frye did not define what symptom evidenced a fine motor
problem. Dr. Snodgrass did not respond to Dr. Frye’s interpretation of the
chiropractor’s March 30, 2005 phone call.

       On March 30, 2005, Ms. Erie from Stark County Social Services left another
message with Dr. McDonough. Dr. McDonough’s notes from the ensuing
conversation recorded that “Mom told Pt that Baby is lazy + will await appt. Told
her that appt has been scheduled in April with Dr. Siriwan.” Exhibit 5 at 75.

       Karl next saw the chiropractor on April 2, 2005. The chiropractor records
the following: “Nebulizer this [illegible, perhaps week]. Up on all 4’s longer –
seeing improvement. Less rigid – ‘good mood this week’ – taking a few crawling
steps.” On the line for assessment, the chiropractor has written in parenthesis “No
red spots for 2 wks.” On the same line, the chiropractor has also written “*‘Doing
well OT/PT since Nov.’ ‘1-2x/wk.’”44 Exhibit 12 at 7. The chiropractor’s use of
quotation marks suggests that Ms. Paluck provided the information about Karl’s
history of occupational therapy and physical therapy. However, the Palucks have
not submitted any records documenting Karl’s participation in occupational
therapy or physical therapy.

      Ms. Paluck brought Karl back to the Dickinson pediatric clinic on April 4,
2005, where they again saw Dr. Peterson. The reason for the visit was Karl’s ears
were draining. The doctor’s examination focused again on respiration. The doctor
mentioned that Karl was not having a rash. Dr. Peterson diagnosed Karl as having
“Bilateral otitis media, draining on the right.” He also said that Karl’s bronchiolitis
was improving. Exhibit 3 at 66.

      Dr. Peterson recommended weaning Karl from the nebulizer, and prescribed
Augmentin. Dr. Peterson also instructed Ms. Paluck to watch for rashes, hives, or
erythema multiforme. Id.

      44
        As noted in the text, these words appear on the line for assessment.
However, they may appear there only because there was no more room on the line
for “symptoms.”

                                          45
      On April 8, 2005, Karl saw the chiropractor again. The chiropractor
reported Karl’s “cold symptoms better.” There is an “X” inside a circle followed
by “Antibiotic / 1 wk. Augmentin.” There is another circled X followed by
“Discussed file with parents. ‘You make decisions re: Karl’s care.’ ‘Not
concerned.’” Exhibit 12 at 7.

      On April 11, 2005, Mr. Paluck telephoned Dr. McDonough’s office. Mr.
Paluck reported that “Karl is crawling about 2 wks ago.” Mr. Paluck also wanted
Karl’s “ears checked.” The nurse advised Mr. Paluck “to keep appt they have
scheduled.” Mr. Paluck agreed. Exhibit 5 at 76.

      The Secretary’s counsel discussed this notation with Dr. Snodgrass. The
discussion was as follows:

            Q: And is it significant against your opinion of vaccine
      causation that Karl was crawling about two weeks ago as of April
      2005?
            A: It supports my view that Karl’s problems were fluctuating.
      He had times when his symptoms were worse, he had times when he
      was improving. And on April 11th he was apparently doing better.

Tr. 794:10-16.

      Due to Dr. Snodgrass’s reliance on Mr. Paluck’s statement that his son was
crawling, the undersigned asked Dr. Frye his views:

              Q: So here there’s a telephone conversation record, Mr. Paluck
      is calling and he says that Karl is crawling about two weeks ago.
      How does Karl’s crawling fit within your theory of the case?
              A: I think that, you know, he has – well, you know, sometimes
      kiddos that have increased tone may find it easier to crawl because if
      you have normal tone you actually have to push off with your
      muscles. If you have actually stiff legs sometimes it’s sometimes
      easier to actually crawl. So I don’t know that it necessarily negates
      the fact that he had these neurologic abnormalities. And to tell you
      the truth this is about the same time that we know that he had
      spasticity. So I would say that he’s actually just trying to learn to
      crawl despite his spasticity.
              Q: Would crawling be evidence of a new achievement I guess?
                                        46
             A: I think it’s hard to say because we know that neurologically
      he’s so abnormal at this point, I don’t know that we could really
      interpret it within the same context of normal development.

Tr. 826:18 to 827:15.

             4.    Dr. McDonough – April 13, 2005

       The appointment to which the nurse referred took place two days later, on
April 13, 2005. It was with Dr. McDonough. The purpose was to evaluate Karl
before he received anesthesia as part of an MRI.45 Because Dr. Frye and Dr.
Snodgrass discuss this report extensively, much of Dr. McDonough’s report is set
forth below.

       Dr. McDonough’s report begins with a history of Karl’s present illness. Dr.
McDonough’s summary is consistent with the preceding recitation of facts,
although Dr. McDonough does not have details about Karl’s status as recorded by
the chiropractor. Dr. McDonough states:

      Karl is a 14-month-old with global developmental delay who comes
      back in for a recheck. I have had numerous phone conversations with
      parents and have been trying to arrange evaluation for the global
      developmental delay and erythema multiforme. The parents have
      been reluctant to do this and are hesitant about any radiation exposure.
      They have not been taking him in to PT as requested but have been
      utilizing chiropractic services.
             The parents have agreed to have him seen by Dr. Siriwan
      Kriengkrairut and I have also had several conversations with the
      Badlands Human Services regarding questions that they have had
      regarding his evaluation.

Exhibit 3 at 9. The next pertinent portion of Dr. McDonough’s report is his review
of systems. Again, this historical overview is consistent. Dr. McDonough writes:


      45
          This MRI was probably scheduled in conjunction with Dr. McDonough’s
discussions with Karl’s parents at the end of March 2005. The message from one
call refers to the need for a consultation with a neurologist and a CT scan. Exhibit
5 at 72.

                                         47
      Positive for wheezing episode in March with otitis media. He has had
      chronic erythema muliforme but he has not had any lesions in the past
      three weeks. He has had global developmental delay and he has had
      increased irritability since he has been sick frequently this winter with
      ear infections. Previously, he was a very happy, laid-back child.

Id.

      Dr. McDonough next describes Karl’s developmental history. Dr.
McDonough states: “Reveals that he does not sit yet. He moves a little bit more
on four-point. He is not being followed by PT or OT as requested, but is seeing a
chiropractor.” Id.

      Dr. McDonough then reports about his examination of various aspects of
Karl. Pertinent parts include:

             GENERAL: Karl is a vigorous, active 14-month-old with
      global developmental delay. He cries when he lays on his back but is
      smiley and happy and playing when he is sitting on his mom’s lap.
             HIPS: His hips are tight with decreased hip flexion to about 70
      degrees bilaterally with increased [sic, a word is probably missing] in
      the lower extremities. This is a change on hip movement over the last
      couple of months. I did call Dr. Siriwan Kriengkrairut. Did
      encourage x-rays to be done of his hips but mom is reluctant to have
      this done.
                                        ***
             SKIN: He has a bruise on his upper forehead and a couple of
      tiny bruises in his lower back. The bruise is from falling forward and
      hitting his head, according to mom.
             NEUROLOGIC: Examination reveals increased [sic, a word,
      perhaps “tone,” is probably missing]46 in the upper and lower
      extremities. Deep tendon reflexes are present. I do not sense any
      clonus. Pupils equal, round, and reactive to light.

Exhibit 3 at 10. Based upon this information, Dr. McDonough assessed Karl as
having “Global developmental delay with resolving otitis media.”

      46
        The Palucks’ attorney suggested that the missing word was “tone.” Tr.
108:23-25.

                                         48
      Setting aside concerns about an ear infection, Dr. McDonough set forth the
following plan:

      The plan is to follow up with Dr. Siriwan Kriengkrairut next week.
      Dad did call and agree to an MRI and an MRI has been ordered on
      4/26/2005 at 7:00 a.m. Hopefully, the parents will agree to evaluation
      for congenital infections, metabolic disorders, and other tests
      requested by Dr. Siriwan for his global developmental delay. He is
      not speaking at this point and has obvious speech and fine and gross
      motor developmental problems with some apparent hypertonicity.

Id.

       As alluded to earlier in this decision, Dr. Frye and Dr. Snodgrass testified
about Dr. McDonough’s April 13, 2005 report extensively, much more than either
doctor testified about the chiropractor’s records. In his initial testimony, Dr. Frye
stated that Karl has deteriorated. Dr. Frye testified:

             A: So now his [Dr. McDonough’s] examination has
      significantly changed, because now he has increased tone in the upper
      and lower extremities, so – and he says, ‘Global developmental delay
      with resolving otitis media.’ So here his concerns are that his
      neurological exam has gotten worse.
             Q: And that’s worse from the examination that had been done,
      both in January of 2005 and December of 2004.
             A: Yes. Exactly.

Tr. 108:15-22.

       When Dr. Snodgrass testified, he disagreed with Dr. Frye’s view that Karl
had gotten worse. In reference to the passage just quoted, Dr. Snodgrass said: “I
think he’s missed the point that Karl was abnormal in the fall and by January he
was showing new findings of increased tone. And that that was an important
marker, something significant had changed.” Tr. 338:5-9.

      In the rebuttal phase, Dr. Frye responded to Dr. Snodgrass’s opinion. The
discussion between the Palucks’ attorney and Dr. Frye in reference to Dr.
McDonough’s April 13, 2005 examination was:

                                         49
       Q: And would that be important for us in understanding what he
finds in April versus what he found in January?
       A: Well [in] January again he had this isolated gross motor
delay and maybe a little bit of increased tone. Here he is described as
having global developmental delay. And again if you have delays in
just one area you have an isolated delay and it’s not called global
developmental delay. Global developmental delay is when you’re
affected in several areas. And so now he’s describing a very different
child who has global developmental delay, that is he has now delays
in many different areas. And, you know, of course it probably isn’t as
accurate as what he should have said would be regression in certain
areas, because he previously was not delayed in these other areas.
       Q: Would you take us through the physical examination that Dr.
McDonough made on April 13th, 2005?
       A: Sure. Also I wanted to mention that he has a very
interesting statement here as he’s talking about Karl as having
increased irritability since throughout the winter. And of course as we
had seen in previous exams Karl was not an irritable child, he was a
very happy child. Then when we actually look at the exam it says that
he has decreased hip flexion, something he had not mentions [sic]
previously, and that hip flexion is decreased suggesting that again he
has spasticity, not just increased tone but spasticity, limitations in his
range of motion, which is what the chiropractor had mentioned back
in I believe it was February, February 11th. So this is very different
than, you know, just a difference in tone. And now he’s seeing this
because this is the first time he’s seen Karl since the previous
examination.
       Q: And the examination that Dr. McDonough is doing on the
13th is a pre-MRI examination, is it not?
       A: It is, yes it is.
       Q: And so what else did Dr. McDonough find on April 13th?
       A: So he also showed, let me just look at this. So it’s
interesting he’s seeing bruises because now Karl is falling and hitting
his head, so it suggests that he’s lost actually coordination.
       Q: The neurological exam?
       A: He has increased tone in his upper, now his upper and his
lower extremities. And he also mentions that he is not speaking at this
point. So on the 19th he was actually saying mama and dada, but now
he’s not speaking at all. And he has obvious speech, fine, and gross
motor developmental problems. So before, where the Denver had
                                   50
      actually showed us that he was normal in fine motor and language,
      now we’re seeing that he has multiple developmental problems and he
      has lost all of his speech.
             Q: Would these findings on April 13th, 2005, suggest
      regression in Karl’s development?
             A: Most definitely.

Tr. 651:9 to 653:18.47

       In one portion of this passage (Tr. 652:12-14), Dr. Frye states that Dr.
McDonough’s report of “decreased hip flexion” means that Karl had spasticity.
Dr. Frye explained that “decreased hip flexion” is “just another term for
spasticity.” He continued:

      So that means there’s a limited range of motion. So spasticity causes
      a limited range of motion. So he is also, he’s talking about the exact
      area where there’s limited range of motion because of the spasticity.

      47
           In this passage, Dr. Frye made several assertions that are not entirely
accurate. For example, he testified that in January, Karl had “maybe a little bit of
increased tone.” Tr. 651:13-14. However, in January, Dr. McDonough indicated
that Karl’s neuromuscular system was abnormal and Karl had increased muscle
tone in his upper and lower extremities. Exhibit 3 at 3 (progress note), exhibit 5 at
35 (Denver screening form).
       Next, Dr. Frye mentioned Karl’s irritability. Tr. 652:6. But, the full context
of Dr. McDonough’s report is that Karl has “had increased irritability since he has
been sick frequently this winter with ear infections.” Exhibit 3 at 9. This
irritability is consistent with Karl’s pre-vaccination history in which he was
reported to be fussy in the context illnesses. See id. at 52, 58, 60. Dr. McDonough
also reported that Karl is “smiley and happy and playing when sitting on his
Mom’s lap.” Id. at 10.
       In addition, Dr. Frye testified that on January 19, 2005, Karl “was actually
saying mama and dada.” Tr. 653:9. Actually, Karl’s ability to say words on
January 19, 2005 was more ambiguous. Although the Denver screening form
contains a “pass” for “dada-mama specific,” exhibit 5 at 35, Dr. McDonough’s
own form does not include a positive notation for this skill. See exhibit 3 at 3. In
any event, even if Karl could say “mama” and “dada” on January 19, 2005, this
limited ability is still a decline in his language abilities from December 27, 2004,
when Karl “ha[d] several words that he says.” Exhibit 3 at 5.

                                         51
      You see he says the hips are tight, so tight is another word for
      spasticity, meaning the muscles are so tight they’re bringing the hips,
      they’re limiting the hips’ ability to move in their normal range.

Tr. 727:23 to 728:7; contra, Tr. 824:22 to 825:8 (Dr. Frye stating that he does not
think that Karl had spasticity on January 19, 2005).

       After hearing Dr. Frye’s testimony, Dr. Snodgrass was asked to explain
whether the vaccines changed the course of Karl’s disorder. Dr. Snodgrass stated
that he saw “no evidence that the vaccines changed the course of [Karl’s]
disorder.” Tr. 793:5-6. Dr. Snodgrass stated (again) that he thought that Karl’s
clinical course fluctuated before and after the vaccine. In this context, Dr.
Snodgrass stated, “I think the amount of hip flexor abnormality that was present
was probably greater in April than in January, but there was no ankle clonus. So in
other words we have certain areas where he looked a bit worse than he did in
January and others where he did not.” Tr. 793:14-19. Dr. Snodgrass also
discusses here Karl’s visit to the neurologist, Dr. Kriengkrairut.

             5.    Dr. Kriengkrairut on April 19, 2005

       Dr. Kriengkrairut saw Karl on April 19, 2005 because Dr. McDonough had
referred Karl “due to delayed development, not sitting up yet, unable to keep
balance when he is sitting up.” Exhibit 3 at 83. Like Dr. McDonough’s April 13,
2005 report, Dr. Kriengkrairut’s report is quoted here in detail because the experts
rely upon this report so heavily.

       Dr. Kriengkrairut’s recitation of Karl’s history begins with his birth. In
pertinent part, Dr. Kriengkrairut recounts the following information beginning with
the onset of the erythema multiforme:

      Mother felt that he did well in the first 6 months, then he did have
      some problem with serious skin lesion. This was approximately in
      October 2004. According to the father, his whole body swelled up.
      . . . It was diagnosed as erythema multiforme, suspected secondary to
      medication hypersensitivity reaction, exact allergy was unknown.
      This was also secondary to viral infection. According to the father
      since then, the child has regressed.

Exhibit 3 at 83. The parents’ narrative (as written by Dr. Kriengkrairut) explains
what happened to Karl before he was vaccinated:
                                         52
      In December of 2004, his condition got worse. His hands and feet
      were swelled up. He was given medications.

Id. At this point, it appears that Dr. Kriengkrairut is presenting information about
more recent history.

      This [sic, a missing phrase might be “skin condition”] has markedly
      improved from a month ago when he seemed to be back to normal.
      Father reported that since he has been improving with the skin lesion,
      he also has made progress in terms of development, but overall he is
      still behind. Parents reported that he has tendency to do fisting of
      both hands, even when he holds a bottle he will keep his hand
      clenched up. Recently, he seemed to open his left hand more.

Id. Then, Dr. Kriengkrairut describes various attempted interventions.

      Mother has tried chiropractic treatment in him. She was told that the
      child had some stiffening of the extremities secondary to a nerve
      pinch in his back. Dr. McDonough has ordered physical and
      occupational therapy in Dickinson; however, parents have not made
      the appointment yet. Parents are very reluctant for any therapy
      treatment. Mother felt that the child is unable to sit up due to unable
      [sic] to balance secondary to curvature of his back. Recently he was
      able to crawl 2-3 crawling movements at the time.
              He has not made any specific words. He has been sick quite
      often. This includes frequent ear infections.

