Pain Ratings in the Context of the AMA Guides


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  • This is the starting point for evaluating pain in the context of the guides.
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  • Pain Ratings in the Context of the AMA Guides

    1. 1. Pain Ratings in the Context of the AMA Guides Marjorie Eskay-Auerbach, MD, JD
    2. 2. No one likes PAIN cases!!!
    3. 3. Definitions – Chapter 1 <ul><li>Impairment: Loss, loss of use, or derangement of any body part, organ system, or organ function. </li></ul><ul><li>Disability: Alteration of an individual’s capacity to meet personal, social, or occupational demands because of an impairment. </li></ul><ul><li>Maximal Medical Improvement: Condition is well stabilized and unlikely to change significantly in the next year, with or without treatment. </li></ul>
    4. 4. Basis of Impairment Rating in The Guides <ul><li>Evaluate pain in the context of the underlying, objectively defined impairment </li></ul><ul><li>% allowed for impairments allows for the “pain that may occur with those impairments.” </li></ul><ul><li>Patients that fall outside this method of rating are discussed in Chapter 18 </li></ul>
    5. 5. Modifications of AMA 5 th Pain Ratings <ul><li>Practical application of the Guides has led to some changes that are described in the text Master the Guides </li></ul><ul><li>Conventional Impairment Rating vs. </li></ul><ul><li>Alternative Method where CIR does not apply  Pain Related Impairment (PRI) </li></ul>
    6. 6. Chapter 18 - Pain <ul><li>Developed after considerable debate </li></ul><ul><li>Pain impairment is already associated with specific diagnoses in many cases and </li></ul><ul><li>“ organ and body system ratings of impairment should be used whenever the capture the actual ADL deficits that individuals experience.” </li></ul><ul><li>Use Chapter 18 when the organ chapters do not “adequately address the pain associated with the impairment </li></ul>
    7. 7. Conventional Impairment Ratings (CIR) <ul><li>Impairment ratings based on measurable losses of function </li></ul><ul><li>Pain is accounted for in the rating of the permanent impairment </li></ul><ul><li>Example: </li></ul><ul><ul><li>Lumbar laminectomy for disc excision with improvement after surgery (DRE category III) has a range of impairment 10-13% </li></ul></ul>
    8. 8. Pain Related Impairment (PRI) <ul><li>Pain chapter provides </li></ul><ul><ul><li>a limited quantitative and </li></ul></ul><ul><ul><li>mainly qualitative system for rating Pain Related Impairment (PRI) in patients who fall into one of three groups </li></ul></ul>
    9. 9. Pain Related Impairment (PRI) <ul><li>The PRI analysis applies to patients who have: </li></ul><ul><ul><li>Excess pain in the context of a verifiable medical condition </li></ul></ul><ul><ul><li>A well established pain syndrome without organ dysfunction to explain it eg. migraines </li></ul></ul><ul><ul><li>Other pain syndromes </li></ul></ul>
    10. 10. Other Pain Syndromes <ul><li>Pain occurs as a component of a condition that is ratable according to the CIR system such as spinal cord injury </li></ul><ul><li>Only some individuals with the condition have a pain syndrome, eg. phantom limb pain </li></ul><ul><li>The CIR does not capture the added burden of illness borne by patients who have the associated pain syndrome </li></ul><ul><ul><li>Examples include phantom limb pain, pain after SCI, brachial plexus injury </li></ul></ul>
    11. 11. How Is the Impairment Accounted For? <ul><li>An examining physician must decide whether the individual’s impairment is accounted for by the CIR . </li></ul><ul><li>If the examining physician believes that </li></ul><ul><ul><li>An individual’s PRI increases the burden of illness slightly and </li></ul></ul><ul><ul><li>The underlying condition is ratable </li></ul></ul><ul><ul><li>then </li></ul></ul><ul><ul><li>the physician can award a discretionary 1-3% </li></ul></ul>
    12. 12. Discretionary Impairment <ul><li>If an individual is given a discretionary impairment award based on concepts in another chapter of the Guides (Ch 15 Spine) then an additional discretionary 3% should not be added. </li></ul><ul><li>Eg. if there is already a range in the rating available, as in DRE categories of the spine which rate 5-8%, then no additional numerical impairment should be added </li></ul>
    13. 13. Discretionary Impairment <ul><li>Patient status-post lumbar laminectomy with residual radicular complaints rates 10-13% using DRE Lumbar Category III, and based on poor relief of leg pain, the patient is rated at 13% </li></ul><ul><li>That patient is not a candidate for an additional 1-3% discretionary IR </li></ul>
    14. 14. Formal PRI <ul><li>If the examining physician’s judgment is that even the additional 3% is not adequate to capture the burden of illness </li></ul><ul><li>A formal PRI assessment can be performed to place the person in an impairment category  mild, moderate, moderately severe, severe BUT there is no associated numerical impairment for these categories </li></ul>
    15. 15. Use of the Pain Chapter <ul><li>Individual has a condition typically associated with pain and impairment but appears to have more pain than most people with the same condition </li></ul><ul><li>??? Does the patient convincingly report symptoms and activity limitations that exceed the norm? ( ADLs do not include work in the 5 th Ed. Guides ) </li></ul>
    16. 16. The Evaluation of Pain Using the Guides <ul><li>International Association for the Study of Pain has defined pain as “an unpleasant sensory and emotional experience with actual or potential tissue damage or that is described in terms of such damage.” </li></ul><ul><li>CAVEAT: Pain is subjective!!! There is therefore, no clearly accepted and validated method of objectively assessing pain. Pain can exist without tissue damage, and tissue damage can exist without pain </li></ul>
    17. 17. Chapter 18 – Working Definitions <ul><li>Pain is a “plural concept” with many components: </li></ul><ul><ul><li>Biological </li></ul></ul><ul><ul><li>Psychological </li></ul></ul><ul><ul><li>Social components </li></ul></ul><ul><li>Perception of pain is influenced by many factors: </li></ul><ul><ul><li>Cognitive </li></ul></ul><ul><ul><li>Behavioral </li></ul></ul><ul><ul><li>Environmental </li></ul></ul><ul><ul><li>Cultural </li></ul></ul>
    18. 18. Chronic Pain Syndrome <ul><li>Considered by The Guides to be a form of abnormal illness behavior seen in a “minority of those with chronic pain.” </li></ul><ul><li>Validity??? </li></ul><ul><li>Accuracy??? </li></ul>
    19. 19. Chapter 18: Overview of Pain <ul><li>“… introduction of the term chronic pain syndrome into common parlance. Although not official nomenclature, it is frequently used to describe an individual who is markedly impaired by chronic pain with substantial psychological overlay . </li></ul><ul><li>CPS is largely a behavioral syndrome that affects a minority of those with chronic pain . It may best be understood as a form of abnormal illness behavior that consists mainly of excessive adoption of the sick role.” –page 567 </li></ul>
