The Pain Validity Test can predict which patient will have abnormal medical test results with 95% accuracy, and surgical abnormalities with 94% accuracy. This on-line questionnaire takes only 5 minutes of staff time to administer, and takes only 15 minutes of patient time.Results are available immediately. This test can be used to document "medical necessity" for insurance pre-authorization for testing and surgery.
Physicians have difficulty detecting when patients are lying or deceiving them. A literature review found that standardized patients, or actors trained to mimic real patients, were correctly identified as fake by physicians only about 10% of the time during office visits. Some real patients were even mistakenly identified as standardized patients. Deception is challenging for physicians given their tendency to assume patients are being truthful. The legal risks of prescribing opioids when deceived mean doctors must take precautions to minimize risks of abuse or diversion, but allowance must be made for the fact that honest physicians can still be misled by deceptive patients.
1) This randomized clinical trial compared opioid vs nonopioid medication therapy over 12 months for patients with chronic back, hip, or knee pain.
2) It found no significant difference in pain-related function between the two groups, but pain intensity was significantly better in the nonopioid group. Adverse effects were significantly more common in the opioid group.
3) The study concludes that opioid therapy was not superior to nonopioid medications for improving pain-related function over 12 months, and the results do not support initiating opioids for moderate to severe chronic musculoskeletal pain.
Pain Validity Test identifies drug seeking behavior. Stop opioid abuse. Prote...Nelson Hendler
Physician prescribing practices are under constant scrutiny. An Internet questionnaire will predict if a patient will have a medical test abnormality with 95% accuracy, and 100% if the patient will not. This Pain Validity Test can be used to detect drug seeking behavior in patients, at a far high level of accuracy than tests currently in use (34.4%-48.2% accuracy).. The Pain Validity test has been admitted as evidence in 30 cases in 9 states.
An Internet questionnaire to predict the presence or absence of organic patho...Nelson Hendler
The Pain Validity Test, developed by a team of physicians from Johns Hopkins Hospital, is available over the Internet, at www.MarylandClinicalDiagnostics.com. The test can predict, with 95% accuracy, which patient will have abnormalities on medical tersting, i.e. who has a valid complaint of pain. The test takes only 5 minutes to set up a patient, 15 minutes for a patient to take the test, and results are available immediately after completion. The test has been admitted as evidence in court cases in over 30 cases in 8 states.
This randomized clinical trial tested the effectiveness of stellate ganglion block (SGB) treatment compared to a sham procedure for reducing posttraumatic stress disorder (PTSD) symptoms over 8 weeks. 113 active-duty service members with PTSD symptoms were randomly assigned to receive either 2 SGB treatments 2 weeks apart or a sham procedure. The primary outcome was change in PTSD symptom severity scores measured by the CAPS-5 scale from baseline to 8 weeks. Participants receiving SGB had a greater reduction in symptoms scores compared to the sham group, with adjusted mean decreases of 12.6 vs 6.1 points respectively, indicating SGB treatment may help reduce PTSD symptoms.
This study surveyed behavioral health clinicians with experience using stellate ganglion block (SGB) as an adjunct treatment for trauma-related disorders like PTSD. Of the 23 respondents, 95% would recommend SGB to colleagues. Respondents rated SGB as at least as useful as the highest rated standard PTSD interventions. SGB was seen as most helpful for reducing arousal/reactivity symptoms. The majority would refer patients for SGB at any stage of therapy, including before starting other treatments.
This study compared patient pain scores to those assessed by emergency healthcare providers (doctors and triage nurses) in the emergency department of a large Malaysian hospital. The mean patient pain score on arrival was 6.8 out of 10, significantly higher than scores assessed by doctors (5.6) and triage nurses (4.3). Significant differences were found for 5 specific conditions: soft tissue injury, headache, abdominal pain, fracture, and abscess/cellulitis. Upon discharge or admission, nearly half of patients still reported moderate pain, suggesting undertreatment of pain in the emergency department. Accurately assessing patient-reported pain scores is important for effective pain management in emergency medicine.
How to Improve the Accuracy of the Initial Evaluation, Using a System Developed By Johns Hopkins Hospital Doctors by Nelson Hendler in Examines in Physical Medicine & Rehabilitation
Physicians have difficulty detecting when patients are lying or deceiving them. A literature review found that standardized patients, or actors trained to mimic real patients, were correctly identified as fake by physicians only about 10% of the time during office visits. Some real patients were even mistakenly identified as standardized patients. Deception is challenging for physicians given their tendency to assume patients are being truthful. The legal risks of prescribing opioids when deceived mean doctors must take precautions to minimize risks of abuse or diversion, but allowance must be made for the fact that honest physicians can still be misled by deceptive patients.