Id.

      Dr. Kriengkrairut’s review of systems is relatively brief, repeating some of
what was just stated. For skin, Dr. Kriengkrairut reports Karl’s past history of
erythema multiforme and says that “[i]n the last one month, seems to be doing
much improved.” Exhibit 3 at 84. For neurologic, Dr. Kriengkrairut states “[t]he
parents were told that he has stiffening of both legs and also delay.” Id.

       As part of the physical examination, Dr. Kriengkrairut conducted a motor
examination. This “revealed truncal hypotonia with marked spasticity of the
extremities. The baby has tendency to do cortical thumb bilaterally, worse on the
right compared to the left.” Id.
                                         53
      Dr. Kriengkrairut also used the Denver screening test. Dr. Kriengkrairut
recorded: “The patient unable to sit alone, does have good eye contact, able to
follow in all directions. The baby does not babble. Parachute reflex is not
detected.” Id.

      Dr. Kriengkrairut reached three impressions about Karl: “1. Global delayed
development. 2. Truncal hypotonia with hypotonicity of the extremities. 3.
Etiology to be determined.” Id. She also recommended various things to the
Palucks, including that Karl would benefit from physical and occupational therapy.

       Since Dr. Kriengkrairut’s evaluation was the first time Karl saw a
neurologist, Dr. Frye and Dr. Snodgrass discussed her assessment extensively. In
Dr. Frye’s direct testimony, he mentioned the following problems that Dr.
Kriengkrairut reported as significant: Karl’s irritability, fisting, truncal hypotonia,48
spasticity in his extremities, and bilateral cortical thumbing.49 Tr. 110:2 to 112:9.
Karl’s lack of babbling, as reported by Dr. Kriengkrairut, was especially important
to Dr. Frye because Karl was babbling before his January vaccinations. See
exhibit 3 at 3. The decrease in babbling is “suggesting that now he’s losing
cognition and language . . . . It’s suggestive of neurodegeneration or regression in
development, which is caused by mitochondrial disorder.” Tr. 112:24 to 113:7.

        Dr. Snodgrass disagreed, at least in part. Dr. Snodgrass viewed other
abilities, such as Karl’s ability to roll over, as consistent between Dr.
McDonough’s January 19, 2005 evaluation and Dr. Kriengkrairut’s April 19, 2005
assessment. See Tr. 358:13-25. For Dr. Snodgrass, “Dr. Siriwan is not finding
that Karl has lost a skill which Dr. McDonough had previously recorded as
present.” Tr. 359:4-6.

      On the other hand, when Dr. Snodgrass was asked to comment upon Dr.
Frye’s testimony that Karl worsened between January 2005 and July 2005, Dr.
Snodgrass stated Karl “got worse in April/May.” Tr. 367:16-17. Unfortunately,

      48
         In truncal hypotonia, “the axial musculature cannot support [the person] to
actually sit up in any way or probably even stand.” Tr. 654:14-16 (Dr. Frye).
      49
        Cortical thumbing occurs when the thumb is inside a closed hand. It is
normal in newborn children but abnormal by age one. Tr. 582:25 to 583:14 (Dr.
Snodgrass), 705:1-9 (Dr. Frye).

                                           54
Dr. Snodgrass was not asked to identify the features in Karl that made him
conclude that Karl was worse in April or May than in January.

       Near the end of the Palucks’ cross-examination of Dr. Snodgrass, their
attorney asked him about two of the features identified by Dr. Kriengkrairut that
Dr. Frye saw as “new” findings. First, there was a question about cortical
thumbing that Dr. McDonough had not reported in January 2005. Dr. Snodgrass
stated, “I would not expect a pediatrician to notice that and that is a very minor
finding. It was not reported by Dr. McDonough, it was not reported by the
chiropractor. But I wouldn’t expect either one of them to notice that.” Tr. 577:21-
25. Counsel then challenged Dr. Snodgrass: “[A]ctually cortical thumbing is quite
a significant finding, isn’t it?” Dr. Snodgrass replied “I would disagree with you.”
Tr. 578:1-3.

      The second topic was the truncal hypotonia. Again, Dr. Snodgrass did not
agree with the characterization that this problem was new in April. The exchange
between the Palucks’ attorney and Dr. Snodgrass was:

            Q: Dr. S also made an objective finding in April 2005 of truncal
      hypotonia, that was not present in January 2005 either, was it?
            A: It was not reported by Dr. McDonough.
            Q: So that’s a new finding.
            A: I don’t think so. In order to determine truncal hypotonia,
      you have to do things with the child which I don’t believe a
      pediatrician would do. I think the issue about - -
            Q: You don’t know that for a fact though, do you, Dr.
      Snodgrass?
            A: I don’t know it for a fact as concerning Dr. McDonough. I
      deal with pediatricians and pediatric residents every day and I know
      what they do.

Tr. 578:4-17.

       The undersigned asked Dr. Snodgrass to elaborate on his answers regarding
truncal hypotonia and cortical thumbing. For cortical thumbing, Dr. Snodgrass
stated “[i]n the context of multiple findings of increased tone in upper and lower
extremities, the presence or absence of this finding is not significant.” Tr. 583:19-
22.


                                         55
       This dispute carried over into the rebuttal phase of the case. Dr. Frye said
cortical thumbing “is a significant sign of advanced upper motor neuron lesions
and something you don’t see with just some type of change in tone or even mild
spasticity, that is a very significant finding.” Tr. 654:22-25. The presence of
cortical thumbing means that the spasticity “now has affected the upper extremities
too and actually the thumbs.” Tr. 655:9-10.

       Dr. Frye also discussed the truncal hypotonia that Dr. Kriengkrairut
detected. Dr. Frye stated that truncal hypotonia meant that Karl was not sitting.
This is a significant change from January 2005, when Dr. McDonough reported
that Karl could pull to stand. Tr. 654:11-25; see also exhibit 5 at 62 (Dr.
McDonough’s report).

       Dr. Frye also repeated the point that between January 2005 and April 2005,
Karl lost language. Dr. Frye stated in January, Karl was saying “mama and dada,”
which is more complex than babbling. Tr. 656:3-10; see also exhibit 5 at 62 (Dr.
McDonough’s report). In contrast, in April, Dr. Kriengkrairut states that Karl was
not babbling. Exhibit 3 at 84. Dr. Frye concludes that Karl “has an obvious very
severe regression in language from where he was at 12 months.” Tr. 656:12-13.

       When Dr. Snodgrass returned to testify again, he did not further address the
cortical thumbing or the truncal hypotonia. Dr. Snodgrass did, however, comment
upon changes in Karl’s language. Dr. Snodgrass pointed out that on March 22,
2005, Karl was reported to be “‘babbling more.’” Tr. 789 (quoting exhibit 5 at 72).

             6.    April 27, 2005 MRI

      Following Karl’s appointment with Dr. Kriengkrairut, he saw the
chiropractor again. For symptoms, the chiropractor has recorded, among other
things, that Karl had a decreased range of motion. Exhibit 12 at 8. Neither Dr.
Frye nor Dr. Snodgrass commented upon this particular record.

       On April 26, 2005, Karl entered Medcenter One Hospital for his scheduled
MRI. Upon admission, Karl was examined by Dr. McDonough. The report from
Dr. McDonough’s examination presents Karl’s history, which is consistent with
what has been described previously. In terms of developmental history, Dr.
McDonough states that Karl “rolls over but does not sit without support. He does
not crawl and does not say any words.” Exhibit 3 at 12-13. For Karl’s skin, he did
not have a rash. For Karl’s extremities, there were “no signs of ankle clonus.” For
Karl’s hips, Dr. McDonough stated, “Hips are tight on range of motion of hips. I
                                         56
have asked mom to have Dr. Siriwan Kriengkrairut evaluate his hips, as well, to
see if we should obtain x-rays. Parents are very hesitant to do any irradiation of
Karl.” Id. at 13. Dr. McDonough recommended that Karl have the MRI as
ordered by Dr. Kriengkrairut and receive services to improve his development. Id.

       When the Palucks were meeting with the anesthesiologist before the MRI,
the Palucks told that doctor that they were concerned that Karl had a possible ear
infection. The doctor requested that Dr. McDonough see Karl again. Exhibit 5 at
52.

      Dr. McDonough’s notes contain a review of Karl’s systems. For this entry,
Dr. McDonough wrote that Karl had a “runny nose, cough, fussiness, irritability,
and possible otalgia.” Dr. McDonough also wrote “[w]e have been urging an
evaluation for developmental delay and the parents have been somewhat reluctant
to have this done and have agreed to have an MRI without contrast.” Exhibit 5 at
52.

       Under “PLAN,” Dr. McDonough recorded his answer to Mr. Paluck’s
question about what was happening with Karl. Dr. McDonough said that he
thought Karl “had problems with development resulting from problems with his
brain function and that we could not determine the etiology of this. I told him I did
not think it was a pinched nerve as told them by the chiropractor.” As to a
recommendation, Dr. McDonough stated that he “also re-encouraged them to get
him in PT/OT. I had made this recommendation four months ago and it has yet to
be accomplished. The parents decided to take him to chiropractor instead.” Dr.
McDonough concluded the entry by stating that Karl was “somewhat croupy
afterwards but seemed to be doing well when anesthesia sent him home.” Exhibit
5 at 53.

       Karl did have an MRI as planned. The results included multiple images,
including diffusion-weighted images. The doctor who interpreted the results
stated: “The corpus callosum is intact. White matter distribution appears normal
and myelination is appropriate for age.” The ultimate conclusion in April 2005,
was that it was a “Normal MRI brain scan.” Exhibit 4 at 11.50


      50
        When Karl was hospitalized due to more serious neurologic problems in
July 2005, this MRI was re-reviewed. Then, the MRI was interpreted as showing
apparent abnormality in his corpus callosum. Exhibit 18 at 11.
                                                                 (. . . continued)
                                        57
       The day after the MRI, Karl was seen at the Dickinson Clinic by Dr.
Peterson. The chief complaint was that Karl had a croupy cough. Dr. Peterson
records the history, provided by Ms. Paluck, that Karl had an MRI yesterday and
that he needed a breathing tube. Dr. Peterson also recorded the history that Karl
had been having cold symptoms for a few days before the MRI. Karl’s parents
estimated his pain level was “8/10.” Exhibit 3 at 67.

      Dr. Peterson assessed Karl as having “Croup, viral versus irritation from the
anesthesia procedure yesterday for the MRI.” Dr. Peterson recommended
continuing an antibiotic, which Dr. McDonough had prescribed, and SVN
treatment. Dr. Peterson also supported the parents’ plan to see an ENT about
having tubes placed in Karl’s ears. Exhibit 3 at 67-68.

             7.    Speech Therapy

      In early May 2005, Karl began seeing Trisha Getz, a speech therapist.
Several of his next medical appointments were with Ms. Getz.51

      At the initial evaluation, Ms. Getz recorded that the Palucks said that Karl
“had an MRI last week which has ‘wiped him out’ and they report a decrease in
many skills since undergoing the anesthesia.”52 The Palucks provided information
about Karl’s sucking, drinking, and swallowing skills. Ms. Paluck “reports

       During the course of the litigation, Dr. Snodgrass reviewed the original MRI
scan. He, too, concluded the April MRI was abnormal. Tr. 371:11-13, 373:13-19;
see also Tr. 484:16-20.
       When asked whether he had reviewed the original MRIs, Dr. Frye stated that
“I believe I did, although I haven’t done that recently.” Tr. 731:10-11.
      51
        Ms. Getz’s reports tend to be written in all capital letters. When there is a
quotation from Ms. Getz, it is restated using lowercase letters as appropriate
without any notation of this alteration.
      52
       In addition to this account provided approximately seven days after the
MRI, Ms. Paluck provided histories to other doctors in which she states that after
the MRI, Karl lost abilities. See, e.g. exhibit 11 at 5 (“Mom states that since the
MRI there has been a loss in abilities”).


                                         58
decrease in speech production in the last few months. Karl was able to produce a
variety of consonants but consonant production has stopped and during today’s
evaluation only a couple vowel sounds were heard.” Exhibit 6 at 5.

      When Ms. Getz tested Karl, he scored in the first and third percentile for
expressive language and auditory comprehension, respectively. In Ms. Getz’s
evaluation, she did not hear any “true words, vocal imitation, solitary vocal play or
sound combinations.” She did not observe Karl demonstrating comprehension of
spoken phrases such as “let’s go bye bye,” although Ms. Paluck reported that Karl
could understand those phrases at home. Ms. Getz recommended more speech
therapy to improve Karl’s expressive and receptive skills. Exhibit 6 at 5-6.

      Dr. Frye stated that a comparison between Karl’s language ability in October
2004 (the K.I.D.S. evaluation including the Bayley and Vineland) and Karl’s
language ability as measured in May 2005 “document[] that he’s now lost
language milestones considerably.” Tr. 114:2-3; accord Tr. 657:24 to 659:6.53
With reference to a slightly later speech evaluation, Dr. Snodgrass essentially
agreed that Karl had lost language skills between October 2004 and May 2005. Tr.
471:5 to 472:8.

      On May 9, 2005, Ms. Getz saw Karl again for 30 minutes of speech therapy.
On four objective measurements (approximate sounds, combine sounds, produce
consonants, and respond to commands), Karl scored a zero. Ms. Getz noted that
Karl “cried throughout most of session. He appeared uncomfortable around new
therapists and therapists today worked on building rapport with Karl.” Ms. Getz
recommended that rapport-building continue and that his parents let Karl see their
faces when they are speaking. Exhibit 6 at 36.

        Also, on May 9, 2005, Karl went to the chiropractor. This visit was his only
visit in the month of May. There is very little information about this visit, no

      53
          In discussing Karl’s language abilities before the vaccination, Dr. Frye
states that Karl “had no problems with language . . . at 12 months of age or before
that.” Tr. 658:5-7. Actually, Karl was slightly delayed in language. See exhibit
15 at 2-3.
       However, Dr. Frye’s arguably rosy characterization of Karl’s ability in
October 2004 does not change his overall point – that Karl’s ability with language
significantly deteriorated between October 2004 and May 2005. On this point, as
noted in the text, the experts agreed.

                                         59
arrows at all. For symptom, the entry states “not much strength since MRI.”
Exhibit 12 at 8.

       On May 11, 2005, Dr. McDonough wrote a letter about Karl to Dr.
Kriengkrairut. It appears that Dr. McDonough did not evaluate Karl on this date.
Rather, the letter summarizes results of various laboratory tests. The letter also
states that the “MRI showed no abnormalities.” Dr. McDonough concludes, “At
this point etiology of [Karl’s] developmental delay has not been discovered and
may not be known.” Dr. McDonough requests Dr. Kriengkrairut’s opinion as to
whether “a brain wave study would be of assistance as he does have intermittent
irritability.” Exhibit 5 at 29.

       Also, on May 11, 2005, Karl had an in-person consultation with Dr. W.
Thomas Coombe, a specialist in ENT. Dr. McDonough had referred Karl because
of recurrent otitis media. Dr. Coombe scheduled Karl for a “BTT” the next day.
Exhibit 10 at 1-2. Karl did have tubes placed in both ears on May 12, 2005. Karl
was given anesthesia. Id. at 5.

       The same day, Karl had another speech therapy session with Ms. Getz. Ms.
Getz recorded that she observed Karl swallowing from a bottle. Karl continued to
score zero on the four objective measurements. Ms. Getz stated that Karl had “less
fussiness throughout this therapy session.” He “did cry frequently but was able to
be calmed easier through movement.” In addition, “Karl did reach for toys and
reached for wanted items during play.” Ms. Getz also recorded that Karl
“[c]ontinues to be seen by PT and OT for gross and fine motor concerns.” Exhibit
6 at 35.

       The next session with Ms. Getz was on May 13, 2005. Based upon the
previous session’s work, Ms. Getz introduced a new objective standard – “indicate
desired toy by reaching for toy.” Karl did this task four times. He also
“respond[ed] to commands” once. For two other objective tests (approximate
sounds and produce consonant commands), Karl again scored zero. Ms. Getz’s
assessment was that “Karl was calm and participated without excessive fussiness
for the first 15 minutes of therapy and then became very fussy and cried the
duration of the session.” Ms. Getz added that “Karl did appear to be able to sit
better and communicate desire for toy with improvement from previous sessions.”
Exhibit 6 at 34.

