Pain Medical Musing

I made a presentation to the Saskatchwan Workmans Compensation Review Panel. Their report left out much of what I had to say so I am putting it here:

1) Case workers make patients worse and obstruct medical care:

dangerous.doc

One deadly tactic is to force a patient back to work or to inappropriate rehab just to see what will happen. I call it deadly because one of my patients with MRI evidence of a hot disc lesion was forced into inappropriate rehab and died 2 weeks later of his heart condition. I call this tactic “the Shakedown”.

shakedown.doc

Family physicians must be allowed to administer medical care without interference.

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2) In Chronic Pain as little as 10% of cases are diagnosable by conventional examination, CT and MRI. If one wants to make a diagnosis discograms and selective nerve root blocks are necessary but are not made available to patients. hence patients are regularly terminated because “nothing was found”.

nothingtoseef.doc

3) MRI’s and CT rarely are of use in CHRONIC pain and do not show the source of pain. Yet negative results are used to conclude the patient is faking

MRIGOD.doc

4) WCB recruits doctors who have similar outlooks to themselves. Without discograms, selective facet blocks, and selective nerve root blocks, they are not operating on tangible evidence; they are operating on their “feelings” on the matter. As disability ratings vary by over 30% by doctors, these feeling can be very inaccurate. The tragedy legacy of cancer patient pain undertreatment underscores how poorly doctors rate pain levels. Operating on feelings is a scam.

Feelings.doc

5) Multiple causes of chronic pain are missed by WCB who are supposed to give the patient the benefit of the doubt but do not.

Missed.doc

6) Honesty tests like Waddell signs and consistency testing lack “consistency” and are invalid yet still used. They are as valid as witchhunting.
witchhunt.doc

7) Psychological decompensation is to be expected in certain chronic pain conditions but is used to contend it is all in their head…

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8) Computer testing for “suitable jobs” does not take into effect many patients have multiple things the matter with them above their main diagnosis and may be socially and otherwise handicapped. A supreme court case in Quebec made it clear handicap had to include ALL problems. There is no evidence counselling someone on a job possibility makes it happen in disabled cases. Canada Disability pension criteria had to be modified to include not just suitable jobs but AVAILABLE and giving sustantive gainful employment - measures ignored by WCB who will terminate cases for any excuse. I call this the “you could be a funeral director” scam.

Funeral_Director_Scam.doc

9) People who don’t get better can be labelled as “Fibromyalgia” even by specialists. This diagnosis cannot be made in the face or injuries and has a very poor consistency record from doctor to doctor in the literature; it cannot be used to terminate benefits where there is doubt.

fm_scam.doc

10) Several legal precedents have been made in the supreme court re WCB:

• Chronic pain without identifiable cause cannot be treated any different than other patient (Nova Scotia 2001)
• Chronic pain is a valid WCB claim and recompensable. Supreme court 2005
• Handicap includes more than just the original injury Supreme court Quebec
• A worker can refuse rehab s/he deems in inapproppriate without being cut off WCB

In an Alberta WCB Case it was ruled that a patient during appeal had the right to cross examine WCB doctors (who are working on their “feelings”) in the conduct of “natural justice”
11) The AMA Guide for disability is old - made before interventional techniques could more determine the cause of back and neck pains. It does not have ratings for chronic pain and does not take age or occupation into account when determining disability. Various Canadian provinces and for example California have had to make changes to how disability ratings are made; this needs to be legislated in Saskatchewan or will be backward and frankly illegally treat chronic pain patients of underdetermine cause (conveniently made by lack of appropriate testing).

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Presentation at Canadian Association of Rehabilitation Professionals June 2007. Summation (version 1) here:

Power points are here.

1) Disc disease(especially chronic) can often not be imaged and the worst chronic cases just show disc bulges. Disc disease and sciatica is mostly the result of the sectretion of irritating substances by damaged discs effecting the rim of the disc and the nerves at that level.
2) FCE’s are not valid because they do not predict the waxing and waning course of disc disease.

3) Malingering tests are invalid and not accepted in court. Symptom magnification is a manifestation of the ill-treatment chronic pain patients have suffered.

4) Facet syndromes are real and real damage is seen in autopsy cases of whiplash and low back MVA cases. They do NOT have any identifiable signs and Xrays are normal. Without selective injection they will never be properly diagnosed and could easily be treated as potential malingerers.
5) Without discograms or facet selective blocks, 85% of back pains will not have significant diagnosable “objective findings” . However, a consultant deciding this means there is nothing wrong, would be like an obstetrician deciding the sex of a baby by the feel of the abdomen. In the 21st century you can do better than that. Consultants who work for insurers are not necessarily dishonest as much as their philosophy merges with that of the insurers. Given that there is a 34% discordance in disability ratings between professionals, according to the RAND review of the California AMA guide use, patients are entitled to a second opinion.