1) This randomized clinical trial compared opioid vs nonopioid medication therapy over 12 months for patients with chronic back, hip, or knee pain.
2) It found no significant difference in pain-related function between the two groups, but pain intensity was significantly better in the nonopioid group. Adverse effects were significantly more common in the opioid group.
3) The study concludes that opioid therapy was not superior to nonopioid medications for improving pain-related function over 12 months, and the results do not support initiating opioids for moderate to severe chronic musculoskeletal pain.
Pain Validity Test identifies drug seeking behavior. Stop opioid abuse. Prote...Nelson Hendler
Physician prescribing practices are under constant scrutiny. An Internet questionnaire will predict if a patient will have a medical test abnormality with 95% accuracy, and 100% if the patient will not. This Pain Validity Test can be used to detect drug seeking behavior in patients, at a far high level of accuracy than tests currently in use (34.4%-48.2% accuracy).. The Pain Validity test has been admitted as evidence in 30 cases in 9 states.
An Internet questionnaire to predict the presence or absence of organic patho...Nelson Hendler
The Pain Validity Test, developed by a team of physicians from Johns Hopkins Hospital, is available over the Internet, at www.MarylandClinicalDiagnostics.com. The test can predict, with 95% accuracy, which patient will have abnormalities on medical tersting, i.e. who has a valid complaint of pain. The test takes only 5 minutes to set up a patient, 15 minutes for a patient to take the test, and results are available immediately after completion. The test has been admitted as evidence in court cases in over 30 cases in 8 states.
This randomized clinical trial tested the effectiveness of stellate ganglion block (SGB) treatment compared to a sham procedure for reducing posttraumatic stress disorder (PTSD) symptoms over 8 weeks. 113 active-duty service members with PTSD symptoms were randomly assigned to receive either 2 SGB treatments 2 weeks apart or a sham procedure. The primary outcome was change in PTSD symptom severity scores measured by the CAPS-5 scale from baseline to 8 weeks. Participants receiving SGB had a greater reduction in symptoms scores compared to the sham group, with adjusted mean decreases of 12.6 vs 6.1 points respectively, indicating SGB treatment may help reduce PTSD symptoms.
This study surveyed behavioral health clinicians with experience using stellate ganglion block (SGB) as an adjunct treatment for trauma-related disorders like PTSD. Of the 23 respondents, 95% would recommend SGB to colleagues. Respondents rated SGB as at least as useful as the highest rated standard PTSD interventions. SGB was seen as most helpful for reducing arousal/reactivity symptoms. The majority would refer patients for SGB at any stage of therapy, including before starting other treatments.
This study compared patient pain scores to those assessed by emergency healthcare providers (doctors and triage nurses) in the emergency department of a large Malaysian hospital. The mean patient pain score on arrival was 6.8 out of 10, significantly higher than scores assessed by doctors (5.6) and triage nurses (4.3). Significant differences were found for 5 specific conditions: soft tissue injury, headache, abdominal pain, fracture, and abscess/cellulitis. Upon discharge or admission, nearly half of patients still reported moderate pain, suggesting undertreatment of pain in the emergency department. Accurately assessing patient-reported pain scores is important for effective pain management in emergency medicine.
How to Improve the Accuracy of the Initial Evaluation, Using a System Developed By Johns Hopkins Hospital Doctors by Nelson Hendler in Examines in Physical Medicine & Rehabilitation
This study evaluated the impact of preoperative opioid use on pain outcomes following total knee arthroplasty (TKA). The study analyzed data from 156 patients who underwent TKA. Twenty-three percent of patients had used opioids prior to surgery. Patients who used opioids preoperatively experienced less pain relief from TKA, with a mean reduction in pain of 27.0 points compared to 33.6 points for patients who did not use opioids preoperatively. The study concludes that preoperative opioid use is associated with less pain relief from TKA and clinicians should consider limiting opioid prescriptions prior to surgery to optimize outcomes.
Comparisonof Clinical Diagnoses versus Computerized Test Diagnoses Using the ...Nelson Hendler
The Diagnostic Paradigm from www.MarylandClinicalDiagnostics.com was able to help the former Dean of Los Angeles Chiropractic College detect medical diagnoses which he had overlooked, and he later confirmed.
