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.