      Karl saw Ms. Getz on May 17, 2005. As a subjective impression, Ms. Getz
recorded that “Dad reports he believe’s [sic] Karl’s strength is increasing.” For
                                        60
objective tests, Karl indicated a desired toy by reaching for it eight times. He did
not approximate sounds. Ms. Getz’s assessment was that “Karl was able to
indicate his desired toy more frequently today than previous visits. Karl continues
to cry during therapy although the amount of time crying is decreasing.” She also
stated that “Karl is producing much more eye contact with therapist and laughed
while appearing to enjoy play with a ball. Karl would reach for the ball and the
sign for ‘more’ was used consistently through therapy as was the sign for ‘all
done.’” Ms. Getz also recommended some stretching exercises to help reduce
Karl’s drooling, which Mr. Paluck associated with getting new teeth. Exhibit 6 at
33.

       In the morning on May 19, 2005, Karl had another appointment with Ms.
Getz. Under “subjective,” Ms. Getz stated that “Karl appeared more tired today
and mom reports he was given a decongestant which may have made him
fatigued.” Ms. Getz continued that “OT and PT noted his high tone was decreased
today and mom reports they have really been working a lot with him at home. Karl
appeared more relaxed today.” In the “objective” section, Karl had a four for
“reaching for desired toy.” He still scored zero for “approximate sounds.” Ms.
Getz also introduced various stretching exercises for his lips and cheeks. Exhibit 6
at 32.

      Also on May 19, 2005, Mr. Paluck brought Karl to the Dickinson Clinic
where he saw Dr. Peterson. Mr. Paluck reported that Karl woke with green nasal
mucus and was crying and unhappy. Dr. Peterson’s record of “objective”
measurements reports normal results, including “normal muscle tone” in Karl’s
musculoskeletal system. Dr. Peterson assessed Karl as having a “[s]inus infection
and viral syndrome.” Dr. Peterson recommended medications, including over-the-
counter cold and cough medicine. Exhibit 3 at 69.

      On May 20, 2005, Karl had another session of speech therapy with Ms.
Getz. He reached for a desired toy six times but still could not approximate or
produce consonants. Karl “tolerated stretches and vibration [to his mouth] with
much less reluctance than last session.” Exhibit 6 at 31. Karl performed similarly
during a May 24, 2005 session. Id. at 30.

      Speech therapy continued on May 26, 2005. His objective score for
producing words or consonants was zero. Ms. Getz reported that “Karl still has not
produced any vocalizations other than crying during therapy. Dad reporting
hearing Karl say ‘mom’ at home in reference [to] his mom.” Ms. Getz’s plan for
the next session was to “attempt tongue lateralization.” Exhibit 6 at 27.
                                         61
       The next three sessions (May 27, 2005, May 31, 2005, and June 2, 2005)
were relatively similar. In the first of these three appointments, Karl did not move
his tongue to get a piece of cereal placed inside his cheek. In these sessions, Karl
did not respond as well to the stretching exercises, possibly because his mouth was
sensitive due to teething. Exhibit 6 at 24-26.

      The June 2, 2005 treatment was Karl’s 12th appointment. On this date, Ms.
Getz created an “Outpatient Speech Therapy Recent Summary” for Dr.
McDonough to review. Ms. Getz recorded that Karl’s diagnosis was “global
developmental delay,” he had “good” motivation/cooperation, and his potential for
rehabilitation was “good for stated goals.” The treatment plan was for Karl to
receive therapy three times per week for four weeks. Exhibit 6 at 23.

       In the next speech appointment, on June 8, 2005, Karl could not reach a
piece of cereal placed inside his cheek. Ms. Getz stretched Karl’s mouth. During
stretches, Karl cried and needed frequent calming. He reached for a desired toy
four times. Exhibit 6 at 20.

       On June 10, 2005, Karl returned to the chiropractic clinic for the first time
since May 9, 2005. The notes for “symptoms” appear to read “Mid TT [illegible]
Upper CP ↓.” In the row of “objective” values, there is an upward pointing arrow
for “progress” and a downward arrow for “ROM C/S.” Exhibit 12 at 8.

       On this date, Karl also had a visit for speech therapy. The progress note was
relatively short, noting how many stretches were performed with Karl. Attempts
for Karl to perform “tongue lateralization” were “not completed due to sensitivity
in mouth with teething.” Ms. Getz’s assessment was “Karl’s only verbalizations
continue to be crying. He does appear to have increasing tone with oral motor
structures. Continues to slowly progress.” Exhibit 6 at 19.

       Dr. Thomas Coombe, the doctor who placed tubes in Karl’s ears, examined
Karl as part of a follow-up appointment on June 13, 2005. One of the nurses
recorded a statement from the Palucks that Karl “has had no ear infections and
sleeps fairly well[].” Dr. Coombe reported that the tubes were in good position in
the ears and expected the tubes would extrude in eight to nine months. Exhibit 10
at 21.

     On June 14-15, 2005, Karl had speech therapy appointments with Ms. Getz.
On both days, he appeared to be teething and his discomfort interfered with the
                                         62
stretching exercises. Exhibit 6 at 18. On the latter day, Ms. Getz’s assessment was
“More attentive to new toys today. Pt smiling with play with cars while sitting on
therapist[’]s lap at table. Pt also enjoyed play with blocks. No vocalizations heard
today other than crying.” Id. at 17.

       Karl had consecutive appointments at the Pokorny Chiropractic Clinic on
June 16 and 19, 2005. On June 16, 2005, the chiropractor’s handwritten notes for
the subjective portion are particularly difficult to read. In the objective portion,
within the “progress” box, there are two up arrows and one down arrow. In the
“ROM C/S” box, there are two arrows, one up and one down. For June 19, 2005,
there is a report that “Baby fell during storm last night.” Another line states “Baby
crying much more Relaxed Post [accident].”54 Karl had a tender thoracic spine.
There was a downward pointing arrow in the progress box. There was no entry for
ROM/CS box. Exhibit 12 at 8.

      On June 20, 2005, Karl returned for more speech therapy. Mr. Paluck
reported that he had been trying to place food in Karl’s cheeks as Ms. Getz had
recommended, to encourage tongue lateralization. Karl tolerated stretches well.
“Karl did appear to enjoy looking at books and models were provided for ‘more’
both verbal and signs. Animal sounds were also modeled for Karl to imitate
including moo and baa.” Exhibit 6 at 15.

      Two more sessions were held on June 27 and 30, 2005. On both occasions,
Karl was sensitive to stimulation in his mouth. Karl also was having difficulty
protruding his tongue in both sessions. Exhibit 6 at 11-12.

        On July 1, 2005, Karl went to the chiropractor. The information from this
visit is sparse. The only word in the subjective line is “irritable.” There are no
arrows, either upwards or downwards, in any of the objective boxes. This was
Karl’s final visit to the chiropractor before the onset of seizures. Exhibit 12 at 8.

      Karl’s next three appointments were for speech therapy on July 5, 7 and 11,
2005. There is relatively little detail about Karl, mostly comments about how he
responded to stretching exercises. Exhibit 6 at 8-10. The July 5, 2005 entry states


      54
        This entry lacks a period. It is difficult to tell whether the chiropractor
meant “Baby crying much more. Relaxed Post-[accident].” or “Baby crying.
Much more relaxed Post-[accident].”

                                          63
that Ms. Getz “attempted use of picture symbols with Karl looking at pictures but
not reaching for or touching pictures.” Id. at 10.

       Ms. Getz reported on her evaluation of Karl in a progress note she wrote to
Dr. McDonough on July 6, 2005. She described Karl as “slow to progress toward
goals, continues to work toward current goals.” She recommended that Karl be
seen two times a week for four weeks. Exhibit 6 at 13.

             8.     Seizures and Hospitalization

       On July 12, 2005, Karl was “napping and woke up and eyes rolled back into
head and became unresponsive.” Exhibit 6 at 66 (report from ambulance service);
accord exhibit 6 at 68 (report from emergency room doctor). An ambulance was
called. When the ambulance personnel arrived, Karl responded to their voices with
eye movements. Karl did not respond to physical stimuli. Later, Karl “returned
unresponsive to verbal or physical stimuli.” The ambulance brought him to the
local (Dickinson) emergency room. Exhibit 6 at 66.

       At the emergency room, Karl’s mother, father and emergency medical
service personnel provided a history. According to this history, Karl did not have a
fever, ear pain, eye irritation or discharge, nasal discharge, congestion, sore throat,
cough, or difficulty breathing. He also did not have vomiting, diarrhea, bloody
stools, headache, difficulty with urination, joint pain, extremity pain or decreased
urine output. The history of present illness includes a statement that Karl “is
severely developmentally delayed.” His temperature was 100.5 initially and was
102.1 one hour later. Exhibit 6 at 68.

       A doctor reviewed Karl’s systems and ordered laboratory tests. Karl also
had a lumbar puncture. The doctor prescribed at least three doses of Ativan. The
third dose came when Karl appeared to have another seizure while a doctor was
examining him. After Karl remained in the emergency department for
approximately six hours, he was transferred by ground ambulance to a hospital in
Bismarck. Exhibit 6 at 68-69; see also id. at 62-65 (discharge summary from
Dickinson).

       Dr. McDonough admitted Karl to the Medcenter One Hospital in Bismarck.
Dr. McDonough described Karl as a “17-month-old . . . with status epilepticus.”
Karl “was in his normal state of health today when he developed his eye deviation,
flaccidity, hypotonicity and jerking of his right arm.” Karl “later developed a
fever.” Exhibit 5 at 55.
                                          64
       In Dr. McDonough’s past medical history, he states that Karl has “global
developmental delay.” Karl “has seen Dr. Siriwan Kriengkrairut in evaluation.”
“He was to have urine organ [sic] acid, amino acids ordered and this was several
months ago and has not been done so his initial evaluation as directed by Dr.
Kriengkrairut has not been completed yet.” Dr. McDonough also notes that Karl
“is getting physical therapy and occupational services in Dickinson.” Id.

      For developmental history, Dr. McDonough wrote “he has no language. He
does do some babbling.” Karl “does roll over. He holds his head up well but has
not been able to crawl, does not pull to stand.” Id.

       Dr. McDonough conducted a physical examination. He noted that “[m]uscle
tone is mild increased tone lower extremities even with the medication effect. He
has tight heel cords. There is no ankle clonus. Deep tendon reflexes are
symmetrical.” Exhibit 5 at 56.

       Dr. McDonough’s plan was to order more laboratory studies, an X-ray, and
an EEG for the next day. He noted that Ms. Paluck was “anxious to get him down
to the twin cities for neurological evaluation.” Exhibit 5 at 57.

      On July 13, 2005, Karl underwent an EEG. Dr. Kriengkrairut wrote the
“neurodiagnostics report,” interpreting the EEG as “abnormal.” There was
“generalized slowing of background rhythm, which may indicate cerebral
dysfunction.” Dr. Kriengkrairut recommended a follow up study noting the
medications that Karl was taking could affect the results of the EEG. Exhibit 4 at
8-9.

       Karl remained in Medcenter One Hospital for five days. Dr. McDonough
presented pertinent information about his course, as well as the results of Dr.
McDonough’s examination when Karl was leaving the hospital in a discharge
summary, dated July 16, 2005. Dr. McDonough assessed Karl as having “[g]lobal
developmental delay with seizure disorder, possible deteriorating neurologic status
in that he is unable to do some things that he was able to do previously.” Dr.
McDonough stated that there was “no obvious[] etiology on MRI,” but when Dr.
McDonough made this statement the abnormalities in the April 27, 2005 MRI had
not been recognized. Dr. McDonough “suspect[ed] that he has an underlying
seizure disorder which hopefully can be controlled with [medication].” Exhibit 3
at 18.

                                        65
      The plan was for Karl to go for more advanced evaluation at another
hospital. Dr. McDonough arranged for Dr. Michael Frost at St. Paul Children’s
Hospital to see Karl and for unnamed doctors at Gillette’s Children Hospital to see
him as well. Id.

       The first of these appointments took place on July 19, 2005, with Dr. Frost
of Children’s Hospital. As a prelude to the examination, an intern / medical
student obtained a history of present illness.55 In this account, Karl “began
showing evidence of motor delay at appox[imately] 11 mo[nths] of age. He was
trying to crawl and had some vocal sounds, was happy and using both hands
purposefully.”56 The history continues: “He then developed rashes. He did have
history of ear infections. His tone began increasing.”57 The history also states “By
14 mo[nths] no significant progress in development. He was seen by Dr.
Kriengkrairut neurologist in April & MRI on 4/27/05 was read as normal.” Karl’s
recent medical history continues: “Mom states that since the MRI there has been a
loss in abilities[,] increase in tone with tremors with stimulation not present in
sleep. He is extremely irritable.” The intern / medical student also recorded that
Karl “has [decreased] truncal tone with loss of some head control. He has been
receiving therapies with some intermittent [decreased] tone but overall declining in
all areas.” Exhibit 11 at 5.

       At this point, the history recounts Karl’s immediate medical history, starting
with the event on July 12, 2005. “[W]hile with baby sitter [Karl] woke up from
nap[,] eyes rolled back & stiffened. Paramedics called. [Karl was] unresponsive
on arrival & continued to seize.” The history lists the medication and treatments
Karl received while hospitalized. Id.

       On the next page of the form, in the section for “past medical history,” there
is a notation “developmental 1st 6 mo[nths] of life.” Also, “11 mo[nths] of age
some evidence of motor delay. . . now loss of skills & seizures.” Exhibit 11 at 6.

      55
           The report mentions “By mom’s report” and “Mom states.”
      56
      This portion of the history is supported by records created by Dr.
McDonough. See exhibit 3 at 5-6 (report from December 27, 2004).
      57
        The use of the word “then,” suggesting that Karl developed rashes after he
was 11 months old is slightly ambiguous. Karl had rashes before he was 11
months old and after he was 11 months old.

                                         66
       Dr. Michael Frost with assistance from a registered nurse, certified, saw Karl
on July 19, 2005. Dr. Frost’s report contains a lengthy history, noting that the
information was obtained from Karl’s mother, records from Medcenter One
Hospital in Bismarck, and Dickinson Hospital. This history is particularly
thorough and is consistent with the medical records created by Medcenter One
Hospital and Dickinson Hospital. Dr. Frost’s history states that Karl “was normal
until approximately 6 months of age and then did have some mild delays.” The
history continues: “By 11 months of age, he had had multiple ear infections. He
had also had [a] rash which was biopsied and diagnosed as erythema multiforme.
He also had mild gross motor delay in that he was attempting to crawl but could
not yet pull to stand.” Exhibit 11 at 229. Dr. Frost’s report mentions the referral to
Early Developmental Services, the chiropractic care “for possible pinched nerve,”
the evaluation by Dr. Kriengkrairut, and the April 27, 2005 MRI. Dr. Frost details
events beginning with the seizure on July 12, 2005. Id. at 229-30.

       Dr. Frost stated that the question was “what etiology might be for his
deteriorating neurological status and he is admitted at this time for further
evaluation to determine etiology for his loss of skills.” Dr. Frost’s plan was to
obtain “video EEG monitoring to clarify events and look at background, also to
review previous MRI and look at what other diagnostic studies need to be
undertaken.” Exhibit 11 at 230. Dr. Frost intended to obtain an EEG, to repeat the
MRI for comparison, and to consult specialists in hematology and genetics. Id. at
232.

       After Karl was admitted, on the form for “patient orders,” there is an entry
for the “Nursing Patient History.” This entry states that “Up until about
[S]ept[ember] 2004 was meeting developmental milestones. Noted gradual but
significant loss in motor skills, and speech. Declines gradually tapered and then in
March/[A]pril of 2005 declines started again.” Exhibit 11 at 225.

        On July 20, 2005, a clinical geneticist saw Karl as Dr. Frost had requested.
Dr. Mary Ella Pierpont obtained another history. Dr. Pierpont records that “[t]he
family feels he was relatively normal for the first 6 months of life. By 9 months of
life, they noticed that he was somewhat developmentally delayed. Prior to this, he
was trying to crawl and some vocalizations. He used his hands in a purposeful
manner. He held his head up well.” Exhibit 11 at 234. Dr. Pierpont also
examined Karl and recorded the results. Her assessment was that “[t]his young
boy appears to have evidence of neurodegeneration. A particular diagnosis is not
immediately apparent.” Dr. Pierpont recommended another MRI. Id. at 235.
                                         67
        On that day, a pediatric hematologist, Dr. Christopher Moertel, also saw
Karl for a possible iron deficiency as Dr. Frost had recommended. Dr. Moertel’s
history, which was taken from Karl’s mother and father, begins: “Karl’s past
medical history is significant for his loss of milestones since approximately 11
months of age.” Exhibit 11 at 46. The remainder of Dr. Moertel’s evaluation is
largely irrelevant because Dr. Moertel stated “I do not believe there is an
association between the patient’s iron status and the current neurological problem.”
Id. at 47.

