WCB Suggestions

I have had some pleas about how to deal with case workers. Worker’s advocate, media, and politicians are impotent because of thier lack of medical knowledge. There is potentially some loose end they don’t know about that could make all the criticism go away… I have tried to include information on potential letters to case workers and some resources for treatment.

Some issues:
1) It is not diagnosable in many cases by history, physical or MRI/CT finding. Good free references to give case workers would be:

Management of chronic low back pain
Nikolai Bogduk
MJA Vol 180 19 January 2004 p 79-83

article here

“While conventional investigations do not reveal the cause of pain, joint blocks and discography can identifyzygapophysial joint pain (in 15%–40%), sacroiliac joint pain (in about 20%) and internal disc disruption (in over 40%).”(p79)

” The prevailing attitude to patients with failed back surgery syndrome has been that it is futile to pursue a pathoanatomical diagnosis. Recent studies are reversing that attitude. If carefully investigated, a treatable lesion can be found in substantial proportions of these patients.39 In those who have predominantly leg pain, unrecognised lateral stenosis is the most common cause. In those who have predominantly back pain, the most common cause is unrecognised internal disc disruption. Such findings are grounds for optimism that, in the future, patients with failed back surgery need not be relegated to symptomatic treatment only.”(p82)
Pain Physician – (there are a number of good articles at this site):

Pain Physician. 2003;6:3-81, ISSN 1533-3159
Evidence-Based Practice Guidelines for Interventional Techniques in the Management of Chronic Spinal Pain
Laxmaiah Manchikanti, MD, Peter S. Staats, MD, Vijay Singh, MD, David M. Schultz, MD, Bradley D. Vilims, MD, Joseph F. Jasper, MD, David S. Kloth, MD, Andrea M. Trescot, MD, Hans C. Hansen, MD, Thomas D. Falasca, DO, Gabor B. Racz, MD, Timothy R. Deer, MD, Allen W. Burton, MD, Standiford Helm, MD, Leland Lou, MD, MPH, Cyrus E. Bakhit, MD, Elmer E. Dunbar, MD, Sairam L. Atluri, MD, Aaron K. Calodney, MD,
Samuel J. Hassenbusch, MD, and Claudio A. Feler, MD

article here
“Modern technology, including magnetic resonance imaging (MRI), computed tomographic axial scanning (CT), neurophysiologic testing, and comprehensive physical examination with psychological evaluation, can identify the cause of low back pain in only 15% of patients in the absence of disc herniation and neurological defi cit (2, 173). In addition, overall inaccurate or incomplete diagnosis in patients referred to pain treatment centers has been described as ranging from 40% to 67%, and the incidence of psychogenic pain has been shown to be present only in 1 of 3,000 patients, with the presence of pain of organic origin mistakenly branded as psychosomatic in 98% of the cases (174, 175).”

reiterated here:
Pain Physician: January 2007:10:7-111
Interventional Techniques: Evidence-based Practice Guidelines in the Management of Chronic Spinal Pain
Mark V. Boswell, MD, PhD, Andrea M. Trescot, MD, Sukdeb Datta, MD, David M. Schultz, MD, Hans C. Hansen, MD, Salahadin Abdi, MD, PhD, Nalini Sehgal, MD, Rinoo V. Shah, MD, Vijay Singh, MD, Ramsin M. Benyamin, MD, Vikram B. Patel, MD, Ricardo M. Buenaventura, MD, James D. Colson, MD, Harold J. Cordner, MD, Richard S. Epter, MD, Joseph F. Jasper, MD, Elmer E. Dunbar, MD, Sairam L. Atluri, MD, Richard C. Bowman, MD, PhD, Timothy R. Deer, MD, John R. Swicegood, MD, Peter S. Staats, MD, Howard S. Smith, MD, PhD, Allen W. Burton, MD, David S. Kloth, MD, James Giordano, PhD, and Laxmaiah Manchikanti, MD