    20. 20. Science/ Medicine of Pain <ul><li>The Guides recognize that there has been an increase in the understanding of the pathophysiology of pain through the use of animal models </li></ul><ul><ul><li>Nerve injuries causing afferent discharges </li></ul></ul><ul><ul><li>Dis- inhibition or injury of spinal inhibitory neurons </li></ul></ul><ul><ul><li>Hyperexcitability of spinal cord neurons associated with disinhibition </li></ul></ul><ul><ul><li>Abnormal responsiveness to afferent input </li></ul></ul><ul><ul><li>Sensitization </li></ul></ul><ul><li>Are the animal models relevant or applicable to humans? </li></ul>
    21. 21. When and How to Use Chapter 18 <ul><li>If the physician believes that the additional 3% discretionary allowance does not adequately account for the individual’s burden of illness, then he/she can perform </li></ul><ul><li>A FORMAL PRI ASSESSMENT </li></ul><ul><ul><li>Place the individual in the appropriate class </li></ul></ul><ul><ul><li>Mild, moderate, moderately severe, severe </li></ul></ul><ul><ul><li>Reassess whether the CRI adequately captures the impairment </li></ul></ul>
    22. 22. Integrating PRI into the Conventional Impairment Rating System <ul><li>Pain is subjective, yet impairment rating is to be based on objective findings. </li></ul><ul><li>“Pain behaviors are influenced by social environment…to establish the financial obligations … or… entitlements. Thus, the social context surrounding impairment ratings might provide an incentive for individuals to exaggerate their reports of pain so as to maximize awards .” – page 569 </li></ul>
    23. 23. Using Chapter 18 <ul><li>When to use Chapter 18 </li></ul><ul><li>When NOT to use Chapter 18 </li></ul><ul><li>Controversies and caveats </li></ul>
    24. 24. DO Use Chapter 18 <ul><li>When pain is associated with other ratable conditions and the occurrence or non-occurrence of the pain syndrome is not predictable, so that impairment ratings in other chapters do not capture the added burden … of pain. </li></ul><ul><li>Examples Table 18-2 </li></ul><ul><ul><ul><li>Post-paraplegic pain, Syringomyelia pain, </li></ul></ul></ul><ul><ul><ul><li>Brachial Plexus Avulsion Pain, </li></ul></ul></ul><ul><ul><ul><li>Nerve Entrapment Syndromes, </li></ul></ul></ul><ul><ul><ul><li>Peripheral Neuropathy , </li></ul></ul></ul><ul><ul><ul><li>Complex Regional Pain (type 2) </li></ul></ul></ul>
    25. 25. Formal Ratings <ul><li>Individual has a pain syndrome </li></ul><ul><ul><li>Pain occurs as a component of a condition that is ratable according to the CIR system such as spinal cord injury </li></ul></ul><ul><ul><li>Only some individuals with the condition have a pain syndrome, eg. phantom limb pain </li></ul></ul><ul><ul><li>The CIR does not capture the added burden of illness borne by patients who have the associated pain syndrome </li></ul></ul>
    26. 26. Example: PRI <ul><li>Eg. Amputation with phantom-limb complaints </li></ul><ul><ul><li>Impairment rating is calculated as 54% WPI based on Guides tables </li></ul></ul><ul><ul><li>This is the CIR regardless of whether the patient has phantom limb pain </li></ul></ul><ul><ul><li>The conventional rating does not capture the added burden of illness and impact on ADLs  PRI impairment </li></ul></ul>
    27. 27. Do NOT Use the Pain Chapter <ul><li>When the conditions are adequately rated in other chapters of the Guides – organ system ratings cover pain - there is no guidance given on how to assess “adequacy” </li></ul><ul><li>Eg. Back pain – even non-specific back pain can be rated if a specific incident is noted and the patient presents with chronic muscle spasm, postural abnormalities, nonverifiable radicular complaints. </li></ul>
    28. 28. Do NOT Use the Pain Chapter <ul><li>When rating individuals with low credibility . Page 581,discusses “… there are no definitive rules for assessing credibility , Section 18.4 Behavioral Confounders, discusses several issues that a physician should consider when making a judgment about a person’s credibility </li></ul><ul><li>Eg., Video surveillance reveals that the individual is able to perform activities of daily living, there are discrepancies in behavior during the examination, etc. </li></ul>
    29. 29. Do NOT Use the Pain Chapter <ul><li>When there are ambiguous or controversial pain syndromes - pain in this setting is considered UNRATABLE; however </li></ul><ul><li>The Guides states that the evaluating physician should characterize the pain using the assessment protocol (to be described) </li></ul>
    30. 30. How to Identify Ambiguous or Controversial Diagnoses <ul><li>QUESTIONS TO ASK: </li></ul><ul><li>Do symptoms and signs match known medical conditions? </li></ul><ul><li>Is the presentation typical of the diagnosed condition? </li></ul><ul><li>Is the condition widely accepted? </li></ul>
    31. 31. How to Identify Ambiguous or Controversial Diagnoses <ul><li>“ Is the diagnosed condition one that is widely accepted by physicians as having a well-defined pathophysiologic basis?” </li></ul><ul><li>“ If the answer to any of the above 3 questions is “no”, the examiner should consider the individual’s pain-related impairment to be unratable on the basis of this chapter.” </li></ul>
    32. 32. Caveat!!! <ul><li>“ Is the diagnosed condition one that is widely accepted by physicians as having a well-defined pathophysiologic basis?” </li></ul><ul><li>Yet, 18.3a (p 570) says rate “Well established pain syndromes without significant, identifiable organ system dysfunction to explain the pain.” </li></ul><ul><li>Obvious Contradiction ! </li></ul>
    33. 33. Established Pain Syndromes <ul><li>Well-established pain syndromes are those that are accepted by the medical community without significant controversy </li></ul><ul><li>Medical reports should contain references to medical lit. that establishes the well-established pain syndrome </li></ul>
    34. 34. EXAMPLE <ul><li>41 yo male s/p laminectomy at L5-S1 with persistent leg pain in the S1 distribution and an MRI that demonstrated epidural fibrosis but no recurrent disc herniation </li></ul>
    35. 35. Example: cont. <ul><li>Exam is remarkable for limited ROM with leg pain reproduced with forward flexion and lateral side bend. Straight leg raise is positive. There is diminished Achilles tendon reflex (S1) </li></ul><ul><li>Dx: lumbar postlaminectomy syndrome with persistent S1 radiculopathy </li></ul><ul><li>Well-recognized, accounted for with range available in DRE ratings </li></ul>
    36. 36. Formal PRI Assessment <ul><li>Algorithm pg 574/ Figure 18-1 </li></ul>
    37. 37. STEP 1 Determine DX using conventional rating methods Conduct an INFORMAL assessment of PRI STEP 2 CIR is adequate IR is % found In Step 1 STEP 3 PRI ↑ burden slightly Add 1-3% to CIR 3% max STEP 4 PRI ↑ burden substantially Increase the % by 3% (max) And perform FORMAL PRI ASSESSMENT