       On July 22, 2005, Karl had an MRI without contrast. The film from the
April 27, 2005 MRI in Bismarck was available for comparison. The radiologist,
Dr. Theodore J. Passe, found “[d]iffuse increased T2 signal throughout the cerebral
white matter involving the deep and superficial portions of the white matter. . . .
Moderate cerebral atrophy has developed since the last exam with further thinning
of the corpus callosum.” Dr. Passe’s impression was that these findings “are
consistent with a progressing leukodystrophy (consider hereditary, toxic or
metabolic etiologies).” Exhibit 11 at 91.58

        Karl stayed in the epilepsy unit of Children’s Hospital in St. Paul from July
19, 2005 to July 31, 2005. Additional details about his course for these 12 days are
recorded in a narrative summary that Dr. Frost dictated after Karl was discharged.
Dr. Frost states that the doctors looked at the April 27, 2005 MRI again. “In
reviewing the previous MRI, it was felt that abnormality was apparent on that
initial MRI, as well.” Exhibit 11 at 52. During his hospitalization, the doctors
placed a feeding tube in Karl. Dr. Frost’s ultimate impression was that “MRI
results are indicative of a neurodegenerative disease, felt to be likely progressing
leukodystrophy. This was also confirmed by impression from geneticist. Further
genetic testing to be pursued, depending upon findings from the lysosomal
enzymes. Prognosis is guarded.” Id. at 56.59



      58
        “Leukodystrophy” means “any of various types of neurodegeneration
involving disturbance of the white matter of the brain.” Dorland’s Illustrated
Medical Dictionary 1029 (32nd ed. 2012).
      59
         The tests for lysosomal enzymes appear to present normal results. Exhibit
18 at 26.

                                         68
             9.    Miscellaneous Visits, including Mitochondrial Testing

      Three days after his discharge from Children’s Hospital, Karl went to the
Dickinson Clinic. His mother reported that he started having a runny nose five
days previous and it had gotten worse. Dr. Oksa diagnosed him as having sinusitis
for which she prescribed an antibiotic and noted his neurodegenerative disease for
which he had been evaluated in Children’s Hospital. Dr. Oksa requested that the
Palucks bring in Karl again in about two weeks. Exhibit 3 at 70.

      The follow up appointment with Dr. Oksa took place on August 15, 2005.
Dr. Oksa deferred her examination, noting only “Fussy little boy being held by
parent. No eye contact or purposeful activity.” Dr. Oksa made some adjustments
for Karl’s nutrition, which he was receiving through a tube, and advised waiting
for more information from laboratory studies that were still pending. Exhibit 3 at
72-73.

      Although some records give information about Karl after August 2005, his
development did not change.60 On October 27, 2005, Karl had another MRI. This
was Karl’s third MRI, following other MRIs on April 27, 2005, and July 22, 2005.
Dr. Frost’s recitation of the results of the October 27, 2005 MRI was, in part:

      Intracranial contents otherwise were not definitely changed from
      07/25/05, again demonstrated some diffuse increased T2 signal in
      cerebral white matter with prominent thinning of the corpus callosum.
      This could represent nonspecific leukodystrophy. Alternatively, the
      progression of a signal change is [sic] between 4/27/05 and 07/22/05
      may have represented evolution of 1 toxic/metabolic event, which is
      now stable.

Exhibit 11 at 280. In reference to the signal changes and stabilization in the corpus
callosum, Dr. Frye explained that “the majority of changes in his brain occurred
between the first two MRIs.” Tr. 120:1-3.

      As doctors continued to treat Karl, they looked to see if Karl could have a
problem in his mitochondria. In October 2005, Dr. Frost at Children’s Hospital in
St. Paul arranged for a muscle biopsy. Exhibit 18 at 39. The results reflected a

      60
        During the July 26, 2010 hearing, the Secretary commented that recent
medical records had not been filed. Tr. 352:12 to 353:17.

                                         69
“[p]robable [m]itochondriopathy.” Id. at 49-51. In August 2006, Baylor College
of Medicine conducted more advanced tests and found more specific evidence of
mitochondrial disorder. Exhibit 18 at 60.

      As mentioned earlier in this decision, the parties have assumed that Karl was
born with the disorder in his mitochondria. See Tr. 80:24 to 81:8 (Dr. Frye),
260:5-10 (Dr. Snodgrass), 377:7-11 (Dr. Snodgrass). Furthermore, the evidence
preponderates in favor of a finding that Karl was experiencing neurological
problems linked to his mitochondrial disease in October 2004, which is before he
was vaccinated. See section III. above.

       The question posed by this case is whether the Palucks have established that
the January 2005 vaccinations significantly aggravated Karl’s mitochondrial
disease. This question is answered by evaluating the six prongs of the Loving test.
The first two prongs have been examined.


      C.    Loving Prong 3: Does Karl’s Current Condition Constitute a
      “Significant Aggravation” of His Condition Prior to the Vaccination?

       The next portion of the Loving test is determining whether there is
“significant aggravation” by comparing Karl’s condition before the vaccination to
his current condition.61 The statute defines “significant aggravation” as “any
change for the worse in a preexisting condition which results in markedly greater
disability, pain, or illness accompanied by substantial deterioration in health.” 42
U.S.C. § 300aa–33(4).

      Here, Karl was much less healthy on July 30, 2005 (when he was discharged
from Children’s Hospital) than he was on January 19, 2005 (when he received the
vaccinations in Dr. McDonough’s office). By virtually any metric, Karl was
worse.




      61
         As noted herein, the Palucks have not filed recent medical records. It is,
therefore, somewhat of a misnomer to look at Karl’s “current condition,” strictly
speaking.

                                         70
      D.   Loving Prong 4: Is There a Medical Theory Causally Connecting
      Such a Significant Worsened Condition to the Vaccination?

       The December 14, 2011 decision found that the Palucks had failed to meet
their burden of proof on this issue. However, the Court vacated that finding,
stating “it is plain that the special master required a higher level of proof from the
Palucks than the Vaccine Act demands.” Opinion and Order, 104 Fed. Cl. at 473.
The Court concluded its analysis of this prong by stating that the “Vaccine Act
requires no more” than a “showing that [a theory] is sufficiently worthy and
reliable to merit . . . extensive scientific inquiry.” Id. at 475.

      In briefing after the Court’s Opinion and Order, the parties essentially
agreed that the Palucks’ evidence met the standard as defined by the Court. The
Palucks maintained that under the Court’s review of the entire record, “there is
more than sufficient evidence to support a finding that Petitioners have met their
burden of proof under all three prongs of Althen.” Pet’r Status Rep’t, filed May 7,
2012, at 7. The Secretary’s position was more equivocal, stating that “the Opinion
may have hamstrung the special master from denying compensation under prong
one of Althen.” Resp’t Resp., filed June 8, 2012, at 4. Although this statement is
not an outright concession, the Secretary did not present any substantive argument
regarding prong one of Althen in any of her post-remand briefs.

       The finding that the Palucks have established prong one of Althen under the
Court’s interpretation of what is sufficient evidence does not necessarily entitle
them to compensation. Petitioners must still establish the second prong of Althen.
See W.C. v. Sec’y of Health & Human Servs., 704 F.3d 1352, 1358 (Fed. Cir.
2013) (affirming special master’s denial of compensation for an alleged significant
aggravation claim where petitioner failed to establish all three prongs of the Althen
test); Hibbard v. Sec’y of Health & Human Servs., 698 F.3d 1355, 1364-65 (Fed.
Cir. 2012) (finding no error in special master’s denial of compensation where
petitioner failed to establish Althen prong two); Ricci v. Sec’y of Health & Human
Servs., 101 Fed. Cl. 385, 391-92 (2011) (affirming special master’s denial of
compensation where petitioners failed to show the existence of the prong two
injury required by their prong one theory).




                                          71
      E.   Loving Prong 5: Is there a Logical Sequence of Cause and Effect
      Showing that the Vaccination Significantly Aggravated Karl’s
      Condition?

       The December 14, 2011 decision found that the Palucks had failed to meet
their burden of proof on this element. The decision was based upon two
propositions. First, the Palucks’ expert presented a theory in which the vaccine
would cause a continual deterioration. 2011 WL 6949326, at *6-17. Second, that
Karl did not decline in the manner that Dr. Frye predicted. Id. at *22.

        The Court held that the December 14, 2011 decision was arbitrary and
capricious with respect to the second finding. (The Court did not disturb the
finding that Dr. Frye’s theory was predicated on a downhill trajectory. See
Opinion and Order, 104 Fed. Cl. at 476.) Without making any affirmative findings
of its own, the Court vacated the December 14, 2011 decision for a discussion of
the chiropractor’s records, the treating doctors’ “statements regarding the cause of
Karl’s decline,” and Dr. McDonough’s referral to a pediatric neurologist.

       In accord with the Court’s instructions, the three specific parts of the record
will be discussed in more detail. Then, there is an overall finding.

             1.     Chiropractor’s Records

       Karl saw an unnamed chiropractor (or chiropractors) at the Pokorny Clinic,
starting on February 7, 2005. Karl had nine visits in February, seven in March,
four in April, one in May, and three in June. Karl had one appointment in July
before his seizures started, and a single visit in 2006.

      The two expert neurologists, Dr. Frye and Dr. Snodgrass, did not discuss the
chiropractor’s records extensively.62 Dr. Frye completed his direct testimony



      62
         In their posthearing brief, the Palucks summarized the chiropractor’s
records in one paragraph, containing seven sentences. Pet’r Posthr’g Br., filed Feb.
18, 2011, at 6-7. The Palucks also argued that the chiropractor’s records support
Dr. Frye’s theory that Karl’s neurological status changed dramatically. Id. at 19-
20.


                                          72
without citing the chiropractor’s records once.63 Similarly, when the Palucks
presented a demonstrative “time line,” summarizing the medical records, the
Palucks omitted the chiropractor’s records completely. See exhibit 23 at 8; see
also exhibit 24 at 3.

       When the Palucks called for rebuttal testimony from Dr. Frye, they elicited
testimony from him about four specific entries from the chiropractor. Tr. 646:15 to
650:22. For February 9, 2005, the chiropractor described Karl as “irritable.”
Exhibit 12 at 5. Dr. Frye found this description significant because previously Karl
was described as “a very happy child.” Tr. 647:2-3. For February 11, 2005, the
chiropractor described Karl as “spastic.” Exhibit 12 at 5. Dr. Frye defined
“spasticity” as “suggest[ing] a very severe neurological event.” Tr. 647:14-15. Dr.
Frye opined that spasticity “suggests that there was a very rapid change in his
central nervous system,” worse than the increased tone that had been found
previously. Tr. 647:17-18.64 On March 30, 2005, a chiropractor used the term
“C.P.” and mentioned a cerebellar tumor. Exhibit 12 at 7. Dr. Frye explained that
children with cerebral palsy have spasticity and the reference to a cerebellar tumor
“suggest[s] that [Karl] has some ataxia or some inability to control his movements
very well.” Tr. 649:10-11. Finally, the Palucks’ attorney drew Dr. Frye’s attention
to the chiropractor’s March 17, 2005 visit in which the chiropractor recorded that
Karl “cries loud when touched” and mentioned back pain. Exhibit 12 at 7. Dr.
Frye interpreted these notations as “suggesting that he’s starting to have spasticity
of some of the axial musculature and back pain, . . . and that this something that is
progressive because we know previously he was a very happy child without pain.”
Tr. 650:1-3.

       After reviewing these four entries, the Palucks asked Dr. Frye whether “any
of the findings identified by the chiropractor in February and March of 2005” were

      63
         The word “chiropractor” appears only twice in the transcript from the
March 22, 2010 hearing. Tr. 7:6 (Respondent’s counsel requesting any updated
records from Karl’s care providers, including his chiropractor), 31:3 (Petitioners’
counsel’s opening statement).
      64
          Later, Dr. Frye stated that a “reactive spasticity” is “a sign of a problem
with a lack of inhibition of certain muscles from the cerebral cortex consistent with
a lesion, or that is not having the neurons in the cerebral cortex to inhibit certain
motor neurons in the spinal cord.” Tr. 705:22 to 706:1.


                                         73
reflected in Dr. McDonough’s January 19, 2005 examination. Dr. Frye responded
that they were not; Karl was “a very different child.” Tr. 650:11-12. To Dr. Frye,
the chiropractor’s notes show that “it’s actually progressing as he sees the
chiropractor.” Tr. 650:13-14. After obtaining an opinion from Dr. Frye that Karl
“had regression after the 19th [of January],” Tr. 650:20-21, the Palucks moved on
to other topics and did not otherwise question Dr. Frye about the chiropractor’s
records.

      However, the chiropractor created other records. These other records reflect
observations made by a person in the health profession within two months of
Karl’s vaccination, and, as such the Court has directed a review of those records.

       Records about which the Palucks did not elicit testimony from Dr. Frye are
not entirely consistent with Dr. Frye’s description of Karl as “a very different
child.” Tr. 650:11-12. While the chiropractor’s second entry states that Karl is
“irritable,” and the next one says that Karl is “spastic,” the next three entries say
that Karl has a “better mood,” is “less rigid – more comfortable on all 4’s,” and is
“less rigid – ‘happier.’” Exhibit 12 at 5 (entries for February 14, 16, and 18,
2005).65 The last notation “‘happier’” seems to contradict Dr. Frye’s view that
Karl was different when he was seeing the chiropractor because he formerly was “a
very happy child,” but after the vaccination was not.

       The undersigned raised with Dr. Frye the notation that Karl was “less rigid.”
Dr. Frye stated that the physical therapy, which Karl was receiving through the
chiropractor, would not correct a problem in the upper motor neurons. Tr. 726:19-
20. However, manipulation of Karl’s muscles “reset[s] the feedback mechanism
that sets the tone of the muscle.” Tr. 726:23-24; see also Tr. 812:15 to 813:12 (Dr.
Snodgrass briefly explaining how damage to the spinal cord can cause
hypotonicity).

       This is the extent of Dr. Frye’s testimony about the chiropractor’s records.
But, there are still more records.

       On February 20, 2005, Karl was reported to be “stiff.” He was also “Happy
– moving around.” In the box for progress, there are three arrows. The first two
point up (suggesting improvement) and one arrow points down (suggesting

      65
        For each of these three entries, there are upward pointing arrows in the
boxes for “progress” and “ROM C/S.”

                                         74
decline). There is another down arrow for ROM C/S. The very next day, Karl is
again “irritable.” For progress, there is one small arrow pointing up and next to it a
dashed line. For ROM C/S, there is a single notation of an arrow pointing up. It is
unclear whether these records mean that Karl is improving or worsening.

      It is difficult to glean much significance from the chiropractor’s records,
especially because the parties did not ask their experts to interpret them. The
records are written in handwriting, which in places is difficult to decipher. The
chiropractors have written their plans using abbreviations and codes whose
meaning is not readily apparent. Neither party elicited testimony from Dr. Frye or
Dr. Snodgrass to explain what phrases such as “T6, At (ASRA)” mean. Moreover,
given that Dr. Frye and Dr. Snodgrass are medical doctors, not chiropractors, it is
not even apparent that Dr. Frye or Dr. Snodgrass could assist.

       Nevertheless, the chiropractor’s records have been studied. They contain
some straightforward descriptions of Karl’s conditions. From February 9, 2005
through February 18, 2005 (inclusive), Karl is listed as “irritable,” “spastic,”
“better mood,” “less rigid – more comfortable on all 4’s,” “less rigid – ‘happier’.”
For this period of time, the “progress” box and the ROM/CS box contain a total of
seven upward arrows and zero downward arrows. Exhibit 12 at 5.

      On the next page of notes, there are six entries, covering from February 20,
2005 through March 8, 2005 (inclusive). Karl is described as “Stiff – mid TP –
Happy – moving around,” “Mid T tite & SO P – irritable,” “spastic,” “No BM
yesterday,” “BMs better – less fussy,” “Less hypertonicity, increased on all fours,
BMs more regular.” In the “progress” and “ROM / CS” boxes, there are 12 arrows
pointing upward.66 Two arrows point down. Exhibit 12 at 6.