article here

“Modern technology, including magnetic resonance imaging (MRI), computed tomographic axial
scanning (CT), neurophysiologic testing, and comprehensive physical examination with psychological evaluation, can identify the cause of low back pain in only 15% of patients in the absence of disc herniation and neurological deficit (1-4, 219-227).” (p7)
“In one prospective evaluation (229), consecutive adult patients with intractable low back pain (who had failed conservative therapy) of undetermined etiology (by medical history, physical examination, x-ray, CT, MRI, EMG/NCV) had pain from facet joint(s) in 24%, combined lumbar nerve root and facet disease in 24%, combined facet(s) and sacroiliac joint(s) in 4%, lumbar nerve root irritation in 20%, internal disc disorder in 7%, sacroiliac joint in 6%, and sympathetic dystrophy in 2%. In a second study (230), the relative contributions of various structures in patients with chronic low back pain who failed to respond to conservative modalities of treatments (physical therapy, chiropractic and drug therapy), with lack of radiological evidence to indicate disc protrusion or radiculopathy, were evaluated utilizing controlled, comparative, double diagnostic blocks. In this study, 40% of the patients were shown to have facet joint pain, 26% discogenic pain, 2% sacroiliac joint pain, and possibly 13% segmental dural/nerve root pain. No cause was identified in 13% (229) and 19% (230) of the patients.”
(p8)

“In a controlled study, the prevalence of pain due to internal disc disruption was reported as 39% in
patients suffering with chronic low back pain (367). Primary discogenic pain was reported in 7% (229) to 26% (230) when no other cause was suspected. The prevalence of cervical discogenic pain in patients with chronic neck pain of traumatic origin in informal studies was estimated to be 20% (415). Discogenic and radicular pain syndromes continue to pose challenges to patients, physicians, and the society at large.” (p17)
“Facet joint involvement in chronic pain following lumbar surgery has been shown to be present in approximately 8% to 16% of the patients (308). Prevalence of sacroiliac joint pain following lumbar fusion has been demonstrated in a study with a single block to be 35% (465). Epidural fibrosis may occur following an annular tear, disc herniation, hematoma, infection, surgical trauma, vascular abnormalities, or intrathecal contrast media (490-496,499-509). Epidural fibrosis may account for as much as 20% to 36% of all cases of failed back surgery syndrome (FBSS) (479,480,510-512). Alternatively, there may be a final common pathway with all these etiologies, which results in peripheral and central facilitation potentiated by inflammatory and nerve injury mechanisms (490-496). Paraspinal muscles may also become denervated and involved in the pathogenesis of FBSS (513).” (p8)
However, there are no specific markers of facet joint pain. Conventional clinical and radiologic techniques are unreliable in diagnosing facet or zygapophysial joint pain. Various patterns of referred pain described for facet joints in the spine are similar to other structures such as discs. Further, most maneuvers used in physical examination are likely to stress several structures simultaneously, especially the discs, muscles, and facet joints, thus, failing to provide any reasonable diagnostic criteria….The evidence
thus far on physical examination and diagnosis has been controversial; demographic features, pain
characteristics, and other signs and symptoms may not correlate and are unreliable; and medical imaging
provides little useful information with radiographic investigations, including magnetic resonance imaging (MRI), revealing only some conditions with certainty (1-4,34-36,50,128,129,300-311,544,545,560-577)”.(p 20)

“There are no definite historical, physical, or radiological features to provide accurate diagnosis of sacroiliac joint pain” (229,230,436-440,460,461,465,562,761-786). (p29)
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Pain Physician 2007; 10:129-146 • ISSN 1533-3159
Systematic Review of Effectiveness and Complications of Adhesiolysis in the Management of Chronic Spinal Pain: An Update
Andrea M. Trescot, MD1, Pradeep Chopra, MD2, Salahadin Abdi, MD, PhD3, Sukdeb Datta, MD4, and David M. Schultz, MD5

article here

“Parke and Watanabe (28) demonstrated epidural adhesions in 40% of cadavers with lumbar disc herniation at L4-L5, 36% at L5-S1, and in 16% at the L3-L4 level. Perineural fibrosis can interfere with cerebrospinal fluid mediated nutrition, which can render the nerve roots hyperesthetic and hypersensitive to compression (29-31).”(p130)