    38. 38. Figure 18-1: Algorithm p. 574 <ul><li>Step 3: </li></ul><ul><li>“If pain-related impairment appears to increase the burden of the individual’s condition slightly, the examiner can increase the percentage found in step 1 by up to 3 %. No formal assessment of pain-related impairment is required.” </li></ul>
    39. 39. Comments: <ul><li>Pain…increases burden SLIGHTLY  increase the percentage by up to 3 %. </li></ul><ul><li>All painful injuries/conditions have a wide range of associated pain, and… </li></ul><ul><li>“ The impairment ratings in the body organ system chapters make allowances for any accompanying pain.” (ch 2, page 20) </li></ul>
    40. 40. STEP 5 PRI ↑ burden substantially Increase the % by 3% (max) And perform FORMAL PRI ASSESSMENT STEP 6 Classify the individual into Classes 1-4 Table 18-3 p575 STEP 7 Class 2-4 Determine if impairment is RATABLE or UNRATABLE STEP 9 RATABLE  Indicate Class and that PRI is ratable If the PRI is Class 1, Award % impairment Determined in Step 1 CIR STEP 9 UNRATABLE  Indicate ratable imp. (CIR) from Step 1 Then indicate that patient has an UNRATABLE PAIN IMPAIRMENT
    41. 41. Pain Related Impairment Data <ul><li>Pain Intensity </li></ul><ul><li>Activity Interference </li></ul><ul><li>Emotional Distress </li></ul><ul><li>Credibility </li></ul><ul><li>Pain Behavior </li></ul><ul><li>Pain related impairment (mild, mod…) </li></ul>
    42. 42. Continuous pain 9-10/10 Req. assist for ADLs, modify or ↑ time Severe affective distress Max med support PE impossible to perform, pain behaviours congruent with organ dysfxn Pain up to 9-10/10 ADLs require modification, eg. can’t drive Maint. Meds Limitations on PE severe -exam difficult to perform and interpret Pain behaviors congruent with organ dysfxn Moderate Mod. difficulty managing ADLs – ground. floor apt. Mild to mod distress Ongoing rx. Pain meds often Pain related limitations on exam, few pain behaviors Mild severity Performs ADLs w/ few modifications No to min. emotional distress No regular rx for pain Mild limitations during PE, few pain behaviors Class 4 Severe Class 3 Mod. Severe Class 2 Moderate Class 1 Mild
    43. 43. Mild Pain Impairment Table 18-3, page 575 <ul><li>Severity based in intensity and frequency is mild . </li></ul><ul><li>ADLs mildly aggravate pain, can perform ADLs with few modifications . </li></ul><ul><li>No or only minimal emotional distress in response to pain. </li></ul><ul><li>NOT receiving pain treatment on a regular basis. </li></ul><ul><li>Pain-related limitations during physical exam are mild and appear appropriate; few pain behaviors. </li></ul>
    44. 44. Moderate Pain Impairment Table 18-3, page 575 <ul><li>Severity based in intensity and frequency is moderate . </li></ul><ul><li>Moderate ADL difficulty, significant modifications to permit. [examples: move to 1 st floor or buy car with automatic transmission] </li></ul><ul><li>Mild to moderate affective distress in response to pain. </li></ul><ul><li>Ongoing medical “monitoring” and using medication much of the time. </li></ul><ul><li>Pain-related limitations during physical exam are significant . </li></ul><ul><li>Few pain behaviors, of indeterminate appropriateness </li></ul>
    45. 45. Moderately Severe Pain Impmt. Table 18-3, page 575 <ul><li>Pain MOST of the time, may be 9 – 10/10 </li></ul><ul><li>ADL only with significant modifications, and unable to perform many. [example: drive a car] </li></ul><ul><li>Moderate to severe affective distress in response to pain. </li></ul><ul><li>On maintenance Medication . </li></ul><ul><li>Severe Pain-related limitations during physical exam that may make examination difficult to perform. Pain behaviors appropriate. </li></ul>
    46. 46. Severe Pain Impairment Table 18-3, page 575 <ul><li>Pain is CONTINUOUS, 9 – 10 at its worst. </li></ul><ul><li>Many ADL require help. [example: prepare food, dress] Other ADL modified [stop bathing] or Inordinate time required [2 hours to get out of bed and dress] </li></ul><ul><li>Severe affective distress in response to pain and communicates that pain is out of control. </li></ul><ul><li>On maximal pharmacologic support . </li></ul><ul><li>Physical exam is impossible to perform . Pain behaviors appropriate - ???? </li></ul>
    47. 47. Errata <ul><li>In 2002, Errata to AMA Guides were published </li></ul><ul><li>In Chapter 18 there were some modifications made to the algorithm used to determine PRI </li></ul>
    48. 48. Step 1, Step 2 <ul><li>Step 1: </li></ul><ul><li>Determine Diagnosis and Function. </li></ul><ul><li>Conduct an Informal Assessment of Pain-related impairment, Using Chapters 1-17 (the rest of the Book) </li></ul><ul><li>Step 2: “If conventional impairment adequately encompasses the burden of the individual’s condition, … rating is the percentage found in step 1 .” </li></ul><ul><li>Errata </li></ul><ul><li>No change </li></ul>
    49. 49. Step 3 <ul><li>Step 3: </li></ul><ul><li>“ If pain-related impairment appears to increase the burden of the individual’s condition slightly, the examiner can increase the percentage found in step 1 by up to 3 %. No formal assessment of pain-related impairment is required.” </li></ul><ul><li>Errata </li></ul><ul><li>If pain-related impairment increases the individual’s burden slightly, proceed to Step 6… </li></ul><ul><li>Determine ratable (award 0 – 3 %), or not ratable , describe class and consequences in words </li></ul>
    50. 50. Errata: Published March 2002 <ul><li>Step 4: </li></ul><ul><li>“ If pain-related impairment appears to increase the burden of the individual’s condition substantially, the examiner can increase the percentage by 3 % and move to step 5.” </li></ul><ul><li>Errata </li></ul><ul><li>If pain substantially increases the burden, perform a formal pain-related impairment assessment (step 5) and proceed to step 6. </li></ul><ul><li>Ultimately  Determine ratable (award 0 – 3 %), or not ratable , describe class and consequences in words </li></ul>
    51. 51. Step 5 <ul><li>Step 5: </li></ul><ul><li>Perform a “formal assessment of pain-related impairment”, and classify the individual into one of classes 1-4.” </li></ul><ul><li>(classes described in Table 18-3 on page 575) </li></ul><ul><li>Errata </li></ul><ul><li>No change </li></ul><ul><li>Scores resulting in placement in classes listed in Table 18-7 on page 584 </li></ul>
    52. 52. Step 6 <ul><li>Step 6: </li></ul><ul><li>“ If apparent pain-related impairment is class 1, award the percentage impairment determined in step 1.” </li></ul><ul><li>Or: If the pain is “Mild”, the Impairment from Chapters 3-17 is adequate. </li></ul><ul><li>Errata </li></ul><ul><li>Determine if the individual’s pain is ratable or unratable </li></ul>
    53. 53. Step 7 <ul><li>Step 7: </li></ul><ul><li>If apparent pain-related impairment is class 2 - 4 (moderate to severe), determine if it is ratable. </li></ul>
    54. 54. Ratable Pain <ul><li>Pain is considered ratable – the patient has pain associated with a medical condition that typically produces both pain and objectively measurable impairment </li></ul><ul><li>Analysis is: </li></ul><ul><ul><li>CIR =13% (DRE III 10-13%) </li></ul></ul><ul><ul><li>Discretionary PRI =0 </li></ul></ul><ul><ul><li>PRI impairment class = moderate </li></ul></ul><ul><ul><li>FINAL RATING: PRI is adequately encompassed in CIR  13% </li></ul></ul>