      The next five entries are from March 10, 2005 to April 8, 2005.67 The
descriptions for Karl read “Not sleeping last nite . . . irritable / good day

      66
        There are also four upward arrows in the box for ROM L/S (and no
downward arrows in this box). However, in the course of Karl’s treatment, the
chiropractors made relatively few entries in the ROM L/S box.
      67
        This page includes notes from a March 30, 2005 conversation between a
chiropractor and a person from Stark County Social Services. Because this note
has some discussion about the chiropractor’s assessment of causation, the March
30, 2005 entry is discussed in more detail in section IV.E.2.a below.

                                         75
yesterday,” “Upper ext[remities] skin blotches – back pain . . . palpation of spine
painful baby cries loud when touched,” “Rigid lower extrem[ities]. . . . ‘Doing well
‘til yesterday,’” “less rigid, good mood this week, taking a few crawling steps . . .
no red spots for 2 wks,” “cold symptoms better . . . antibiotic / 1 wk. Augmentin
. . . Discussed file with parents ‘not concerned’ ‘You make decisions Karl’s care.’”
For this period, there are five upward arrows and five downward arrows. Exhibit
12 at 7.

       The next page of entries begin on April 15, 2005, with a notation of “‘doing
so-so’ – some crawling.” These entries record Karl’s status starting approximately
three months after his January 19, 2005 vaccinations. Thus, they are relatively less
germane to the question posed by the Court. Opinion and Order, 104 Fed. Cl. at
480.

             2.    Statements Regarding the Cause of Karl’s Decline from His
             Treating Physicians

       The next topic for which the Court ordered reevaluation was statements of
treating doctors regarding the cause of Karl’s decline. In this regard, the Court
ordered further discussion of a chiropractor’s March 30, 2005 entry, a doctor who
examined Karl’s MRI, and a report from Dr. Frost who examined Karl’s MRIs.
These are discussed in turn.
                   a)     Chiropractor’s March 30, 2005 Note

      By March 30, 2005, Karl had been treated at the Pokorny Chiropractic
Clinic 15 times. On March 30, 2005, a person, probably Brenda Erie, from Stark
County Social Services, called the chiropractor to discuss Karl’s condition. (A
week earlier, Ms. Erie had called Dr. McDonough about Karl’s case. Exhibit 5 at
73; exhibit 3 at 7). The reason for the call was a “poss. Adverse Rx / vaccine.”
The chiropractor’s notes say “I responded – No.” Exhibit 12 at 7.

       This record does not assist the Palucks in establishing that a vaccine
adversely affected Karl. The overall context suggests that, between the
chiropractor and Ms. Erie, the idea that Karl could have had an adverse reaction
originated with Ms. Erie. Until the discussion with Ms. Erie, the chiropractor has
no notes mentioning a vaccine. To the extent that Ms. Erie was proposing an
adverse reaction to a vaccine, there is no information in the record about Ms. Erie’s
qualifications to link a vaccine to an adverse health outcome. See 42


                                         76
U.S.C. § 300aa–13(a) (stating a special master may not award compensation when
claims are “unsubstantiated by medical records or by medical opinion”).

       Regardless of who initially proposed the adverse reaction, the more
important point is how the chiropractor replied. The chiropractor answered “No.”
The chiropractor’s opinion was that Karl did not have an adverse reaction to a
vaccine. The chiropractor’s opinion is the opposite of what the Palucks are
asserting. See Resp’t Resp., filed June 8, 2012, at 8 n.1.68
                   b)  Dr. McDonough’s Referral to Neurologist in
                   March 2005

      The Court also directed consideration of Dr. McDonough’s referral to Dr.
Kriengkrairut in March 2005. The context for this referral was that Dr.
McDonough had seen Karl on January 19, 2005, for Karl’s one-year check-up. (It
was at this appointment that Karl received the vaccinations at issue in this case.)
As of that date, Karl “was rolling over and babbling but not sitting yet and not
crawling much.” Exhibit 3 at 7; see also exhibit 3 at 3. Dr. McDonough referred
Karl for physical and occupational therapy as well as a stimulation program.
Exhibit 3 at 7.

       After Dr. McDonough’s referral, the parents did not take Karl for physical
and occupational therapy. See exhibit 3 at 9. Rather the parents were taking Karl
to a chiropractor. See exhibit 12, passim.

      It appears that in mid-March 2005, someone from the office of Stark County
Social Services contacted Dr. McDonough “regarding Karl’s lack of participation

      68
         If the chiropractor had provided an opinion supporting the Palucks’ claim
that a vaccine harmed Karl, then that opinion would be considered as part of the
record as a whole. See 42 U.S.C. § 300aa–13. The chiropractor’s training and
experience to reach a medical conclusion about causation would, however, be
factored into the evaluation of any such opinion. See Tiufekchiev v. Sec’y of
Health & Human Servs., No. 05-437V, 2008 WL 3522297, at *11 (Fed. Cl. Spec.
Mstr. July 24, 2008) (chiropractor’s “diagnosis [of petitioner’s] symptoms as post-
vaccination syndrome . . . is afforded the least evidentiary weight of [petitioner’s]
treating doctors” (citing Anderson v. Sec’y of Health & Human Servs., No. 06-
168V, 2006 WL 5626962, at *3 (Fed. Cl. Spec. Mstr. Oct. 13, 2006); Diaz v.
Shalala, 59 F.3d 307, 314 (2d Cir. 1995))).

                                         77
in physical and occupational therapy.” Exhibit 3 at 7. Although the record is not
entirely clear on this point, it appears that the call from Social Services prompted
Dr. McDonough to call the Palucks. See exhibit 5 at 72 (noting that on March 22,
2005, Ms. Paluck returned Dr. McDonough’s call). Mr. and Ms. Paluck reported
that Karl was doing “some brief crawling, not sitting on his own, leans to one side,
babbling more, rash – comes & goes.” The result of this call was Dr.
McDonough’s referral of Karl to Dr. Kriengkrairut. Id.

       Before Dr. McDonough formally referred Karl to Dr. Kriengkrairut, Brenda
Erie from Stark County Social Services called Dr. McDonough about an emergent,
yet unspecified, matter. Dr. McDonough noted that he was planning an evaluation
with a pediatric neurologist. Exhibit 5 at 73.

      Dr. McDonough’s written referral to Dr. Kriengkrairut came on March 24,
2005. Dr. McDonough recommended “a CT scan and medical evaluation for
congenital infection and inborn areas [sic, possibly errors] of metabolism.” Dr.
McDonough asked that Dr. Kriengkrairut investigate “etiology of [Karl’s]
developmental delay and hypertonicity.” Exhibit 3 at 7.

       There was relatively little testimony about the significance of Dr.
McDonough’s referral to a pediatric neurologist. Dr. Frye stated Dr. McDonough
wanted additional testing, including a CT scan. Tr. 107:4-13. This testimony is
certainly correct because it restates what is clearly in the medical record.

      What is less clear is why Dr. McDonough made a referral to a pediatric
neurologist in March 2005, when Dr. McDonough did not make a similar referral
in January 2005. Dr. McDonough did not explain his motivation in his referral.
Thus, a certain amount of inductive reasoning is needed. Arguably, Dr.
McDonough’s referral could reflect a concern that Karl’s condition is either not
improving as quickly as Dr. McDonough would like or worsening.69 Karl’s

      69
          The Palucks, however, have not made this argument. In their post-trial
brief, the Palucks mention Dr. McDonough’s referral only in passing. See Pet’r
Posthr’g Br., filed Feb. 18, 2011, at 12 (noting Dr. McDonough sought “an
evaluation and medical investigation into Karl’s developmental delay and
hypertonicity”). In their reply brief, the Palucks do not discuss Dr. McDonough’s
referral. See Pet’r Resp. to Resp’t Posthr’g Br., filed Mar. 11, 2011, at 18
(discussing medical records for March and April 2005 without mentioning
referral). Even after the Court’s Opinion and Order in which the Court instructed
                                                                      (. . . continued)
                                           78
apparent lack of developmental progress may have alerted Dr. McDonough to
consider whether Karl had a neurologic disease that a pediatric neurologist could
diagnose. Another explanation, which is not inconsistent with the first reason, is
that Dr. McDonough was frustrated that the Palucks were not following his
recommendations for physical therapy, occupational therapy, and a stimulation
program for Karl. At different points in his records, Dr. McDonough comments
that Karl is not receiving the services he recommended. Dr. McDonough,
therefore, may have seen the referral to a specialist as an opportunity for that
doctor to reinforce Karl’s need for therapy. Since there is no testimony from Dr.
McDonough about his reason(s) for the referral to the pediatric neurologist, any
conclusion is necessarily tentative and speculative.70


                     c)     Report from July 22, 2005 MRI

      The Court also ordered reconsideration of the report interpreting Karl’s July
22, 2005 MRI. Dr. Frost, from the Children’s Hospital in St. Paul, Minnesota,
ordered this MRI for Karl. The doctor who dictated and released the report was
Dr. Theodore J. Passe. Dr. Passe’s impressions included “[m]oderate cerebral
atrophy has developed since the last exam with further thinning of the corpus
callosum” and “[f]indings are consistent with a progressing leukodystrophy
(consider hereditary, toxic, or metabolic etiologies).” Exhibit 11 at 91-92.

      Two aspects of this report merit additional attention – “further thinning” and
“toxic or metabolic etiology.”

Further Thinning

      Concerning Dr. Passe’s statement that the July 22, 2005 MRI showed
“further thinning,” the Court stated that “[t]he word ‘further’ suggests that the
corpus callosum was already thin by April 27, 2005, and thus had begun to thin, or
was thin, even earlier than that.” Opinion and Order, 104 Fed. Cl. at 479. The
Court additionally cited a portion of Dr. Frye’s testimony. The undersigned asked


consideration of Dr. McDonough’s referral to the pediatric neurologist, the Palucks
did not comment on this referral directly. See Pet’r Status Rep’t, filed May 7,
2012, at 6.
      70
           The parties declined to offer additional testimony.

                                           79
Dr. Frye what he thought was happening to Karl between January and March /
April. In this context, Dr. Frye stated that Karl’s worsening

      would start at a cellular level, and then start to become more and more
      clinical, and one of the things I kind of base that on is the first MRI
      seemed equivocal. Right at first, it was read as normal, and then it’s
      read abnormal, and that’s not that unusual sometimes when you go
      back.
             But that suggests this process was just starting, so over several
      months, you know, you started getting it at the cellular level, and then
      it was just beginning to be on the point where you can actually see it
      on MRI, which means it has to be pretty severe.

Tr. 232:5-15.

       Dr. Frye’s reasoning that a showing of an abnormality on the April 27, 2005
MRI means that the abnormality must have existed before the scan was performed
is certainly correct. See W.C. v. Sec’y of Health & Human Servs., 100 Fed. Cl.
440, 451-53 (2011) (finding that special master was not arbitrary in finding that
non-enhanced lesions on MRI was evidence that petitioner suffered from non-
eloquent multiple sclerosis before the vaccination), aff’d, 704 F.3d 1352 (Fed. Cir.
2013). Dr. Frye, however, does not offer a discrete opinion as to when the corpus
callosum began to thin.71

       When asked about the April 2005 MRI, which showed abnormalities in
Karl’s white matter, Dr. Snodgrass testified “[o]f course we don’t know when that
injury occurred.” Tr. 484:19-20. The Palucks’ attorney, who was cross-examining
Dr. Snodgrass at the time, followed this answer by asking:

             Q: Well, I believe it was Dr. Frye’s testimony that the evidence
      – that the scan – characteristics of the scan would indicate that that
      injury was close in time to the MRI, which would put it within the
      time frame after the vaccine; wouldn’t it?
             A: Maybe that’s Dr. Frye’s opinion but that’s not mine. I have
      seen similar scans in people who had prenatal infections with the
      same kind of white matter abnormality, six or 12 months later.

      71
       Dr. Frye states that the process may have been taking place for “several
months” without explaining how long “several months” is.

                                         80
Tr. 484:21 to 485:4.

       In an ideal circumstance, an MRI where Karl’s brain appeared “normal”
would be available for the experts to reference in their effort to date the onset of
Karl’s neurological injury. Unfortunately, this is not the case. Instead, the experts’
ability to offer any definitive opinion as to the onset is severely constrained by the
available evidence.

       In sum, the April 27, 2005 MRI provides radiographic information that one
structure of Karl’s brain was not normal on that date. But, the next inference –
deciding when the corpus callosum started to thin – necessarily requires some
speculation. The Palucks have not established that Dr. Frye’s conclusion that
Karl’s corpus callosum started to thin after the vaccination is more likely than Dr.
Snodgrass’s conclusion that the corpus callosum could have been thin before the
vaccination. The finding that Karl was evidencing CNS dysfunction before
vaccination, however, weighs against Dr. Frye’s view.

Toxic or Metabolic Etiology

      The Court also directed consideration of Dr. Passe’s impression that Karl’s
July 22, 2005 MRI was “consistent with a progressing leukodystrophy (consider
hereditary, toxic, or metabolic etiologies).” Exhibit 11 at 91-92. This statement is
not persuasive evidence that a vaccine harmed Karl for two reasons.

      First, Dr. Passe stated that the etiology could be metabolic and Karl was
found to have a metabolic disorder. Karl’s mitochondrial disease is a dysfunction
in Karl’s metabolism. Thus, of the three possibilities Dr. Passe listed, “metabolic”
seems most likely to fit Karl’s situation.

      Second, although the term “toxic” is broad enough to include an injury
caused by a vaccine, this category includes other sources as well. A prominent
non-vaccine potentially “toxic” substance is the anesthesia Karl received before the
April 27, 2005 MRI. See Tr. 561:4 (the scan “required him to receive general
anesthesia”). Dr. Snodgrass proposed that the anesthesia could have harmed Karl.
See Tr. 582:5-11.

      Dr. Frye did not say that Dr. Passe’s statement that Karl’s progressing
leukodystrophy could have a “heredity, toxic or metabolic” etiology meant that Dr.
Passe was stating that a vaccine caused the leukodystrophy that Dr. Passe
                                         81
identified in Karl. The only testimony from Dr. Frye about Dr. Passe’s reference
to a toxic etiology in the July 22, 2005 report was as follows:

             Q: And the radiologist makes a suggestion for considering the
      etiology of this change in his white matter. What was that suggestion
      that the radiologist made?
             A: So he was suggesting hereditary abnormalities, toxic
      abnormalities, and metabolic etiologies.

Tr. 118:7-11. While the Palucks have cited Dr. Passe’s July 22, 2005 report as a
statement of a treating doctor showing that the reason for Karl’s decline was the
vaccination, see Pet’r Resp. to Resp’t Posthr’g Br., filed Mar. 11, 2011, at 20, the
Palucks’ argument is really an attorney’s argument. The argument is not
persuasive because the Palucks have not addressed the other possible causes listed
by Dr. Passe (metabolic) and have not explained why the “toxic” etiology means
“vaccine.” See, e.g., Tr. 121:16-24 (Frye direct examination) (Q: “[W]hen you’re
mentioning the term “toxic event,” that is the toxic events occurring intracellularly,
not necessarily that it is a toxin like thimerosal or something such as that.” Dr.
Frye: “No. You’re absolutely right. I’m sorry.”).


                   d)     Dr. Frost’s December 5, 2005 report

      In a footnote, the Court mentioned that the undersigned did not discuss Dr.
Frost’s December 5, 2005 report. Opinion and Order, 104 Fed. Cl. at 479 n.29.
This report followed Karl’s hospitalization in October 2005.

       Although this report summarized Karl’s history, the focus appears to be on
the report from an MRI conducted on October 27, 2005. Essentially, this report
compares the results of the three MRIs. It states that between the first MRI (in
April) and the second MRI (in July), Karl deteriorated. Between the second MRI
and the third MRI (in October), Karl remained about the same. Neither Dr. Frye
nor Dr. Snodgrass testified that the third MRI offered any meaningful information
about the cause of Karl’s neurologic problem. Similarly, the parties have not
presented any argument based on the third MRI in their post-hearing briefs,
including the briefs submitted after remand.




                                         82
             3.    Conclusion

      The December 14, 2011 decision found that Karl’s post-vaccination
developmental decline was not linear, as the Palucks argued. 2011 WL 6949326,
at *23. The Court vacated this finding for additional consideration. After
reevaluating the evidence in accordance with the Court’s instructions, the special
master again concludes that Karl’s deterioration was non-linear.