“Is spinal endoscopy an effective treatment? Manchikanti et al (66) showed 80% improvement at 3 months, 56% improvement at 6 months, and 48% improvement at 12 months. They also showed significant improvement in pain relief, as well as other parameters including return to work at 3 months, 6 months, and 1 year. The prospective evaluations (67- 69) also showed improvement. Both the retrospective evaluations (58,70) included in the analysis showed positive short-term and long-term results.”(p142)”Gerdesmeyer et al (45) in a prospective pilot study evaluated 25 patients with mono segmental radiculopathy of the lumbar spine. All the patients suffered from chronic disc herniations or failed back syndromes after surgery, all of them with radiculopathy.”(p137-138)
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Management of chronic low back pain
Nikolai Bogduk
MJA Vol 180 19 January 2004 p 79-83

article here

“While conventional investigations do not reveal the cause of pain, joint blocks and discography can identifyzygapophysial joint pain (in 15%–40%), sacroiliac joint pain (in about 20%) and internal disc disruption (in over 40%).”(p79)

” The prevailing attitude to patients with failed back surgery syndrome has been that it is futile to pursue a pathoanatomical diagnosis. Recent studies are reversing that attitude. If carefully investigated, a treatable lesion can be found in substantial proportions of these patients.39 In those who have predominantly leg pain, unrecognised lateral stenosis is the most common cause. In those who have predominantly back pain, the most common cause is unrecognised internal disc disruption. Such findings are grounds for optimism that, in the future, patients with failed back surgery need not be relegated to symptomatic treatment only.”(p82)

——

JAOA • Vol 105 • No suppl_4 • September 2005 • 1-6
Interventional Pain Management: An Overview for Primary Care Physicians
Stephen S. Boyajian

article here

“Because different structures in the lumbar spine share similar innervation, pain patterns do not assist in distinguishing the exact pain generator. Without use of precision diagnostic injection techniques, pain originating from the intervertebral disc, facet, or SIJs is indistinguishable.^“

——

The validity of manual examination in assessing patients with neck pain .
The Spine Journal , Volume 7 , Issue 1 , Pages 22 – 26
W . King , P . Lau , R . Lees , N . Bogduk

abstract here

“The present study found manual examination of the cervical spine to lack validity for the diagnosis of cervical zygapophyseal joint pain. It refutes the conclusion of the one previous study. The paradoxical lack of statistical difference between the two studies is accounted for by the small sample size of the previous study.”

—–

Why I Pursue Discogenic Pain*
Nikolai Bogduk 2005
International Spine Intervention Society Newsletter 5(4) Dec. 2005 p14-29

article here

“The fundamental reason why I pursue the diagnosis of discogenic pain is that patients have no other valid alternative. Patients with chronic back pain get caught in a circus (Figure 1). They are told that there is nothing wrong with them medically; or they are told something fallacious such as: they once did have nociception; but that has now ceased; and now they have only a “memory” of that pain. Under those
conditions, medical treatment will not help; and the only prospect of treatment is behavioural and physical
rehabilitation. But that treatment does not work. The patients still have pain. Yet again they are told that there is nothing wrong. They failed rehabilitation, and the only recourse is to repeat it.

It is politically correct to declare that multidisciplinary pain treatment is not only effective, but is also superior to medical treatment. Yet examining the literature casts doubt on this.

Systematic reviews have found that behavioural therapy may be superior, in some respects, to no treatment but it is not more effective than exercises, and if added to physical rehabilitation it does not improve outcomes.1 A review of multidisciplinary treatment programs, i.e. functional restoration programs, found evidence that programs with less emphasis on physical domains are NOT effective; the evidence supported only those programs with an emphasis on intensive physical rehabilitation.2 If one consults the source literature upon which the reputation of multidisciplinary therapy is based, a more sobering impression arises.

Deadorff et al3 treated 55 patients with physical therapy conditioning, work training, psychological pain management, and operant condition, and compared their outcomes with those of 15 patients who had no treatment. The treatment group achieved an average of 15 points reduction in pain scores, from 64 to 49, at 10-13 months follow-up. But the group who had no treatment also achieved a similar reduction, from 71 to 54. Yet this is held to be a positive study. Moreover, excluded from the treatment group were
Medicare and patients who were considered not appropriate fro therapy or who were not motivated. The control group was a convenience sample of patients who were denied payment for therapy by their insurance company.

The use of convenience samples is common in studies of multidisciplinary therapy. The Volvo Award-winning study of Mayer et al,4 which founded functional restoration, used a convenience
sample as its control group. Thus, it appears acceptable to use convenience samples when the objective is to validate multidisciplinary therapy. This raises an intriguing comparison when, later, it comes to evaluating the literature on intradiscal therapy (see below).