    55. 55. What is Unratable Pain <ul><li>Unratable means that the physician is unable to determine how the activity restrictions reported by an individual are linked to a disease or injury  </li></ul><ul><li>the decision as to how to construe this becomes administrative! </li></ul>
    56. 56. Step 8 <ul><li>Step 8: </li></ul><ul><li>If unratable , impairment is the percent found in step 1, but indicate that the individual also has unratable pain-related impairment. </li></ul><ul><li>Final Answer: Rate by Chapters 3-17, </li></ul><ul><li>with words “Unratable pain impairment”. </li></ul><ul><li>Errata : Step 8 </li></ul><ul><li>If “unratable”, no impairment %, but describe in terms of class and consequences with words. </li></ul>
    57. 57. Step 9 <ul><li>Step 9: </li></ul><ul><li>If pain is ratable , indicate the class & RATABLE </li></ul><ul><li>Does not state it clearly, but remember Step 4 permitted increasing the impairment by up to 3 %. (Increase over the chapter 3-17 impairment from Step 1 . </li></ul><ul><li>Errata : Step 7 </li></ul><ul><li>If “ratable”, add 0 – 3 % and describe class (class 1 – 4). </li></ul>
    58. 58. Is That Your Final Answer?? <ul><li>“ __ % from chapters 3-17, </li></ul><ul><li>plus (usually) 3 % for RATABLE pain-related impairment.” </li></ul><ul><li>Remember, there is no NUMERICAL rating for PRI of mild, moderate, etc. and therefore, it must be described in words. </li></ul>
    59. 59. PRI is Unratable <ul><li>In the context of a vague or controversial medical syndrome </li></ul><ul><li>Unratable impairments do not receive any quantitative rating </li></ul><ul><ul><li>Do the medical findings match any known medical conditions? </li></ul></ul><ul><ul><li>Is the presentation typical of the condition </li></ul></ul><ul><ul><li>Is the dx. condition widely accepted by physicians as having a well defined pathophysiology? </li></ul></ul>
    60. 60. Validity of PRI <ul><li>Assessment of PRI relies on self-reports (by necessity, since pain is subj.) </li></ul><ul><li>If the individual is not credible, the assessment of PRI is invalid </li></ul>
    61. 61. PRI is Unratable <ul><li>Inherently controversial </li></ul><ul><ul><li>fibromyalgia </li></ul></ul><ul><li>The more common setting </li></ul><ul><ul><li>The individual’s symptoms have been attributed to a condition that is well-accepted and has specific markers </li></ul></ul><ul><ul><li>The individual does not have the objective markers that are typically found in the condition </li></ul></ul>
    62. 62. PRI is Unratable <ul><li>Thoracic Outlet Syndrome vs. Chronic Pain </li></ul><ul><ul><li>Complaints of arm, shoulder, hand pain </li></ul></ul><ul><ul><li>No neurologic or vascular findings on examination or studies to corroborate the complaints </li></ul></ul><ul><ul><li>No objective findings, so the dx is not based on any objective measures, and may be misleading b/c a specific dx. has been made and the patient’s complaints are more reasonably attributed to a chronic pain syndrome </li></ul></ul>
    63. 63. PRI is Unratable <ul><li>Does not mean the pain is fabricated or unreal </li></ul><ul><li>Either the condition thought to produce the PRI is vague or controversial or </li></ul><ul><li>The individual’s symptoms and reported behavioral limitations are so non-specific that they cannot be attributed to any specific medical disorder </li></ul><ul><li>Limitations of science and calculating impairment ratings </li></ul>
    64. 64. Headache Not Mentioned in Chapter 13 Nervous System
    65. 66. How Do We Measure Pain ?
    66. 67. Formal PRI Assessment – Calculations: § 18.3f – 18.5, pages 575-84; Table 18-4 <ul><li>Table 18-4: Questionnaire to Self Report </li></ul><ul><li>Pain: 5 questions rating pain on 0 – 10 scale (A-E). A+B+C+D/ 4, + E = score (0-20) The max is 20 points </li></ul><ul><li>This is NOT an Impairment percentage! </li></ul><ul><li>Eg. </li></ul><ul><ul><li>A-D Rate how severe your pain is right now, worst, etc. </li></ul></ul><ul><ul><li>E. Rate how frequently you experience pain </li></ul></ul>
    67. 68. Formal PRI Assessment – Calculations: § 18.3f – 18.5, pages 575-84; Table 18-4 <ul><li>Activity Limitation or Interference: 16 questions on 0 – 10 scale, Total score (A-P) /16, Multiply by 3, max = 30 “Points” </li></ul><ul><li>Effect of Pain on Mood: 5 questions, 0-10 Total score (A-E) / 5 max. of 10 “Points” </li></ul>
    68. 69. Table 18-5 Assessment of Pain Behavior (p. 580) <ul><li>Observable Pain Behaviors </li></ul><ul><ul><li>Facial grimacing </li></ul></ul><ul><ul><li>Holding or supporting affected body part </li></ul></ul><ul><ul><li>Limping or distorted gait </li></ul></ul><ul><ul><li>Frequent shifting of position/ posture </li></ul></ul><ul><ul><li>Extremely slow movements </li></ul></ul><ul><ul><li>Sitting with a rigid posture </li></ul></ul><ul><ul><li>Moving in a guarded or protective fashion </li></ul></ul><ul><ul><li>Moaning </li></ul></ul><ul><ul><li>Using a cane, cervical collar, or other device </li></ul></ul><ul><ul><li>Stooping while walking </li></ul></ul><ul><li>Rate from -10 (exaggerated) to +10 (appropriate) </li></ul>
    69. 70. Alternative Assessment (p 577-9) <ul><li>Pain: Visual analog scale, etc., McGill Pain Questionnaire. </li></ul><ul><li>Activity Restrictions: Pain Disability Index, SF-36, Oswestry, Roland-Morris, ask about ADLs of Table 1-2, Sickness Impact Profile, West Haven-Yale Pain Inventory. </li></ul><ul><li>Emotional Distress: Beck, Zung, or Hamilton Depression scale (or anxiety scale), Profile of Mood States. </li></ul><ul><li>!!! NO GUIDANCE as to how to convert these to a similar numerical score !!! </li></ul>
    70. 71. Table 18-6 Pain Impairment Score <ul><li>Pain </li></ul><ul><li>Activity Interference </li></ul><ul><li>Effect on Mood </li></ul><ul><li>Pain Behavior Rating </li></ul><ul><li>Sum (add/subtract) </li></ul><ul><li>Physician “adjustment” based on judgment of individual’s credibility </li></ul><ul><li>Total Pain Related Impairment Score </li></ul><ul><li>0-20 </li></ul><ul><li>0-30 </li></ul><ul><li>0-10 </li></ul><ul><li>-10 to + 10 </li></ul><ul><li>_______ </li></ul><ul><li>-10 to +10 </li></ul><ul><li>____ pts. THIS is NOT an IMPAIRMENT RATING </li></ul>
    71. 72. Credibility of the Individual p 581 <ul><li>“ Physicians routinely assess the credibility of individuals in the course of their clinical work.” </li></ul><ul><li>“ Although there are no definite rules for assessing credibility, Section 18.4, Behavioral Confounders, discusses several issues that a physician should consider…” </li></ul><ul><li>Thus, rate “pain behavior” and “credibility” separately, yet pain behaviors are used to judge credibility – appears to be evaluating the same thing twice. </li></ul>