       The Federal Circuit has recently explained that part of the Althen prong 2
analysis may consider whether the expert’s “theory accounted for [the vaccinee’s]
injury.” Hibbard, 698 F.3d at 1364. Here, Dr. Frye’s theory predicts that the
vaccine would cause a dramatic and continual deterioration, beginning within two
to three weeks after receipt. See Tr. 126:14-23 (“immunizations . . . result in
immune activation, which causes a fever . . . , followed by irritability for several
days to weeks and then loss of skills which continues from weeks to months”),
145:12-13 (“usually reactions happen within two weeks of having a vaccine”),
132:6-12 (initiation of the downward spiral “happens probably within a week of
the inciting event). And, Dr. Frye testified that Karl responded in accordance with
his theory. Tr. 657:10-19 (subsequent to vaccination “he has devastating
regression that continues until April, and continued after that with the development
of seizures and him continuing to lose function”), 663:20 to 664:1 (“the vaccine
triggered a process that was self-perpetuating and caused a downward spiral to
continue to damage the body and cause cell death”). Karl, however, did not
decline as expected in the relevant time. Thus, the Palucks have failed to meet
their burden regarding Althen prong 2, which corresponds to Loving prong 5.


      F.   Loving Prong 6: What is a Proximate Temporal Relationship
      between the Vaccination and the Significant Aggravation?

       The last element in the six-part Loving test has origins as the third prong of
Althen. As stated by Loving, this element is “a showing of a proximate temporal
relationship between the vaccination and the significant aggravation.” Loving, 86
Fed. Cl. at 144. Based upon Bazan v. Sec’y of Health & Human Servs., 539 F.3d
1347, 1352 (Fed. Cir. 2008), the December 14, 2011 decision divided this element
into two components: “(a) the timeframe for which it is ‘medically acceptable to
infer causation,’ and (b) the onset of the condition for which petitioner seeks
compensation.” 2011 WL 6949326, at *24. The Court’s Opinion and Order did
not reject this organizational construct. 104 Fed. Cl. at 480-83.


                                         83
      The December 14, 2011 decision analyzed the evidence for each of these
components and found that the appropriate medical interval was two weeks and
that Karl did not manifest neurodegeneration until after two weeks. 2011 WL
6949326, at *26-28. The Court’s Opinion and Order, however, vacated both
findings, stating that these findings were “arbitrary and capricious.” 104 Fed. Cl.
at 483. Although the Court vacated the findings in the December 14, 2011
decision, the Court did not state that the December 14, 2011 decision failed to
discuss relevant evidence. The Court, as noted previously, did not make any
findings of its own.

             1.    Medically Acceptable
                   a)     Standards for Adjudication

       On occasion, the Federal Circuit has examined how special masters have
implemented the third prong of Althen. One example is Pafford v. Sec’y of Health
& Human Servs., 451 F.3d 1352 (Fed. Cir. 2006). There, the Federal Circuit stated
that “[e]vidence demonstrating petitioner’s injury occurred within a medically
acceptable time frame bolsters a link between the injury alleged and the
vaccination at issue under the ‘but-for’ prong of the causation analysis.” Id. at
1358.

       The Federal Circuit viewed how the special master had examined the
evidence. The Federal Circuit quoted the special master’s decision as stating
“Petitioners provide no objective evidence indicating an appropriate time frame in
which Still’s disease will manifest subsequent to a triggering event.” Id. at 1359
(quoting Pafford v. Sec’y of Health & Human Servs., No. 01-165V, 2004 WL
1717359, at *7 (Fed. Cl. Spec. Mstr. July 16, 2004)) (internal quotation marks
omitted). The Paffords’ evidence on this point was lacking because one expert
(Dr. Levin) did not provide any evidence on this point and the other expert (Dr.
Geier) was not persuasive. The special master found Dr. Geier’s testimony
insufficient because, in part, the scientific literature he relied upon did not “show
the specific temporal relationship for Still’s disease[,]” only “the temporal
relationship for arthralgia episodes and joint syndromes in general[.]” Id. (citing
2004 WL 1717359, at *7 n.42). Under its standard of review, the Federal Circuit
did not identify a “reversible error” in the special master’s decision. Id.

       Another example of a Federal Circuit case involving the appropriate medical
interval is Bazan, 539 F.3d 1347. There Ms. Bazan claimed that a tetanus toxoid-
diphtheria vaccine caused her to suffer acute disseminated encephalomyelitis

                                         84
(“ADEM”) approximately 11 hours later. The special master accepted the
testimony of the government’s expert who testified that 11 hours was an
insufficient amount of time for the vaccine to have caused the ADEM. Id. at 1349-
50. The special master rejected the testimony from Ms. Bazan’s treating
neurologist, who acted as her expert witness, for two reasons. First, her
neurologist relied upon case studies that did not connect a vaccination and ADEM
in as little as 11 hours. Second, her neurologist’s attempt to draw an analogy
between diseases of the peripheral nervous system (“PNS”), which might occur
within 11 hours, and diseases of the CNS, such as ADEM, was unpersuasive
because the myelin in the PNS differs from the myelin in the CNS, making “the
timeframes of PNS disorders . . . not probative of timeframes in CNS disorders.”
Id. at 1353; see also Bazan v. Sec’y of Health & Human Servs., No. 03-620V,
2006 WL 5616947, at *5-8 (Fed. Cl. Spec. Mstr. Feb. 7, 2006). When the Federal
Circuit reviewed the special master’s finding, the Federal Circuit ruled that it could
discern no error in how the special master evaluated this evidence. 539 F.3d at
1354.

       A close reading illuminates several points. First, a special master is not
required to find a petitioner’s evidence that the interval between vaccination and
the onset of the condition for which the petitioner seeks compensation is
“medically acceptable.” In Pafford, Dr. Geier testified that the relationship was
“medically acceptable.” 451 F.3d at 1359 (citing Trial Tr. 39-40). In Bazan, the
treating neurologist “defend[ed] her conclusions with strong conviction.” 2006
WL 5616947, at *8. Nevertheless, the special master did not deem that the
petitioners in either case had met their burden of establishing the proximate
temporal interval based upon the expert’s testimony by itself.

       Second, rather than simply looking at whether the petitioner had presented
any relevant evidence, a special master may explore whether the expert’s opinion
was based upon “reliable medical or scientific evidence.” Bazan, 2006 WL
5616947, at *8. An assessment of the quality of the purported reasons for the
medically appropriate interval is consistent with other aspects of the evidence-
weighing function. See Vaccine Rule 8(b)(1); Moberly, 592 F.3d at 1325
(“Finders of fact are entitled–indeed, expected–to make determinations as to the
reliability of the evidence presented to them and, if appropriate, as to the credibility
of the persons presenting that evidence.”). Whether the petitioner’s expert asserted
that medical articles supported the expert’s opinion was not dispositive. The
Federal Circuit has approved a methodology in which the special master
considered all evidence (including evidence offered by the Secretary), weighed the

                                          85
evidence, and reached a conclusion about what testimony was more probative.
Bazan, 539 F.3d at 1354.


                    b)    Evidence

      Here, the Palucks rely upon three passages from Dr. Frye’s testimony (Tr.
127-32, 231-32, 659).72 They buttress this testimony by citing two articles, the
Poling article and the Shoffner article. Pet’r Posthr’g Br., filed Feb. 18, 2011, at
21-22; see also id. at 29-31.

        Dr. Frye opined that an adverse reaction to a vaccine “would be thought to
appear sometime probably within a week of receiving the vaccine. It may not be
immediate.” Tr. 127:21-23. Consistent with his general theory, Dr. Frye stated
that adverse reactions to vaccines “lead to this metabolic decompensation, which is
an ongoing process, and if it’s not interrupted, it’s going to continue until it burns
itself out.” Tr. 128:6-9. When asked how long it would take for the child to
express neurodegenerative changes clinically, Dr. Frye provided an answer that
suggested the timeframe is not bound. He stated the clinical manifestation of
neurodegeneration is

      probably going to depend on the severity and type of mitochondrial
      disorder, so what we try to describe as a cascade of events that are
      ongoing, so I try to make analogies to some of the other diseases, such
      as Parkinson’s disease and Alzheimer’s disease that people have
      talked about, this relation between oxidative stress and mitochondrial
      disorder, and also the other thing, aging.
             Well, aging is a process that happens over decades, you know.
      The process that happens in mitochondrial – the interaction between
      mitochondrial disorders and oxidative stress and some of the
      neurodegenerative diseases also happen over years or decades, too.
      So it’s not unreasonable to think that, with a mild mitochondrial
      disorder, that you can have something that spans, you know, spans


      72
         Some of this testimony pertains to what happened to Karl. Those portions
are discussed in the following section. Likewise, the Palucks’ reply brief primarily
discusses when Karl had problems, not the medically appropriate interval. See
Pet’r Resp. to Resp’t Posthr’g Br., filed Mar. 11, 2011, at 16-19.

                                          86
      years, you know, whereas with a more severe mitochondrial disorder,
      that it could happen within days or weeks or months.

Tr. 128:22 to 129:14. Dr. Frye summarized his position with regard to the
appropriate medical interval by, again, identifying two different periods. He
stated:

      I think there’s two periods of time that we have to look at: one, when
      the inciting event caused the immune system to get to the point where
      it initiated the cascade of events that caused dysfunction between the
      mitochondria and oxidative stress, and then this process of this kind of
      – this spiral of activity, this downward spiral of activity between the
      mitochondria and oxidative stress, which occurs on a different time
      scale.
              So, one, there’s the time scale of actually initiating the
      dysfunction or this downward spiral, and then the time in which this
      downward spiral occurs. And it appears reasonable to suggest that the
      first portion happens probably within a week of the inciting event, and
      then it’s reasonable to think the second portion is going to depend on
      the underlying dysfunction in the mitochondria.

Tr. 131:23 to 132:12.

      In regard to the second phase, the period in which the damage to
mitochondria is becoming manifest, Dr. Frye referenced an additional set of
papers. He testified:

      [Y]ou actually start stressing an already vulnerable mitochondria
      which then creates more reactive oxygen species which then damages
      itself more, and this process goes on . . . and gets worse and worse
      over time until the mitochondria actually then signals cell death. And
      if we look at the experimental uveitis papers there is some very nice
      data that show that early on the changes are isolated to the
      mitochondria but that after some time these changes can then become
      so severe that then they signal apoptosis or programmed cell death
      after the degenerative changes occur within the mitochondria.

Tr. 660:24 to 661:11.


                                        87
       The Secretary addressed these arguments through Dr. Snodgrass’s testimony
and in her brief. See Resp’t Posthr’g Br., filed Feb. 18, 2011, at 46-49. In
addition, the Secretary cited an article by Edmonds (Exhibit 21, tab D, Joseph L.
Edmonds et al., The Otolaryngological Manifestations of Mitochondrial Disease
and the Risk of Neurodegeneration with Infection, 128 Archives of Otolaryngology
- Head & Neck Surgery 355 (2002)), which Dr. Frye cited but did not discuss. Id.
at 50-51.

      Dr. Edmonds and his colleagues identified 40 patients who had
mitochondrial diseases. The researchers collected information, via interview and
medical chart review, about the number of infections, episodes of acute otitis
media, and episodes of neurodegeneration from 27 patients. The researchers
explained their findings:

      The timing of the infection and neurodegenerative event varied. In a
      few patients (3/13), the neurologic setback occurred early in the
      course of infection. In most patients (10/13), the neurologic event
      occurred 3 to 7 days after the onset of infection and frequently
      appeared at a time when the infection was resolving. This pattern of
      delayed neurodegeneration in association with infection is depicted
      graphically in Figure 3.

Exhibit 21d at 6. Figure 3 and its caption are reproduced below:




                                        88
Exhibit 21d at 7.

       The Court interpreted Figure 3 as showing “a bell curve peaking at nine days
and representing that the tails on either side of the peak ranged from one day at one
side to nineteen days on the other side.” Opinion and Order, 104 Fed. Cl. at 481.

       This article is useful because the subjects are people with mitochondrial
disease. Therefore, they have at least some similarity to Karl, who also has a
mitochondrial disease. By retrospective chart review, the researchers looked for
evidence of “neurodegeneration,” which is, nominally, the condition that Dr. Frye
says that Karl has.73 One difference between the people in the Edmonds study and
Karl is that the patients in the study were infected, while Karl received a
vaccination. Dr. Snodgrass explained that “the Edmonds paper does not deal with
vaccine injuries, it deals with changes in the status of patients with mitochondrial
disease with infection. That’s not the same as a vaccine, but it provides some
guideline.” Tr. 524:1-5.74 Dr. Snodgrass continued, “So if the change did not
come within a few weeks, we have to say there’s no evidence that the vaccine
caused that problem in this particular person.” While Dr. Snodgrass discussed the
Edmonds paper and viewed it as a “guideline,” the Palucks did not solicit any
comments from Dr. Frye during his testimony on redirect, even though it was Dr.
Frye who originally cited the paper.75 Dr. Frye, however, appears to offer his
implicit acceptance of this timeframe in the following exchange on redirect.

             Q: I’d like to talk about the medically acceptable time frame.
      Dr. Snodgrass said in his testimony that he would need to see timing
      of regression within a few weeks after receipt of vaccines, and that’s



      73
         Because Edmonds did not define the term “neurodegeneration,” it is not
absolutely clear whether Karl’s case would have fit the Edmonds criteria. The
decision assumes that Karl would.
      74
         In the transcript, “Edmonds” is sometimes produced as “Edmunds.” This
decision corrects the transcript without notation.
      75
        See Tr. 619:24 (petitioners’ counsel incorrectly asking about the Edmonds
paper that “was written in the context of sepsis”).


                                         89
      at transcript page 526 to 527[76]. . . . [B]ased upon the evidence of
      scientific and medical literature and the clinical course that we’ve just
      reviewed with Karl, was Karl’s regression within a medically
      accepted period of time to be . . . caused by his January 2005
      immunizations?
               A: Most definitely. [W]e seem to see the pattern of regression
      . . . of fever, irritability . . . . We see spasticity emerging [in] Karl on
      February 11th, which is about three weeks after he has the vaccines.
      So we have documented evidence that within three weeks he actually
      has neurological changes in his motor system.
               Q: Is that consistent with your medical theory of causation?
               A: Yes it is, it very much is.

Tr. 659:14 to 660:10 (emphasis added); see also Tr. 666:4-7 (Dr. Frye: I think that
we’ve actually shown that we have documented evidence of neurological
regression within three weeks of receipt of the vaccine.” (emphasis added)).
Because of the similarities between the sequence of events Dr. Edmonds identified
and the sequence of events in Karl’s life proposed by Dr. Frye, Dr. Snodgrass’s
point that Edmonds can serve as a “guideline” for anticipating whether a vaccine
adversely affected a person with a mitochondrial disease is well-taken.

        Another article that discusses possible adverse effects of vaccines in people
with mitochondrial disorders is the Shoffner paper. Dr. Shoffner and his
colleagues wanted to explore “the relationship of autistic regression with fever and
vaccination in autistic spectrum disorder patients” who essentially displayed a
problem in how they produced energy in their cells. Dr. Shoffner’s team
retrospectively reviewed charts and identified “28 patients who met diagnostic
criteria for autism spectrum disorders and diagnostic criteria for mitochondrial
diseases.” Dr. Shoffner also looked to see whether any of these patients suffered
“autistic regression,” which, for this study, was defined as “loss of developmental
skills that included speech, receptive skills, eye contact, and social interests in
individuals <3 years of age.” Exhibit 21, tab Z (John Shoffner et al., Fever Plus
Mitochondrial Disease Could Be Risk Factors for Autistic Regression, J. Child
Neurol (2009)) at 2.

      76
         This transcript citation is to an exchange that follows Dr. Snodgrass’s
discussion of the Edmonds paper, where the undersigned sought to “distill some of
the factors” that Dr. Snodgrass would look for with regard to timing and whether a
“vaccine has caused neurological problems.”

                                           90
       Of the 28 patients, 17 (approximately 60%) had autistic regression. Dr.
Shoffner found that in 12 cases, the autistic regression occurred within two weeks
of having a fever. Furthermore, in four of those 12 cases, Dr. Shoffner stated that
the fever, which preceded the autistic regression, was a “febrile response to
vaccination.” The article explains that details about the duration of the fever were
“difficult to ascertain because patients were usually managed in the home. The
duration of the fever appeared to extend for at least 3 to 7 days in conjunction with
decreased oral intake.” Id. at 3.

       For purposes of evaluating the evidence regarding the interval between
vaccination and significant aggravation, the sixth Loving prong, Dr. Shoffner’s
definition of an autistic regression in the context of fever is important. Dr.
Shoffner selected “2 weeks” as the period to investigate. Dr. Shoffner’s use of that
period of time suggests that he would consider that a regression occurring within
two weeks of a fever could be caused by the fever.