6) Numerous studies have demonstrated people with chronic pain do not get better after successful litigation, belying the fact people on disability are often malingerers.

7) The link between neurotism and chronic pain is weak and these so called neurotic features have been found to diminish or disappear with treatment of the chronic pain. Attempts to discredit a chronic pain patient on the bases of neurotism (narcissistic, histrionic, anxious etc.) is baseless. Dr Harold Merskey, well known for his research and publishings in this field stated: ” Psychologists should not be diagnosing psychological problems as the major origin of someone’s pain any more than they can prescribe medications for them.” (personal communication 2007 Canadian Pain Society to Dr. M. Montbriand).

8) The association between chronic pain and depression is complex because they share the same pathways. Recent prospective trials suggest the depression results from the pain.

9) fear-avoidance, health anxiety and other psychological factors are driven by the level of pain although some studies obscure that variable by calling it “how much pain they think they are in” or “how disabled they think they are”.

10) There is no scientific basis that TSA vocational couselling leads to job employment in WBC or related chronic pain patients who feel they are not ready for work. On the contrary, A CPP study found the group who left a retraining program because they did not feel well enough, did not go back to work; this was despite the fact they were unique in their desire to return to work by volunteering for retraining. A 1986 study quoted in the CPP report found job advice in itself did not help bring about employment. According to a recent Supreme court decision, “handicap” includes more than just their injury - it includes their age, education, social abilities and so on. These need to be factored into any assessment. According to a 2001 CPP legal decision, re-entering the workforce must consider job availability and whether it could give substantial financial return. If someone can only work for 2 hours at a time before needing a break, no employer would hire such a person so question is moot.

11) In Canada, two supreme court decisions have made it clear that chronic pain without discernable findings is real and requires compensation.

12) The AMA guide is old, made before the day the causes of chronic back pain could be discerned and in their book they still say that 85% of chronic back pain is unknown. Given that it is so dated, it must be used only as a guide and modifications found necessary in California include:

- Age - over 39 gets upgraded disability ratings

-right or left hand concerns

-Occupation concerns - a radio announcer with a larynx injury has a much higher disability

- 3% extra disability is afforded for mild pain and for more pain it is considered “unrateable” so it is “anyone’s game”.

- Chronic pain of undetermined origin - very real if discogram of facet blocks have not been done - in Canada that is compensatable. Given that the AMA guide considers this unrateable, it cannot be used and other measures including occupation have to be considered.

- In Saskatchewan, the pychological disability resulting from the pain, is added to the physical to get a final rating.

13) Fibromyalgia cannot be diagnosed in post trauma cases because the tender points in the injured areas cannot be counted. There is very poor inter-observer agreement into that diagnosis and the use of that to discredit an injured party from receiving benefits is suspect. There is a tendency for some specialists to diagnose all people with widespread pain as having Fibromyalgia, yet only 20% of people with widespread pain actually qualify. True Fibromyalgia, however, might actually be a post-traumatic induced disease. It is a serious affliction with Imaging evidence of excessive appreciation of pain. There is also imaging evidence (from McGill) of progressive gray matter loss in the order of 1 3/4 cm cubed of gray matter loss a year. One study suggested in relation to people with regional pains or no pains, there is twice the death rate.

14) There are multiple “new” chronic pain diseases becoming recognized (eg. femoro-acetabular disease hip). An older one, Thoracic outlet syndrome, though found common after MVA’s in one Canadian study, remains unrecognized because scalene nerve blocks are never done. Only 20% of cases recovered in the Canadian study and in one article written for IME’s it was suggested this is such an intense disease that psychological distress is universal.

Other entrapment disorders and facet disorders remain undiagnosed because of failure to do nerve and facet blocks.

15) Much of chronic pain has now been recognized to have a neurogenic component and the use of a questionnaire like the Leeds Neurogenic Pain scale can help identify these. This might prove valuable in eliciting “objective findings” of disability.

16) People with chronic pain are vicitmized and basically told it is their fault. Many felt they would have been better off with no “help” from adjudicators and rehab people (who use a “try harder” approach to therapy). An effort must be made to be better than “adversarial” help.

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