    72. 73. Assessing Patient “Credibility” <ul><li>Is the condition congruent with established condition (e.g. RSD)? </li></ul><ul><li>Is the condition consistent over time and situation (internal consistency in exam)? </li></ul><ul><li>Is exam consistent with known anatomy & physiology (e.g. Waddell’s signs)? </li></ul><ul><li>Is there interobserver consistency (e.g. collateral information from other sources)? </li></ul>
    73. 74. Table 18-7 Determining Class on the Basis of Total Pain-Related Impairment Score (p. 584) <ul><li>Impairment Score </li></ul><ul><li>0 – 6 </li></ul><ul><li>7 – 24 </li></ul><ul><li>25 – 42 </li></ul><ul><li>43 – 60 </li></ul><ul><li>61 – 80 </li></ul><ul><li>Class </li></ul><ul><li>No sig. Impairment </li></ul><ul><li>Mild Impairment </li></ul><ul><li>Moderate Impairment </li></ul><ul><li>Moderately Severe </li></ul><ul><li>Severe Impairment </li></ul>Score is NOT an impairment rating
    74. 75. Table 18-7: Perhaps How to Use It ? <ul><li>Pain Impairment Class Perhaps Rating </li></ul><ul><li>Score (WholePerson) </li></ul><ul><li>0 – 6 No sig. Impairment 0 % </li></ul><ul><li>7 – 24 Mild Impairment 0 % </li></ul><ul><li>25 – 42 Moderate Impairment 1 % </li></ul><ul><li>43 – 60 Moderately Severe 2 % </li></ul><ul><li>61 – 80 Severe Impairment 3 % </li></ul><ul><li>Again: “Score is NOT an impairment rating.” </li></ul>
    75. 76. “ Double Dipping” When Rating Pain
    76. 77. The Problem of “Double Dipping” Guides Newsletter Jan/Feb 2002, page 10 <ul><li>“ Specific problem…allows…1% to 3% for PRI at their discretion. Other chapters…also permit…discretionary impairment of up to 3%. </li></ul><ul><li>This raises the question of whether it is permissible…to award 3% discretionary impairment…conventional rating, and then award an additional 3% on the basis of …PRI. </li></ul><ul><li>The answer is “no”. </li></ul><ul><li>For example,… DRE II 8 %, …cannot make an additional quantitative award based on …Chapter 18.” </li></ul>
    77. 78. Pain Evaluation: Fifth Edition Approaches by J Robinson, Dennis Turk , and J Loeser The Guides Newsletter Jan/Feb 2002; pages 1-5, 9-11 <ul><li>Restates chapter 18 and the Errata. </li></ul><ul><li>“Examples …do not mention the discretionary 1 % to 3% PRI. This was an oversight.” </li></ul><ul><li>Examples 18-1, 18-3, & 18-4 should be given 3%. </li></ul><ul><li>Example 18-2 gets no additional impairment. </li></ul>
    78. 79. Pain Evaluation: Fifth Edition Approaches by J Robinson, Dennis Turk , and J Loeser The Guides Newsletter Jan/Feb 2002; pages 1-5, 9-11 <ul><li>Question: Is it Permissible to rate pain with discretionary 1 – 3 % for pain and to also award 3 % discretionary impairment in the context of a conventional impairment [example: Spine chapter, Injury method ] ?? </li></ul><ul><li>“ The answer is ‘NO’.” </li></ul>
    79. 80. Determine If Pain Behaviors Are Present Pages 579-81 <ul><li>“ Pain behaviors are the ways that individuals communicate about their pain… may be verbal or nonverbal.” </li></ul><ul><li>“… may be viewed as symptom magnification…” </li></ul><ul><li>“… examiner has a twofold task… to decide whether they tend to authenticate the validity of the individual’s suffering, or to raise questions about his or her communication style.” </li></ul><ul><li>“ Physicians probably differ significantly in what they view as exaggerated pain complaints.” </li></ul>
    80. 81. Pain Behaviors, continued (p 580) <ul><li>“ The specific behaviors an examiner considers vary according to the individual’s medical condition … a pain behavior that would be considered concordant in one clinical context would be considered discordant in a different one. … behaviors that tend to validate an individual’s pain are generally specific to that … condition. In contrast, exaggerated pain behaviors-such as emotional displays and pain-limited weakness- tend to occur in conjunction with a wide variety of medical conditions.” </li></ul>
    81. 82. Unexplained, and Unexplainable Paradox of “Credibility” <ul><li>Page 571: “This chapter should not be used…when rating individuals with low credibility.” </li></ul><ul><li>Page 583: assess credibility, “ Assign a score between – 10 and + 10, where – 10 indicates very low credibility…” </li></ul><ul><li>?? Like saying to your kids “Don’t have sex, but when you have sex…” ?? </li></ul>
    82. 83. Comment: The Consequence of Numbers <ul><li>Lawyers and Insurance companies have always had a “subjective opinion” that a particular physician had a “plaintiff-patient bias”, or a “defense-insurance company bias”, but with no “objective” way to document the bias. </li></ul><ul><li>Once doctors rate “pain behavior” and “credibility” with NUMBERS, Computers can track and report physicians “average rating” and compare that to “the average of other physicians rating the same patient.” </li></ul><ul><li>Numbers permit using data to measure (bias ?) </li></ul>
    83. 84. 18.4 Behavioral Confounders (p 581) <ul><li>“An extensive literature demonstrates what common sense suggests: pain behaviors and perception of pain are strongly influenced by beliefs, expectations, rewards , attention and training.” </li></ul><ul><li>Studies consistently show that spouse solicitousness is correlated with pain behavior.” </li></ul>
    84. 85. 18.4 Behavioral Confounders (p 581) <ul><li>“ Prospective studies consistently show that onset of disabling pain is highly associated with such factors as job dissatisfaction, lack of support at work, stress, and perceived inadequacy of income . Once initiated, the progression of pain to chronicity is contingent on similar factors. Financial compensation, receipt of work-related sickness payments, and compensation-related litigation are also associated with chronicity, as are such social and economic factors as poor education, language problems, and low income.” </li></ul>
    85. 86. 18.4 Behavioral Confounders (p 581) <ul><li>“Although the suffering induced by a miserable vocational situation may equal or exceed that from disease or injury, it is the intent of the Guides to assign impairment based on disease and injury, not on such environmental situations as an individual’s fear of returning to a hostile work environment.” </li></ul><ul><li>(“Impairment” is not the same as “Disability”.) </li></ul>
    86. 87. 18.4 Behavioral Confounders (p 581) <ul><li>“Thus, examiners face a dilemma . They know that a variety of non-biological factors strongly influence the disability status and ADL deficits of individuals they rate, but they are charged with the task of rating impairment on the basis of measurable dysfunctions of organ or body parts.” </li></ul>
    87. 88. 18.4c Cautions (p 583) <ul><li>“…symptom exaggeration can be created by fear or by having learned that certain actions or positions provoke pain.” </li></ul><ul><li>“…pain behavior can be a response to feeling discounted or mistrusted, so that one must emphasize symptoms to persuade physicians of their reality…Thus, symptom magnification can be an iatrogenic phenomenon that occurs when an individual feels mistrusted or poorly cared for.” </li></ul>