       This same period was also used by researchers investigating experimental
autoimmune uveitis through animal models. In various articles, the Lewis rats
experienced the adverse effect of an injection within 14 days of the injection. See
Exhibit 21, tab J (Rahul N. Khurana et al., Mitochondrial Oxidative DNA Damage
in Experimental Autoimmune Uveitis, 49 (8) Investigative Ophthalmology &
Visual Sci. 3299(2008)) at 3302; exhibit 37, tab B (Sindju Saraswathy & Narsing
A. Rao, Photoreceptor Mitochondrial Oxidative Stress in Experimental
Autoimmune Uveitis, 40 Ophthalmic Res. 160 (2008)) at 160; exhibit 37, tab C
(Guey-Shuang Wu et al., Photoreceptor Mitochondrial Tyrosine Nitration in
Experimental Uveitis, 46(7) Investigative Ophthalmology & Visual Sci. 2271
(2005)) at 2271-72; see also Tr. 301:10 (Dr. Snodgrass’s testimony that damage in
the autoimmune uveitis animal experiments occurs “early on”); 487:23 to 488:10
(same); 605:2 to 606:22 (Dr. Frye’s testimony discussing the animal studies);
742:25 to 743-2 (Dr. Frye’s testimony that “the processes that can occur as a result
of a vaccination do not have to be immediate and can occur weeks afterward”
(citing the Wu article)). The results of these experiments suggest that if a human
being is going to have an adverse reaction, then the time for the adverse reaction
would be within 14 days.77

      77
        Because the Lewis rats are (obviously) not human, conclusions drawn
from an animal model would need a step of extrapolation to humans. However,
Dr. Frye cited these articles as supporting his opinion. See exhibit 21
                                                                      (. . . continued)
                                          91
       The remaining article is about Hannah Poling. The authors report that
Hannah received a set of vaccinations and developed a fever within 48 hours. She
had a low-grade intermittent fever for the next 12 days. Six days after
immunization, she lost the ability to climb stairs, and four days after that she
developed a macular rash beginning in the abdomen. She later lost the ability to
communicate, although years later she had improved to some degree. Exhibit 21,
tab Q (Jon S. Poling et al., Developmental Regression and Mitochondrial
Dysfunction in a Child with Autism, 21(2) J. Child Neurology 170 (2006)).

       To the extent that a case report about a single person provides information
about the period in which the medical community would accept an inference of
causation, Hannah Poling lost a skill (climbing stairs) six days after vaccination.
She displayed symptoms of a stimulated immune system (a fever and a rash)
within two weeks of the vaccination. She also showed evidence of impairment in
her extremities. While she may have deteriorated further, special masters focus on
the onset of the problem, not the duration of the problem. See, e.g., Doe/11 v.
Sec’y of Health & Human Servs., No. 99-212V, 2008 WL 4899356, at *30 (Fed.
Cl. Spec. Mstr. Oct. 29, 2008) (rejecting petitioners’ claim under prong 3 because
the onset of clinical symptoms was not within the expected time frame), mot. for
rev. denied, 87 Fed. Cl 1 (2009), aff’d, 601 F.3d 1349 (Fed. Cir. 2010); Pafford,
2004 WL 1717359, at *7 (“the timing of onset of Still’s disease subsequent to a
triggering event is not a telling characteristic of the disease. Accordingly, absent
an appropriate time frame, the Court cannot find the mere temporal proximity of
the vaccination and injury dispositive”), mot. for rev. denied, 64 Fed. Cl. 19
(2005), aff’d 451 F.3d 1352 (Fed. Cir. 2006).

(supplemental expert report); exhibit 30 (supplemental report explaining relevance
of approximately 20 articles filed after first hearing); Notice of Filing Exhibits,
filed October 15, 2010 (“Exhibits 37a-f & h address the[] concerns of Dr.
Snodgrass.”).
       In discussing the Palucks’ evidence relating to the reliability of the theory
that vaccines can produce an excessive amount of oxidative stress at least in people
with mitochondrial defects, the December 14, 2011 decision found that the
experimental autoimmune uveitis articles did not support the reliability of that
aspect of petitioners’ case. See 2011 WL 6949326 at *13, 17. The Court’s
Opinion and Order, however, appears to indicate that the rejection of the articles
vis-à-vis the reliability of the oxidative stress theory means that the articles also
must be rejected vis-à-vis the timing. See 104 Fed. Cl. at 481 n.31.

                                         92
       The December 14, 2011 decision found that the appropriate temporal
interval was two weeks. The Court vacated this aspect. Upon further reflection,
especially in light of the interpretation of Edmonds’s figure 3, which extends a tail
of symptoms of neurodegeneration to 19 days, the undersigned finds that the
appropriate temporal interval extends to three weeks.

             2.    Onset of Karl’s Neurodegeneration

       The December 14, 2011 decision found that Karl’s neurodegeneration did
not start within the time expected by the medical community. Rather, the decision
found that Karl’s significant decline started in April 2005. The Court vacated this
finding, ordering re-examination of Karl’s medical records, including his
chiropractor’s records and Dr. Frye’s testimony.

      The important time is within three weeks of January 19, 2005. This date is
February 10, 2005.78 Thus, for the Palucks to meet their burden of proof they must
show that Karl manifested signs or symptoms of neurodegeneration within this
timeframe. As a preliminary matter, it is worthwhile to explain, again, what
“neurodegeneration” is because the definition of that term will guide the following
assessment of the medical records.
                   a)     Neurodegeneration

      Dr. Frye did not define “neurodegeneration,” although his reports state that
Karl suffered from neurodegeneration. Exhibit 16 at 1; exhibit 21 at 3. However,
Dr. Frye did define the term “regression,” which is similar to neurodegeneration.

      78
         Although the Court characterized the finding that the medical community
would accept two weeks (now modified to three weeks) as establishing a “hard and
fast” period, the undersigned does not view the outside marker as an unsurpassable
boundary. For example, the December 14, 2011 decision considered information
about Karl’s condition as the chiropractor reported it on February 7 through April
2, 2005, even though these appointments occurred outside of the temporal window
found in the decision. In practical and hypothetical terms, given the same record
but that Karl had his first seizure on the 22nd day after vaccination, the petitioners
would have met their burden of proof regarding the temporal association prong.
However, Karl’s records did not show significant declines until months after the
vaccination, making any assessment of shades of grey unnecessary.

                                         93
Regression means that a person becomes unable to do something that the person
previously could do. Tr. 117:4-10; see also exhibit 21, tab Z (Shoffner) at 2
(defining autistic regression) and Tr. 194-96 (discussing Shoffner’s definition of
autistic regression even though Karl is not autistic). Dr. Snodgrass stated that a
loss of skill constituted regression. Tr. 430:16-20.

       A definition of “neurodegeneration” comes from Dr. Snodgrass. He testified
that he understands the term “as meaning that there is a decline – a continuing, it
keeps going on, decline in the function of the brain in multiple areas.” Tr. 531:8-
10. Dr. Snodgrass provided a similar definition of “neurodegenerative disease.”
He stated that it means “a progressive disease where the brain gets worse and
worse.” Tr. 502:22-23.

       Consequently, it is important to review the information available about Karl
to see if he was losing any functions between January 19, 2005 and February 10,
2005.79
                   b)     Medical Records

      Between January 19, 2005, and February 10, 2005, there are two
contemporaneously created sources of information about Karl: the daycare records
and the chiropractor’s records.

Daycare records and testimony thereon

The records from daycare (exhibit 22) report the following:

      January 21, 2005: Karl had a fever 101.5.
      January 24, 2005: Karl was “very fussy – didn’t eat very good. Likes his
                        blanket[,] wants his bottle.
      January 25, 2005: Karl “[d]idn’t eat very good. Fussy.”


      79
         Unfortunately, some testimony was vague about when certain events
occurred. For example, the Palucks’ counsel asked Dr. Frye “in Karl’s case, his
loss of skills progressed from sometime after January 19, 2005, to July 2005, when
he had regressed to the point of approximately a one-month-old.” To which, Dr.
Frye simply responded “Exactly.” Tr. 126:24 to 127:2. This exchange is not
helpful because Dr. Frye does not state when the regression started.

                                         94
      January 26, 2005: “Fussy again[,] very tired” and Karl “talked about a cup.”
      January 28, 2005: Karl fever 101.3. Very fussy – act tired all day.
      January 31, 2005: Karl act very tired [and] fussy. He has spots all over his
                        arms and legs again.80
      February 1, 2005: Sheila from the Kids Program came to work with Karl
                        [and] commented that Karl acts very tired and wants to
                        be held.
      February 2, 2005: Parents comment about Karl not sitting up yet.
      February 3, 2005: Sheila said Karl did very good today. Karl eats 3 to 5
                        bites of food at meals then wants his bottle.
      February 4, 2005: Fussy again – Acts like he is tired.
      February 7, 2005: [Ms. Paluck] took Karl to the chiropractor today.
      February 8, 2005: Karl not very content not sleeping very long 1/2 [hour] at
                        a time. Tries to crawl pulling his body.

       Following the February 8, 2005 entry, there is a note from the child care
provider. It states “[t]he fussy or crabbiness maybe due to tired, hungry[,] maybe
teeth or gums hurting. Or he could be in pain and be angry for not being able to
get around. In classes that I have taken[,] they say every child develops at their
own rate.” This entry concludes the daycare records that the Palucks submitted.81

      To Dr. Frye, Karl’s irritability and lethargy were evidence that Karl suffered
an encephalopathy. Tr. 193:10-25, 702:23-704:2; see also Tr. 126:15-127:2.
“Encephalopathy” is a broad term, meaning, in common medical parlance, “any
degenerative disease of the brain.” Dorland’s at 614.


      80
        Both experts stated that spots on Karl’s body probably indicated another
recurrence of the erythema multiforme. Tr. 645:2-10 (Dr. Frye), 804:4-11 (Dr.
Snodgrass).
      81
         Dr. Snodgrass stated “we have a narrow slice of evidence. For instance, I
would like to know about the fever charts, those infant-grams for September,
October, November and December. I don’t think it’s proper to give us
temperatures only during the month of January.” Tr. 256:8-12. Again, the Palucks
were ordered on July 22, 2011 to file any additional daycare records, but they
reported that there were none. Pet’r Status Rep’t, filed Aug. 22, 2011. See
footnote 28 above.


                                         95
       As every parent knows, irritability and lethargy even in the presence of a
fever do not always foreshadow an encephalopathy, or in non-medical terms, a
“degenerative disease of the brain.” Dr. Frye stated that Karl’s tiredness,
irritability, and decrease in appetite were “not specific.” Tr. 68:9. Dr. Snodgrass
stated that Karl “did not have [an] encephalopathy in January.” Tr. 389:2-3.

       Regarding the question of whether Karl had a vaccine-induced
encephalopathy in January 2005, Dr. Frye’s opinion was less persuasive than Dr.
Snodgrass’s opinion. Dr. Frye did not explain why Karl’s relatively minor and
relatively common problems (irritability, two instances of fever, and decreased
appetite) constituted a more severe process, an encephalopathy.82

       In contrast, Dr. Snodgrass pointed out that Karl was well enough to attend
daycare. Tr. 297:7-8, 344:18. Dr. Snodgrass also noted the difference in the
frequency of visits to health care providers. For the remainder of January after the
vaccination and throughout February 2005, Karl’s parents did not take him to a
medical doctor’s office. This absence of medical appointments contrasts with
Karl’s situation “between November and December [2004] when he was often
seeing the doctors, either in Bismarck or at the Dickinson Clinic or his parents
were telephoning them.” Tr. 341:23 to 342:1; accord Tr. 336:19-22. From this
difference, Dr. Snodgrass drew the following conclusion: “So I have every reason
to believe that his parents are attentive to his needs, so I have to conclude that he
was more sick in November and December than he was in January and February.”
Tr. 342:2-5. Dr. Frye did not persuasively refute this point. For these reasons, the
evidence does not preponderate in favor of finding that Karl had a new
encephalopathy between January 19, 2005 and February 10, 2005 that aggravated
his condition.83

      82
         For academic support for the proposition that fever is relatively common
in children, see exhibit J (Ellen R. Wald et al., Frequency and severity of infections
in day care: Three-year follow-up (pt. 1), 118(4) J. Pediatrics 509 (1991)); Tr. 291,
345 (discussing Wald). See also exhibit L (S. Michael Marcy et al., Fever as an
adverse event following immunization: case definition and guidelines of data
collection, analysis, and presentation, 22 Vaccine 551 (2004)) at 2 (noting the
“known high background rates . . . of fever); Tr. 347 (discussing Marcy).
      83
       Although Dr. Frye introduced the question of encephalopathy, whether
(and when) Karl suffered an encephalopathy is not quite the right issue. The issue
                                                                     (. . . continued)
                                      96
       Although Dr. Snodgrass opined that Karl’s irritability and other problems
did not constitute an encephalopathy, Dr. Snodgrass recognized that the irritability
and other problems could be symptoms of a significant problem. See Tr. 291:13-
14 (irritability “might indicate something serious”). Vaccine case law, too,
provides examples of histories in which a relatively minor problem (such as
excessive eye blinking) is understood, in retrospect, to be the beginning of a more
serious problem (such as a seizure disorder). See Markovich v. Sec’y of Health &
Human Servs., No. 03-2015V, 2005 WL 6117470 (Fed. Cl. Spec. Mstr. July 22,
2005), mot. for review denied, 69 Fed. Cl. 327 (2005), aff’d, 477 F.3d 1353 (Fed.
Cir. 2007). Consequently, the chiropractor’s records will be reviewed, even
though, with one exception, the visits took place outside of the appropriate medical
interval.

Chiropractor’s Records

      Karl’s parents began taking him to see a chiropractor on February 7, 2005.
Not much additional information can be gleaned from the intake forms and neither
Dr. Frye nor Dr. Snodgrass discussed the February 7, 2005 visit specifically. See
exhibit 12 at 1-6. The chiropractor, however, reports that on February 9, 2005,
Karl was “irritable” and records that Karl was having problems with his hips on

that fits Dr. Frye’s theory of the case more tightly is whether Karl suffered from
neurodegeneration during this timeframe because Dr. Frye’s theory is that the
vaccines caused Karl to suffer neurodegeneration. Exhibit 16 at 1; exhibit 21 at 3.
        Dr. Frye’s testimony in this regard is inconsistent. Generally, Dr. Frye
described Karl’s regression as occurring over a long period, such as January to
April or January to July, rather than immediately after the vaccination. See, e.g.,
Tr. 659:7-13 (agreeing that Karl’s regression occurred “in a four to five-month
period of time”). But he also testified on redirect that the timing of Karl’s
regression was within the medically accepted period of three weeks after
vaccination. See Tr. 659:14 to 660:10; see also section IV.F.1.b (discussing Dr.
Frye’s implicit acceptance of the Edmonds paper).
        In either case, Dr. Frye did not identify any medical records which show that
Karl, in the last two weeks of January and first two weeks of February, stopped
being able to do something he previously could do. Dr. Frye did, however,
indicate that a review of Karl’s medical records from before February 11, 2005
revealed that none of his caregivers noted spasticity during an examination. Tr.
647:25 to 648:4.

                                         97
cross-crawl. Id. at 6. Even more important to Dr. Frye’s opinion is the notation on
February 11, 2005, that Karl was “spastic.”84 Id. A medical definition of “spastic”
is “hypertonic, so that the muscles are stiff and the movement awkward.”
Dorland’s at 1741.

       Dr. Frye stated that spasticity differs from increased tone. Tr. 647:12-23,
707:12-14. Spasticity suggests that “the neurons in the motor cortex are severely
damaged and are no longer controlling the neurons in the spinal cord. And with
that time period to go from maybe some increased tone to becoming spastic
suggests a very quick and fast regression.” Tr. 648:9-14.

       Dr. Snodgrass did not agree that the chiropractor’s report of “spasticity”
marked a regression in Karl. Tr. 788:23 to 789:8; see also Tr. 577:12-16. Dr.
Snodgrass acknowledged that the chiropractor’s records “often say spastic, stiff, et
cetera.” But, unlike Dr. Frye, Dr. Snodgrass saw the chiropractor as “reporting on
the same general phenomenon which first became evident to Dr. McDonough in
January.” Tr. 336:26 to 337:4. In this context, Dr. Snodgrass stated that “I think
he’s [Dr. Frye has] missed the point that Karl was abnormal in the fall and by
January he was showing new findings of increased tone. And that was an
important marker, something significant had changed.” Tr. 338:5-9.