A Swedish study, compared patients treated with applied relaxation, or applied relaxation combined with operant conditioning, and patients put on a waiting list.5 In the three groups, pain scores dropped from 4.3 to 4.1, 6.0 to 4.7, and 5.6 to 5.4, respectively. Despite these clinically inconsequential changes and differences the study is considered positive. A Norwegian study compared the outcomes of 142 patients treated with multimodal cognitive behavioural therapy with those of 81 patients who underwent usual care.6 In the treatment group, 50% returned to work. Meanwhile, 58% of the usual care group returned to work.

A study by a prominent US proponent of behavioural therapy compared the outcomes of patients put on a waiting list with those treated with behavioural therapy, exercises, or a combination behavioural therapy and exercises.7 The outcomes of behavioural therapy were not significantly better than those of no treatment (Figure 2). Those patients who had exercise therapy were only slightly more improved than those who were put on a waiting list.

A German study found no difference in pain scores between patients treated with cognitive behavioural therapy and those put on a waiting list (Figure 3).8 Nor did this study find any differences if scores for depression (Figure 4).

Although a review of multidisciplinary functional restoration found that intensive programs do reduce pain and do improve function,2 the source literature reveals the magnitude of these supposedly beneficial effects. Functional disability improves from a score of 15.5 out of 30 to 8.5, and pain decreases from 5.3 to 2.7, at four months follow-up.10 Yet other studies from the same investigators attest to improvements in disability 16.9 to 12.1, and reductions in pain scores from 6.1 to only 5.7.11

Studies such as these indicate that whatever else multidisciplinary and behavioural therapy programs might or might not achieve, they do not succeed in abolishing pain, or even substantially reducing it. Pain persists despite rehabilitation.” (pages 14-16)

“Cumulative proportions showed that more patients treated with IDET achieved large reductions in pain, such that the number needed to treat for an outcome of complete reduction in pain was 5; for 50% reduction the number needed to treat was 3 (Table 13). When composite criteria were applied, 54% of patients treated with IDET achieved at least 50% reduction of pain with return to work and no need for opioids, compared to only 10% of patients treated with rehabilitation.” (p23)
2) Back pain often does not go away:

Pain Physician 2007; 10:129-146 • ISSN 1533-3159
Systematic Review of Effectiveness and Complications of Adhesiolysis in the Management of Chronic Spinal Pain: An Update
Andrea M. Trescot, MD1, Pradeep Chopra, MD2, Salahadin Abdi, MD, PhD3, Sukdeb Datta, MD4, and David M. Schultz, MD5

article here
“Chronic low back pain has a prevalence ranging from 35% to 75% at 12 months after the initial attack of pain (1,2). It is widely held that 90% of low back pain is short-lived and that most patients get better on their own. However, this myth has been dispelled in multiple studies (3-6). Croft et al (3) followed 490 patients, aged 18 – 75 years, for 12 months. 463 patients consulted the authors regarding low back pain over the 1-year study period; of those, 59% had only the single consultation, suggesting resolution of their pain. However, 25% still complained of low back pain one year later. Elliott et al (4) followed more than 2000 individuals over 4 years and concluded that chronic pain is a common, persistent problem with a relatively high incidence and low recovery rate. More specifically, Enthoven et al (5) prospectively followed 314 primary care patients with neck and back pain over a 5-year period; 52% still had pain at the end of the five years, confirming that the pain didn’t “just go away”.”

Interventional Techniques in The Management of Chronic Spinal Pain: Evidence-Based Practice Guidelines
Mark V. Boswell, MD, PhD, Rinoo V. Shah, MD, Clifford R. Everett, MD, Nalini Sehgal, MD, Anne Marie Mckenzie- Brown, MD, Salahadin Abdi, MD, PhD, Richard C. Bowman, MD, PhD, Timothy R. Deer, MD, Sukdeb Datta, MD, James D. Colson, MD, William F. Spillane, MD, Howard S. Smith, MD, Linda F. Lucas, MD, Allen W. Burton, MD, Pradeep Chopra, MD, Peter S. Staats, MD, Ronald A. Wasserman, MD, and Laxmaiah Manchikanti, MD
Pain Physician. 2005;8:1-47 article here
“Conventional beliefs are that most episodes of low back pain will be short-lived, with 80% to 90% of attacks resolving in about 6 weeks irrespective of the administration or type of treatment, and 5% to 10% of patients developing persistent back pain. However, this concept has been questioned, as the condition tends to relapse, so most patients will experience recurrent episodes. Modern evidence has shown that chronic persistent low back pain and neck pain in children and adults are seen in up to 60% of patients, 5 years or longer after the initial episode (1, 72-78).