    88. 89. 18.6 Psychogenic Pain (p 585) <ul><li>DSM – IV Diagnosis: Pain Disorder Associated with Psychologic Factors. Criteria </li></ul><ul><li>Pain is the predominant focus </li></ul><ul><li>Pain causes significant distress </li></ul><ul><li>Psychologic factors have the major role, while general medical conditions play little or no role. </li></ul><ul><li>“… almost any person with persisting pain would meet the inclusion criteria.” </li></ul><ul><li>“… a variety of conditions formerly considered psychogenic have been found to be neurologically based…” </li></ul>
    89. 90. 18.6 Psychogenic Pain (p 585) <ul><li>“… key question …chronic pain…not fully explainable on …organ pathology: … psychologic factors played a major role in the initiation of the pain…or its continuation?” </li></ul><ul><li>If “YES” use Chapter 14 (Mental Disorders) </li></ul><ul><li>If “NO”, or “UNCERTAIN”, use Chapter 18 (Pain) </li></ul>
    90. 91. 18.7 Malingering (p 585-6) <ul><li>“… conscious deception for the purpose of gain.” </li></ul><ul><li>“… quite uncommon, (but) …few data regarding its frequency.” </li></ul><ul><li>Fishbain: literature review: chronic pain patients 1.25 % - 10.4 % malingering , but serious flaws with methodology, thus, no conclusions. </li></ul><ul><li>Among 333 people claiming compensation for noise-induced hearing loss, exaggeration (by cortical evoked response study) was 17.7 % </li></ul><ul><li>Weintraub: “20 - 46 % of people consider purposeful misrepresentation of compensation claims to be acceptable behavior.” </li></ul>
    91. 92. Malingering (cont.) <ul><li>“… keep an open mind as to the possibility (of malingering) …less likely in those seeking treatment than in those seeking compensation.” </li></ul><ul><li>“ Confirmation of malingering is extremely difficult and generally depends on intentional or inadvertent surveillance.” </li></ul>
    92. 93. Behavioral Confounders <ul><li>Interpretation of pain behaviors and how they are incorporated into impairment ratings </li></ul><ul><li>Assess pain behaviors based on: </li></ul><ul><ul><li>Congruence with established conditions </li></ul></ul><ul><ul><li>Consistency over time and situation </li></ul></ul><ul><ul><li>Consistency with known anatomy and physiology </li></ul></ul><ul><ul><li>Agreement among different observers </li></ul></ul><ul><ul><li>Incorporation with other behavioral confounders </li></ul></ul>
    93. 94. Chronic Pain Syndrome <ul><li>Eight “D”s (Sternbach 1974) </li></ul><ul><ul><li>Duration </li></ul></ul><ul><ul><li>Dramatization </li></ul></ul><ul><ul><li>Diagnostic </li></ul></ul><ul><ul><li>Drugs </li></ul></ul><ul><ul><li>Dependence </li></ul></ul><ul><ul><li>Depression </li></ul></ul><ul><ul><li>Disuse </li></ul></ul><ul><ul><li>Dysfunction </li></ul></ul>
    94. 95. Eight D’s in depth <ul><li>Duration </li></ul><ul><ul><li>>6 months </li></ul></ul><ul><ul><li>Some patients demonstrate chronic pain behaviors very early </li></ul></ul><ul><ul><li>Current recommendations for back pain are 3 months </li></ul></ul><ul><ul><li>These behaviors can predict delay in RTW </li></ul></ul><ul><ul><li>Does chronic pain  chronic pain syndrome? </li></ul></ul>
    95. 96. Eight D’s in depth <ul><li>Dramatization </li></ul><ul><ul><li>Similar to somatisization </li></ul></ul><ul><ul><li>Somatic complaints without objective findings </li></ul></ul><ul><ul><li>Distress </li></ul></ul><ul><li>Diagnostic Dilemma </li></ul><ul><ul><li>Lack of objective findings </li></ul></ul><ul><ul><li>Repeated, extensive work-ups </li></ul></ul>
    96. 97. Eight D’s in depth <ul><li>Drugs: </li></ul><ul><ul><li>Substance abuse/ dependence </li></ul></ul><ul><ul><li>Large amounts of medication without relief </li></ul></ul><ul><ul><li>Chronic pain pt, somatisizer, personality disorder pt. </li></ul></ul><ul><li>Dependence: on physicians, demand excessive care, extensive passive rx, dependence on family and spouse </li></ul>
    97. 98. Eight D’s in depth <ul><li>Depression: common in chronic pain patients AND in the general population </li></ul><ul><li>Dysfunction: withdrawal from the social environment, disengagement form social and work activities, feels rebuffed by the medical provider  consistent with a wide variety of psych. dx and NOT SPECIFIC for chronic pain </li></ul>
    98. 99. Estimating Pain Impairment <ul><li>Complicated by: </li></ul><ul><ul><li>Poorly validated criteria for some diagnoses </li></ul></ul><ul><ul><ul><li>Central pain </li></ul></ul></ul><ul><ul><ul><li>Neuropathic pain </li></ul></ul></ul><ul><ul><ul><li>FIbromylagia </li></ul></ul></ul><ul><ul><ul><ul><li>Studies of small # of patients, lack of adequate controls, insufficient analysis </li></ul></ul></ul></ul>
    99. 100. Legal Issues <ul><li>Chapter 18 provides a method to classify patients with PRI, but does not provide a method for quantitatively combining PRI with CIR  admin. uncertainty </li></ul><ul><li>The Guides indicate that administrative agencies can make informed decisions about whether or not to compensate individuals. </li></ul>
    100. 101. Rating Pain <ul><li>Rated in the context of the underlying objectively defined impairment </li></ul><ul><ul><ul><li>AMA Guides, 5th edition </li></ul></ul></ul><ul><ul><ul><li>Social Security Administration </li></ul></ul></ul><ul><ul><ul><li>US Dept. of Veterans Affairs </li></ul></ul></ul><ul><ul><ul><li>WC: varies state to state, meant to compensate straightforward injury </li></ul></ul></ul><ul><li>85% of LBP sufferers cannot be given a definitive diagnosis </li></ul>
    101. 102. MRI Imaging of LBP <ul><li>Degenerated or bulging disc of at least one level is very common </li></ul><ul><li>In NEJM series 52% had bulge, 27% protrusion, 1% extrusion) </li></ul>
    102. 103. CT Imaging of LBP <ul><li>50% of CT scans were abnormal in those ≥ 40; herniated disc, facet degeneration, stenosis were most frequent </li></ul>
    103. 104. Myelography <ul><li>Patients receiving myelography for acoustic neuroma, 1/3 of normal persons had asymptomatic but myelographically demonstrable prolapse! </li></ul>
    104. 105. Annular Tears & HIZ <ul><li>Both were touted to be the MRI “finding” for unexplained LBP </li></ul><ul><li>Both shown to be common in a population without a LBP syndrome </li></ul>
    105. 106. Discography <ul><li>High rate of false positives when there is a history of chronic pain, compensation issues, somatization features </li></ul><ul><li>A high percentage of asymptomatic patients have positive discograms post-discectomy. </li></ul><ul><li>In asx patients, discography does not prognosticate LBP </li></ul>
    106. 107. Alf Nachemson, MD, PhD <ul><li>“ I believe we should rethink the way we investigate our patients, and should stop using these imaging techniques prematurely.” </li></ul>
    107. 108. Muscle Relaxants <ul><li>Some proof of efficacy in acute LBP </li></ul><ul><li>Considerable side effects </li></ul><ul><li>Widely used on a chronic basis even though there is no proof of efficacy </li></ul>