      84
           Dr. Frye defines “spasticity” as

      an abnormality in the balance of the muscles of the limb such that the
      limb which the muscles affect[ed] are either limited in range of
      motion on either passive or dynamic exam. That is, you can have
      spasticity where you can have some contracture which limits your
      range of motion, or you could have a reactive spasticity[,] when you
      dynamically look at the muscle there is what we call a catch because
      one set of muscles has abnormal reaction to that movement.

Tr. 705:13-22. According to Dr. Frye, “hypertonia” is “not the same thing” as
spasticity. “Hypertonia . . . is no limited range of motion, and . . . can be to a mild
or severe extent. You can think of somebody with spasticity as being on the severe
end of hypertonia.” Although “spasticity is related to . . . the same process[,] it is a
much more severe form of what we would say hypertonicity. . . . [I]f you say
hypertonicity you’re just talking about, you know, some tone in the limb without
any limitations in movement of the limb.” Tr. 706:6-19.

                                              98
      Dr. McDonough’s medical records support a finding that Karl’s motor
function was worse in January 2005 than it was in December 2004. At the
December 27, 2004 appointment, Dr. McDonough recorded that Karl has “normal
muscle tone. There is no ankle clonus. Deep tendon reflexes appear to be
symmetrical. He has good head control and fairly good truncal control but is not
pulling himself to stand or crawling yet.” For the December visit, Dr. McDonough
assessed Karl with “possible mild gross motor delay.” Exhibit 3 at 5-6.

       On January 19, 2005, Dr. McDonough saw Karl again. The pediatrician’s
form shows that Karl’s neuromuscular system was abnormal. The handwritten
notation says “muscle tone [increased]” possibly in the upper and lower
extremities. The note also seems to indicate that Karl was having two beats of
clonus in his right ankle. Dr. McDonough determined that Karl had “gross motor
delay” and referred him to physical therapy. Exhibit 3 at 3. The change from
“possible mild gross motor delay” without a referral to therapy to “gross motor
delay” with a referral to therapy constitutes a worsening from December to
January.85

       The question becomes using January 19, 2005, as a point of comparison, do
the chiropractor’s records show that Karl was becoming worse in his gross motor
functions? The first challenge in answering this question is that spasticity and
increased tone are related concepts. According to Dr. Frye, “[y]ou can think of
somebody with spasticity as being on the severe end of hypertonia. So . . .
spasticity is related to . . . the same process but it is a much more severe form of


      85
           The experts appear to accept that Karl worsened between December and
January. Dr. Snodgrass, as quoted in the text above, stated that in January, Karl
“was showing new findings of increased tone . . . something significant had
changed.” Tr. 338:5-9.
        When Dr. Frye testified on redirect, he stated that Dr. McDonough’s January
19, 2005 examination “found and suggested that there was some increase in tone in
what looks like the lower extremities, and two beats of clonus on the right ankle.”
Tr. 640:16-19; accord Tr. 648:13-14 (Dr. Frye’s testimony that before Karl saw the
chiropractor, he had “maybe some increased tone”), 651:12-14 (Dr. Frye’s
testimony that in “January again he had this isolated gross motor delay and maybe
a little bit of increased tone”). On cross-examination following his redirect
testimony, Dr. Frye stated that on January 19, 2005, Dr. McDonough found
“increased tone in Karl.” Tr. 707:15-17.

                                         99
what we [term] hypertonicity.” Tr. 706:11-16. Dr. Frye also stated that “changes
in tone sometimes are very subtle things.” Tr. 647:13.

       A second challenge is that the person observing and recording these “very
subtle things” is a chiropractor. In Dr. Snodgrass’s opinion, a chiropractor has
limited ability. Dr. Snodgrass stated:

      I have trouble with, I agree with Dr. Frye that chiropractors do pay
      attention to motor function and muscle tone, and I think that a
      chiropractor would have some idea of what spastic means, but not
      necessarily the same that a physician would. And I think when you’re
      talking about a 13 or 14-month-old child, I don’t think chiropractors
      are in a position to make any nuanced statements about them. I think
      if they say he’s stiff or he’s less stiff as they said later, less rigid, I’d
      accept that. But I don’t believe they are trained to evaluate infants,
      and infants are tough to deal with.

Tr. 805:12-23.

      A third challenge is that the chiropractor’s records show that the condition of
Karl’s muscles fluctuated throughout February and March 2005. A selective
summary of pertinent records is:

Visit Date        Note                                         ROM C/S        ROM L/S
3     2/11/05     Spastic                                        ↑
5     2/16/05     Less rigid – more comfortable on all           ↑
                  4’s
6     2/18/05     Less rigid – ‘happier’                            ↑
7     2/20/05     Stiff mid T ‘Happy moving around                  ↓
                  til last night’
9     2/24/05     Spastic                                           ↑                 ↑
12    3/8/05      Less hypertonicity.                               ↑                 ↑

Exhibit 12 at 5-6.86 Even if Karl’s chiropractor(s) (who remained unnamed) could
skillfully detect “subtle changes in tone” in a 13-month-old boy, the resultant notes

      86
       A check box with the heading “SPASM” is marked with a “T” or “T/L” in
numerous entries, presumably noting the presence of spasm. The meaning of these
                                                                (. . . continued)
                                      100
are not consistent with Dr. Frye’s opinion that after the vaccinations Karl “has
devastating regression that continues until April.” Tr. 657:16-17.

       Dr. Frye did not make a persuasive case that Karl had any regression, let
alone a “devastating regression,” from January through mid-March 2005. Again,
Dr. Snodgrass observed that the Palucks were not taking Karl to see a medical
doctor in February. When the Palucks provided histories about Karl’s
development after his seizures began in July 2005, the Palucks generally told the
doctors that Karl was not doing well in December 2004 (when he was 11 months
old) and got worse in April 2005 (when he had an MRI). See, e.g., exhibit 11 at 5
(Children’s Hospital narrative summary). Nonetheless, it is Dr. Frye’s opinion that
Karl was “worsening between January and March even though the parents may not
have been seeing or perceiving that same worsening.” Tr. 731:3-5.

       The Palucks have not provided any evidence that they observed Karl
worsening in February. The Palucks have also not provided any evidence to
explain why, if Karl was as sick as they claim, they did not take him to a medical
doctor in February. Previously, the evidence shows, when the Palucks thought that
Karl was sick, such as November and December 2004, they brought him to the
doctor’s office. The Palucks brought Karl to Dr. McDonough’s office for his one-
year check-up. After the vaccination, the Palucks again took Karl for a possible
ear infection on March 3, 2005. Exhibit 3 at 63.

       While the March 3, 2005 visit was not to check on Karl’s development, Ms.
Paluck’s encounter with Dr. Sherman gave Karl’s mother an opportunity to note
any new problems. Dr. Sherman’s record does not memorialize any observations
or discussions that Karl was in the processing of experiencing anything like the
“devastating regression” that Dr. Frye opined he was having between January and
April. See exhibit 3 at 63.

      Arguably, the chiropractor’s entry for March 17, 2005, could represent a
marked deterioration in Karl’s functioning. On that date, the chiropractor recorded
“palpation of spine painfull [sic] Baby cried loud when touched.” Exhibit 12 at 7.
Dr. Frye interpreted this note as “suggesting he’s starting to have spasticity of
some of the axial musculature and back pain.” Tr. 650:1-3.


marks is not known for certain, but could be abbreviations for “thoracic” and
“lumbar.” See Medical Abbreviations (15th ed. 2011) at 184, 312.

                                        101
      This is only an arguable position because Karl’s health cannot be assessed
accurately with just one record. On March 27, 2005, Ms. Paluck informed Dr.
Peterson at the Dickinson Clinic that Karl had experienced a runny nose for two
weeks, and had a wheezy cough for four days. Exhibit 3 at 64. In addition, on
March 27, 2005, Ms. Paluck told the chiropractor that Karl was “‘Doing well ‘til
yesterday’ [and] ‘took a few crawl steps.’” Exhibit 12 at 7. These entries create
some uncertainty about whether Karl on March 17, 2005 was having an isolated
bad day in the context of a common cold or was starting a more significant
regression.

       The experts continue the dispute over when Karl started having regression
after the January 2005 vaccinations. Dr. Frye compared Dr. McDonough’s April
13, 2005 and January 19, 2005 reports. In January, Dr. McDonough reported Karl
as having “isolated gross motor delay and maybe a little increased tone,” whereas
in April “he’s describing a very different child who has global developmental
delay.” Tr. 651:12-14 and 19-20. Dr. Frye also noted that the April report
recorded that Karl “has decreased hip flexion, something [Dr. McDonough] had
not mention[ed] previously, [a development] suggesting that again he has
spasticity, not just increased tone . . . , which is what the chiropractor had
mentioned back [o]n . . . February 11th.” Tr. 652:11-17. With regard to Dr.
McDonough’s neurologic examination, Dr. Frye stated

      [Karl] has increased tone in his . . . upper and his lower extremities.
      [Dr. McDonough] also mentions that he is not speaking at this point.
      So on the 19th he was actually saying mama and dada, but now he’s
      not speaking at all. And he has obvious speech, fine, and gross motor
      developmental problems. So, before, where the Denver had actually
      showed us that he was normal in fine motor and language, now we’re
      seeing he has multiple developmental problems and he has lost all of
      his speech.

Tr. 653:6-15. According to Dr. Frye, the findings on April 13, 2005, “most
definitely” suggest regression in Karl’s development. Tr. 653:16-18.

      Dr. Snodgrass, however, disagreed that Karl’s health experienced a
“precipitous decline with no improvement” between January and April 2005. Tr.
790: 3-7. Dr. Snodgrass gave several reasons for his opinion:

      [T]he single most important thing is that we had a lot of calls and
      doctor visits in November and December. If Karl had a precipitous
                                        102
      decline in January and February, these parents who seem to be
      responsible parents would have been calling and visiting the doctor,
      that’s number one. Number two, when they did visit Dr. Siriwan . . .
      in April they said that he had improved rather than that he had had a
      precipitous decline. I think Karl was going through cycles of getting a
      bit better and a bit worse going back in the fall, and those cycles of
      getting better and worse continued after the 1st of the year.

Tr. 790:9-21. When asked if the course of Karl’s condition would have been
different but for the vaccination – a question asked of Dr. Frye by the undersigned
– Dr. Snodgrass stated that he saw “no evidence that the vaccines changed the
course of his disorder.” Tr. 793:5-6. Dr. Snodgrass continued:

      [A]s I have said[,] Karl was fluctuating getting better and getting
      worse in the fall, and then in January, February, and March. But his
      parents told Dr. Siriwan that he was actually better at the time they
      saw the doctor in April. I think his parents would be the single best
      judge of that. I think the amount of hip flexor abnormality that was
      present was probably greater in April than in January, but there was
      no ankle clonus. So in other words we have certain areas where he
      looked a bit worse than he did in January and others where he did not.
      And he was not speaking, Dr. McDonough said no words in January.
      Dr. Siriwan indicated no words. But he was babbling at least
      according to mother’s phone call on March 22nd.

Tr. 793:9-23.

       These disputes are largely academic. Even if Karl’s March 17, 2005 visit to
the chiropractor marked a turning point – a proposition for which there is a scintilla
of support in the medical records – a worsening on this date would be
approximately eight weeks after the January 19, 2005 vaccination. Since the
bound of the appropriate temporal limit is three weeks, a March 17, 2005
worsening would be approximately five weeks too late.87

      For these reasons, the Palucks have not met their burden of presenting
preponderant evidence that they are entitled to compensation. Karl’s development

      87
        If the appropriate temporal relationship were doubled from three weeks to
six weeks, a worsening on March 17, 2005 would still be two weeks too late.

                                         103
after the January 19, 2005 vaccinations did not fit Dr. Frye’s prediction. This
discrepancy undermines their attempts to establish Loving prongs five and six
(corresponding to Althen prongs two and three). See Pafford, 451 F.3d at 1358
(Fed. Cir. 2006) (“If, for example, symptoms normally first occur ten days after
inoculation but petitioner’s symptoms first occur several weeks after inoculation,
then it is doubtful the vaccination is to blame.”).

V.    Factors Unrelated to the Vaccinations

       Because the Palucks did not meet their burden of proof, the Secretary does
not face the burden of establishing a factor unrelated to the vaccinations caused
Karl’s neurodegeneration. See Doe v. Sec’y of Health & Human Servs., 601 F.3d
1349, 1358 (Fed. Cir. 2010) (“[petitioner] Doe never established a prima facie
case, so the burden (and attendant restrictions on what ‘factors unrelated’ the
government could argue) never shifted”). Nevertheless, the Secretary has
identified various factors that caused or contributed to Karl’s decline. One of these
factors is Karl’s mitochondrial disorder. The Secretary argues that “Dr. Frye
himself has provided no reason to conclude logically that Karl’s condition more
likely than not resulted from immunizations as opposed to simply the progress[ion]
of his mitochondrial dysfunction.” Resp’t Posthr’g Br., filed Feb. 18, 2011, at 65.
Another set of factors can be classified as environmental stressors, including Karl’s
otitis media, erythema multiforme, and April 27, 2005 MRI. See id. at 62-64.

       The parties paid relatively little attention to these potential alternative
etiologies. Dr. Snodgrass offered some testimony, Tr. 294:24-295:14, 336:19-
337:19, 374:5-21, 476:19-22, 483:2-25, 581:23-582:24, but the quantum of
evidence was relatively small.

       Because resolution of this topic would have no effect on the outcome and
because any assessment would be based upon limited information, the undersigned
chooses not to determine whether any of the factors unrelated to the vaccinations
affected Karl. See Hibbard, 698 F.3d at 1364-65 (noting a special master may
resolve only the issues necessary to determine whether the petitioners are entitled
to compensation). These issues, however, would be relevant if the Palucks had
met their burden of proof regarding all six Loving factors.

VI.   Conclusion

      The Court’s Opinion and Order required an assessment of (1) whether the
Palucks’ case should be categorized as one seeking compensation for a new injury
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or for a significant aggravation of a pre-existing condition and (2) the evidence
pertinent to the appropriate test. On the first point, the evidence preponderates in
favor of finding that Karl was showing neurologic problems before his vaccination.
See section III. Thus, the Palucks’ claim for post-vaccination neurodegeneration is
a claim for significant aggravation.

       On the second point, the evidence and arguments have been re-examined
pursuant to the significant aggravation test set forth in Loving. As discussed in
section IV, Dr. Frye’s opinion was not as persuasive as Dr. Snodgrass’s opinion.
Although Dr. Frye asserted that Karl experienced a “devastating” neurologic
regression through April 2005, Tr. 657:10-19, this view is not borne out by the
evidence. Dr. Snodgrass’s opinion about how Karl developed immediately after
the vaccination more closely tracked the medical records. Karl’s parents, who had
previously taken Karl to his pediatrician for routine and non-routine illnesses, had
a chiropractor treat Karl. At least for the first two months following vaccination,
the chiropractor’s records contain more indications that Karl was improving than
notations that Karl was declining. Ultimately, the weight of the expert testimony
does not support the Palucks’ position. See Barnette v. Sec’y of Health & Human
Servs., No. 06-868V, --- Fed. Cl. ---, 2013 WL 1384429, at *10 (2013) (concluding
that the special master committed no reversible error “in choosing the
interpretation of one qualified expert over another”); Lankford v. Sec’y of Health
& Human Servs., 37 Fed. Cl. 723, 727 (1996) (affirming a special master who
“confronted the task of choosing between two competing expert opinions by
articulating a reasoned basis – drawn from the evidence – for preferring one over
the other”).




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       For reasons explained above,88 the Palucks have not demonstrated that they
are entitled to compensation. The Clerk’s Office shall enter judgment in accord
with this decision unless a motion for review is filed. The Clerk’s Office is also
instructed to provide a copy of this decision to the assigned judge pursuant to
Vaccine Rule 28.1(a).

      IT IS SO ORDERED.

                                              s/Christian J. Moran
                                              Christian J. Moran
                                              Special Master




      88
        After the Court’s Opinion and Order, the chief special master found Dr.
Frye’s opinion about how a vaccination can affect a mitochondrial disorder not
persuasive. Bast v. Sec’y of Health & Human Servs., No. 01-565V, 2012 WL
6858040 (Fed. Cl. Spec. Mstr. Dec. 20, 2012), mot. for rev. filed (Jan. 22, 2013).
The decision in Bast has not affected the outcome in the Palucks’ case.

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