Also useful was the recent article that showed people with chronic nerve root pain obtain little to no relief from opioids and drugs used for neurogenic pain. (see prior blog article on Enbrel).

Potential letters:

I understand that you have been put in the position to manage my medical care which includes financial aspects. Given that you appear to be making these decision, please supply a CV of your trainng so I can better understand how this decision was concluded.

I understand that the assumption is that I should be better by now and if I am not this indicates non-WBC related issues. Yet recent studies have demonstrated that persistence is the rule (included the two articies above and maybe add quotes I made above). Also there is very little evidence rehab programs achieve recovery, and certainly one not multi-facetted like the one here would be even less so. The supreme court case Nova Scotia 2001 made it clear, failure to respond to rehab is not any indication someone should be prejudiced against and has in fact made it illegal to do so.
I understand decesions of my case may have been determined by medical personelle of high standing. Yet as the enclosed articles make quite clear, without facet and SI joint blocks, discograms, and selective nerve root blocks, 85% of chronic back pain is undiagnosable. This would only leave the medical personelle to work from their feelings on the matter. It has been stated that, however expert, this would be like a renowned obstetrician diagnosing the sex of a baby by the “feel” of the abdomen. – it cannot be done and I have supplied current literature supporting this claim. Physiotherapist are no different here and enclosed is an example of how physiotherapy failed to diagnose facet pain in the neck.(mentioned above). Given there are no accurate findings on history, physical, CT and MRI imaging; I require confirmation of how my case was concluded:

Please supply the results to the tests that may diagnose these conditions:

facet disease – facet blocks (not just doing one level and giving up)
disc disease – discograms

scaroliliac disease – SI joint injection

chronic sciatica – selective nerve root blocks

epidural scarring – Epidurography (mentioned in article above re adhesions)

Spinal instability – specialized back brace (mentioned in previous blog article on how should be worked up) and for upper neck – functional MRI (an MRI “cine”) as decribed here

Given that I have not had any of these might it be more prudent to continue my coverage? I suspect negatve comments will be included in my file. This tactic was discussed in the supreme court decicion as well (cut and paste their comments.) I would suspect if you were injured and did not improve, negative comments about you would also work their way into your file. This is not valid criteria for dismissal. It has been suggested that someone should not sleep much for a couple weeks and sit on a tack all day during the same period and then see if they were any better.
If these tests have not been undertaken then this falls into the situation described in a recent Supreme Court Decision (mentioned in blog article describing how chronic pain patients are obviously suffering and treated shabbily)
If this goes any further, I demand the right to cross-examine the doctor who had made these decisions as was decided in an Alberta case over the point of natural justice. ( have enclosed decision in blog about what might help WCB cases).
One last thing mentioned by one email – Never deal with anyone alone – have a witness – get someone else on another line if on the phone. If examined, have someone with you to confirm the doctor didn’t even touch you.

I’m sure the national WCB site may supply other ideas.

In Regina, Dr. Mike Lang and Dr. Yakub Abu-Ghazaleh are anesthetists who see patients with chronic pain. Your doctor can phone the Regina General Hospital and ask for one of them to be paged. They are particularly helpful for cases of pain referring down arm or leg – they do steroid epidurals for such and similarly for cases of spinal stenosis. For back pain alone, your doctor can also use one or the interventional radiologists like Dr. Shantilal Lala. I had the pleasure of meeting him recently and found him to be one of those beautifully pleasant people. Your doctor can fax him and ask for facet block if the pain is more localized to the back. His fax – 306-766-4385. I had recently mentioned (prior blog article) that the chronic pain support group at Wascana Hospital. I know one psychologist particularly interested in chronic pain – her name is Dr. Marlene Harper but she is private..

In Saskatoon they have a Pain Clinic but refuse to handle WCB case. There are anesthetists that work out of St. Pauls hospital.

Please supply other suggestions for injured victims – some of the emails I have got speak of great desperation. nike air max nike air max