    108. 109. Narcotics & Nonmalignant Pain <ul><li>Literature is based on surveys and uncontrolled case series </li></ul><ul><li>“ Reassessment of narcotic risk comes at a time of skyrocketing rates of misuse and abuse” </li></ul><ul><li>Dramatic misquotation of addiction rate. One study only followed inpatients! </li></ul><ul><li>Many patients are on dosages far beyond what has been shown effective </li></ul><ul><li>Many using methadone for treatment of addiction became addicts for pain problems </li></ul><ul><li>Narcotics users have increased self-perception of disability and poorer function </li></ul>
    109. 110. More on Narcotics <ul><li>Narcotics have important long-term side effects that remain poorly understood </li></ul><ul><ul><li>Hormonal: infertility, libido </li></ul></ul><ul><ul><li>Immunosuppression </li></ul></ul><ul><ul><li>Mild impairments in cognitive function </li></ul></ul><ul><ul><li>Addiction </li></ul></ul><ul><li>Patients in a pain rehab program do better when opioids are withdrawn </li></ul>
    110. 111. RTW Post Discectomy <ul><li>45 year old with microdiscectomy </li></ul><ul><li>How long before RTW if on sedentary duty? </li></ul><ul><li>What work should he be excluded from? </li></ul>
    111. 112. Dynamic Interrelationships
    112. 113. Chronic Pain <ul><li>Nerve injuries cause primary afferent discharges </li></ul><ul><li>Injure or kill spinal inhibitory neurons </li></ul><ul><li>Changes in SC neurons: hyperexcitiability due to disinhibition </li></ul><ul><li>Abnormal responsiveness of thalamic and cortical neurons </li></ul><ul><li>Abnormalities become independent of primary pathology </li></ul>
    113. 114. Is CP Model Viable? <ul><ul><li>There are currently no widely accepted methods for determining whether the symptoms of an individual with chronic pain can be ascribed to sensitization </li></ul></ul><ul><ul><li>90% of central pain = stroke or thalamic insult </li></ul></ul><ul><ul><li>Neuropathic pain = polyneuropathy (DM) or mononeuropathy (PHN) </li></ul></ul><ul><ul><li>Presence of allodynia & hyperpathia </li></ul></ul>
    114. 115. Problems Rating the Pain Patient <ul><li>No clear end-organ damage-  Lack of objective findings </li></ul><ul><li>Impairment due to pain alone is not well defined </li></ul><ul><li>Narcotics users have increased self-perception of disability and poorer function </li></ul><ul><li>“ Pain, even severe & persistent, is widely found among the general population” </li></ul>
    115. 116. Pain in the General Population <ul><li>22% of 1° care patients had persistent pain </li></ul><ul><li>Pain sufferers had more anxiety & depression </li></ul><ul><li>LBP in 35-45 year olds </li></ul><ul><ul><li>66% prevalence of spinal pain; 1/4 marked LBP </li></ul></ul><ul><li>47% of patients ≥ 25 </li></ul><ul><li>35% of 15-74 year olds </li></ul><ul><li>28% of adults in 3rd decade had head/neck pain; the incidence was predicted by psychosocial factors </li></ul>
    116. 117. Dizziness & General Population <ul><li>Primary care patients who complain of dizziness have much higher rates of  disorders than control population </li></ul><ul><li>High correlation to “negative affectivity” </li></ul><ul><ul><li>High levels of anxiety </li></ul></ul><ul><ul><li>High level of depression </li></ul></ul>
    117. 118. Head Injury and Chronic Pain <ul><li>Post concussion syndrome syndromes are not unique to MTBI, and may be seen in conditions such as chronic pain </li></ul>
    118. 119. Pain Drawing <ul><li>Quantification of pain drawings show high criterion and construct validity </li></ul><ul><li>Poor correlation with MRI </li></ul>
    119. 120. Example of a Pain Drawing
    120. 121. Forced Choice Paradigm <ul><li>For example, assessment of numb hand </li></ul><ul><li>Must guess which finger touched </li></ul><ul><li>Random guess ~ 50% </li></ul><ul><li>Malingering patient scored << 50% </li></ul>
    121. 122. Waddell Signs <ul><li>Superficial/non-anatomic </li></ul><ul><li>Axial loading or en bloc rotation </li></ul><ul><li>SLR discrepancy </li></ul><ul><li>Non-anatomical numbness/weakness </li></ul><ul><li>Overreaction </li></ul><ul><li>Cervical nonorganic signs as well </li></ul>
    122. 123. Clinical Assessment Aids <ul><ul><li>MMPI </li></ul></ul><ul><ul><li>Cornell Medical Index Health Questionnaire </li></ul></ul><ul><ul><li>McGill Pain Questionnaire (1) </li></ul></ul><ul><ul><li>Beck & Zung Depression Indices </li></ul></ul><ul><ul><li>Westhaven-Yale Muldidimensional Pain Inventory </li></ul></ul><ul><ul><li>PRIME-MD </li></ul></ul>
    123. 124. Step 3: Calculate Pain “Impairment” <ul><li>Calculate scores based on: </li></ul><ul><ul><li>Formal assessment (≤ 70) </li></ul></ul><ul><ul><li>Pain behaviors (-10 to +10) </li></ul></ul><ul><ul><li>“ Credibility” score (0 - 10) </li></ul></ul><ul><li>Determine Impairment Class </li></ul><ul><ul><li>Mild = 7-24 (I) to severe = 61-80 (IV) </li></ul></ul><ul><li>The numerical score “should not be misunderstood to represent a quantitative impairment rating(!)” </li></ul>
    124. 125. Carroll M. Brodsky, MD, PhD <ul><li>“Futile are attempts to find a single or simple factor that explains why some workers become and remain disabled while others, seemingly suffering no lesser injury, either do not enter into a disability status role or recover much earlier.” </li></ul>
    125. 126. Psychiatric Confounders <ul><ul><li>Job satisfaction predicts LBP recovery (1) </li></ul></ul><ul><ul><li>In PCP office,  morbidity predicts new LBP </li></ul></ul><ul><ul><li>Compensation adversely affects pain </li></ul></ul><ul><ul><li>Studies of aborigines show pain more readily expressed in certain cultures </li></ul></ul><ul><ul><li>2 Lithuanian, Greek, and German studies undermine the concept of “chronic whiplash injury” </li></ul></ul>
    126. 127. More on  Confounders <ul><li>Anxiety acutely, depression chronically </li></ul><ul><li>Can predict LTD, but no meaningful intervention </li></ul><ul><li>Cognitive/behavior tx decreased chronic disability </li></ul><ul><li>Catastrophizing predicts soft tissue disability </li></ul><ul><li>Simple psychosocial questionnaire at time of LB injury predicted who would become chronic </li></ul>
    127. 128. Still more on  Confounders <ul><li>98% of CLBP had ≥ 1 DSM-IIIR Dx </li></ul><ul><ul><li>Major depression </li></ul></ul><ul><ul><li>Substance abuse </li></ul></ul><ul><ul><li>Anxiety disorder </li></ul></ul><ul><ul><li>Childhood abuse </li></ul></ul><ul><li>Most diagnoses preceded LBP onset </li></ul><ul><li>Low management support and low decision authority predict neck, low back and general MS pain </li></ul>
    128. 129. Even more on  Confounders <ul><li>Many with CLBP have antecedent  disease </li></ul><ul><li>Psychosomatic and  factors predict outcome for neck pain and persistence of sciatica and whiplash </li></ul><ul><li>Best prognosticator of sick listing is previous sick listing </li></ul><ul><li>Familiy member on disability predicts worker’s disability </li></ul><ul><li>Meta-analysis shows distress, depression, and somatization predict transition to chronic LBP </li></ul>
    129. 130.  Disorders in MS Rehab Inpts. <ul><li> patients </li></ul><ul><li>31% had  diagnosis at 4 weeks </li></ul><ul><li>47% had  diagnosis at 12 months </li></ul><ul><li>65% had  diagnosis for their lifetime </li></ul><ul><li>Most common: anxiety disorder, affective disorder, substance abuse </li></ul>
    130. 131. Depression <ul><li>Somatic symptoms are the core symptoms of depression </li></ul><ul><ul><li>83% of depressed patients in PCP </li></ul></ul><ul><ul><li>50% recognized with somatic presentation </li></ul></ul><ul><li>500 adults in PCP clinic with physical symptom: </li></ul><ul><ul><li>29% had depressive or anxiety disorder </li></ul></ul><ul><ul><li>Especially with >6 physical complaints </li></ul></ul><ul><ul><li>Mood & anxiety sx predict increased utilization </li></ul></ul>
    131. 132. 2/3 of Depressed Have Chronic Pain! <ul><li>Study from Stanford/Kaiser Permanente </li></ul><ul><li>Primary care patient population </li></ul><ul><li>26% reported pain for > 60 months </li></ul><ul><li>41% had chronic disabling pain </li></ul><ul><li>Type: headache, back, limb/joint </li></ul><ul><li>Increased pain also in anxiety patients </li></ul>
    132. 133. More on Depression <ul><li>Undetected >50% of PCP population </li></ul><ul><li>16% have major depression over their lifetime </li></ul><ul><li>$44 billion dollars per year in lost productive time due to depression </li></ul><ul><li>Treatment of depression improves pain outcomes </li></ul><ul><li>Chronic WAD is strongly related to pre & postmorbid depression </li></ul>
    133. 134. Somatoform Disorders <ul><li>Somatization: 4 pain, 2 GI, 1 sexual, 1 pseudoneurological </li></ul><ul><li>Note emphasis on pain complaints </li></ul><ul><li>Multisomatoform disorder: less restrictive, based on PRIME-MD: 8.2% of a PCP population! </li></ul><ul><li>Undifferentiated somatoform disorder: least restrictive </li></ul><ul><li>Somatization: 1 disorder, many specialists? </li></ul><ul><li>Overlap of CFS, FM, IBS, multiple chemical sensitivity, TMJ, tension HAS, postconcussion syndrome </li></ul>
    134. 135. Problem Patients by Specialty <ul><li>Cardiology: atypical chest pain, palpitations </li></ul><ul><li>Dentistry: TMJ </li></ul><ul><li>ENT: tinnitus </li></ul><ul><li>Endocrine: hypoglycemia </li></ul><ul><li>GI: IBS </li></ul><ul><li>Internist: CFS </li></ul><ul><li>Neurology: dizziness, headache </li></ul><ul><li>Ob/Gyn: pelvic pain, PMS </li></ul><ul><li>Occ Med: multiple chemical sensitivity </li></ul><ul><li>Ortho: LBP, neck pain </li></ul><ul><li>Pulmonology: hyperventilation, dyspnea </li></ul><ul><li>Rehab: CHI </li></ul><ul><li>Rheumatology: FMS </li></ul><ul><li>Urology: interstitial cystitis </li></ul>
    135. 136.  Disorders in Rheumatology <ul><li>Higher incidence of  disorders (40%) than in a general medical clinic (29%) utilizing the PRIME-MD </li></ul><ul><li>Rheumatology patients more likely to be anxious and have multiple  diagnoses </li></ul><ul><li>The presence of a  diagnosis markedly decreased likelihood of a CTD </li></ul>
    136. 137. Somatization vs. CPS <ul><li>Hallmark of both Dx is chronic pain </li></ul><ul><li>Recurrent sx in different body parts </li></ul><ul><li>“ Did a lot of tests but found nothing” </li></ul><ul><li>Megachartitis </li></ul><ul><li>More MD visits than controls with no more pathology </li></ul>
    137. 138. The Somatizer “ It hurts when I do this.”
    138. 139. Symptom Magnifiers <ul><li>Functional limitations ≠ ƒ(pathology) </li></ul><ul><li>Unconscious phenomenon </li></ul><ul><li>Patients controlled by their sx </li></ul><ul><li>Compensation neurosis? </li></ul><ul><li>Belief system regarding nature & causation? </li></ul><ul><li>Somatizers overreport symptoms </li></ul>
    139. 140. Medical Sx w/o Identified Pathology <ul><li>Significantly higher rates of anxiety and depression </li></ul><ul><li>Childhood maltreatment </li></ul><ul><li>Psychological trauma in adulthood </li></ul><ul><li>High negative affectivity </li></ul><ul><li>Axis II disorders with poor coping </li></ul>
    140. 141. Outcome of Undiagnosable Neurological Patients <ul><li>Followed 90 patients with no organic etiology for their neuro complaints </li></ul><ul><li>Eight months later, none had an organic basis found for their complaints </li></ul><ul><li>Half felt worse at the follow-up period </li></ul>
    141. 142. Do sx appear to be produced on a conscious basis? <ul><li>Somatizing </li></ul><ul><ul><li>Symptoms not on a conscious basis </li></ul></ul><ul><li>Factitious Disorder </li></ul><ul><ul><li>Symptoms on a conscious basis </li></ul></ul><ul><ul><li>No obvious motivation </li></ul></ul><ul><li>Malingering </li></ul><ul><ul><li>Symptoms on a conscious basis </li></ul></ul><ul><ul><li>Obvious motivation </li></ul></ul>
    142. 143. Malingering <ul><li>Certain PDs have a high incidence of malingering </li></ul><ul><li>14% of intractable diarrhea patients had (+) samples for laxatives despite denied usage </li></ul><ul><li>18% of those claiming WC hearing loss exaggerate results of hearing tests </li></ul><ul><li>20-46% of patients consider purposeful misrepresentation of WC claims to be acceptable behavior </li></ul><ul><li>“ How easy it is to deceive sympathetic individuals . . . and how dangerous it is to be overly confident about our powers of detection” </li></ul>
    143. 144. Is disability in the CLBP patient iatrogenic? <ul><li>Can physicians truly assess the role of disability? </li></ul><ul><li>Is adequate science available? </li></ul><ul><li>Do we magnify LBP disability when we attribute it to a certain disease? </li></ul>
    144. 145. Chronic Pain Disability <ul><li>“[while attempts to] label chronic pain disorders as solely psychosocial issues to the exclusion of biological issues appear to be misguided” </li></ul><ul><li>[we must also] “explain to the patient the therapeutic benefit of work and the reality that giving disability to all 65 million or so Americans with chronic pain would bankrupt our society” </li></ul>
    145. 146. S omatization Tips <ul><li>Important questions: </li></ul><ul><ul><li>Low libido? </li></ul></ul><ul><ul><li>Undiagnosed medical problems? </li></ul></ul><ul><ul><li>Married to ASPD? </li></ul></ul><ul><ul><li>EtOH and drug problems? </li></ul></ul><ul><ul><li>Marital problems or domestic violence? </li></ul></ul>
    146. 147. More Somatization Tips <ul><li>Treatment </li></ul><ul><ul><li>Concerned PCP is most effective management mode </li></ul></ul><ul><ul><li>Show concern for symptoms: careful H&P </li></ul></ul><ul><ul><li>Testing only when considerable suspicion exists (see Righter) </li></ul></ul><ul><ul><li>Frequent visits until symptom complaints extinguish </li></ul></ul>
    147. 148. Even More Somatization Tips <ul><li>Psychiatry consult of questionable benefit </li></ul><ul><li>Psychiatric “consultation,” not transfer of care </li></ul><ul><li>Explore use of patient journal </li></ul><ul><li>Establish realistic goals </li></ul>
    148. 149. Why Does The Patient Hurt?
    149. 150. George Bernard Shaw <ul><li>“ . . . the rank and file of doctors are no more scientific than their tailors . . .” </li></ul>