1. The document describes Resolution Health's Glidepath predictive modeling approach to identify patients who are likely to undergo elective orthopedic surgeries well in advance, in order to provide targeted interventions for informed decision making.
2. Logistic regression models were developed using claims data to predict likelihood of low back surgery and knee replacement. Significant predictors for low back surgery included diagnoses, medications, treatments, and follow-up visits.
3. The models identified patients at various risk levels, achieving sensitivity over 40% and PPV over 16% at standard risk thresholds. This allows targeting interventions appropriately.
Incident opioid abuse and dependence sullivan 2014Paul Coelho, MD
This study investigated the association between prescription opioid exposure and risk of opioid use disorder (OUD) among individuals with chronic noncancer pain (CNCP). The study used claims data from 2000-2005 for over 500,000 individuals with a new CNCP diagnosis and no recent opioid use or OUD. The results showed significantly higher rates of OUD among those prescribed opioids compared to those not prescribed opioids. Risk increased with longer duration of therapy and higher daily doses. Chronic opioid therapy, even at low doses, was associated with substantially increased risk of OUD compared to acute therapy or no opioids. Duration of opioid therapy was more important than daily dose in determining OUD risk.
Comparative evaluation of 2g single dose versus conventional dose azithromycin in uncomplicated skin and skin structure infections. Indian Journal Of Pharmacology. August 2015;Vol. 47; Issue 4
1) The document summarizes several journal articles related to physical medicine and rehabilitation (PMR). It includes abstracts on topics like cognitive communication skills after mild traumatic brain injury, seizure comorbidity and hospital readmissions after traumatic brain injury, effects of traumatic brain injury and spinal cord injury on sexual function, the relationship between white matter hyperintensities and response to language treatment in post-stroke aphasia, using mental imagery therapy to treat neuropathic pain in spinal cord injury patients, and impairments in spatial navigation during walking in younger patients with mild stroke.
2) The editor's preface welcomes readers to the first issue of 2021 and thanks contributors and the recognition from IAPMR. It encourages readers to keep learning with the
The best of_the_pem_literature_in_the_last_year_terry_klassen_presentationtrekkca
This document summarizes several key pediatric emergency medicine studies from 2012-2013. It discusses 10 topics:
1. A randomized controlled trial compared polyethylene glycol 3350 vs enema for fecal disimpaction, finding no significant differences in symptom improvement between groups at day 5.
2. A clinical practice guideline stratified appendicitis risk into low, medium, and high to guide imaging and surgical referral.
3. Two studies examined diagnostic tools and physician accuracy for diagnosing intussusception.
4. An intervention to improve structured pain management in the pediatric ED led to more patients receiving analgesics faster and more frequent reassessment.
5. Studies found that rest improves concussion symptoms and reductions in
Fibromyalgia Over-Diagnosed 97% of the timeNelson Hendler
97% of patients told they have fibromyalgia do not meet the diagnostic criteria for this diagnosis, and have treatable disorders, such as nerve entrapments, thoracic outlet syndrome, discs which do not show on MRI, facet syndromes, etc.
Brain Health: The Importance of Recognizing Cognitive Impairment: An IAGG Con...Nutricia
This document summarizes the conclusions of an expert panel convened by the International Association of Gerontology and Geriatrics to discuss early detection of cognitive impairment. The panel agreed that:
1) Validated screening tests that take 3 to 7 minutes can identify early cognitive impairment.
2) The most effective approach is to use both patient-reported and informant-reported screening tools.
3) Early cognitive impairment may have treatable components, and emerging evidence supports interventions like medical treatment, nutrition changes, and physical/cognitive exercise to delay or reduce decline.
The document provides revised recommendations for the management of fibromyalgia based on a review of evidence from systematic reviews and meta-analyses published since the original 2005 guidelines. Key findings include:
- Exercise is the only therapy strongly recommended based on meta-analyses showing benefit for pain, sleep, and functioning.
- A graduated four-stage approach is proposed, beginning with patient education and non-pharmacological therapies.
- If non-response, further therapies such as psychological therapies, pharmacotherapy, or rehabilitation may be tailored to the individual. However, meta-analyses only found weak evidence for all potential pharmacological therapies.
- Most treatments show relatively modest effects. Future research priorities are identifying who benefits from specific interventions,
The document provides revised recommendations for the management of fibromyalgia based on a review of evidence from systematic reviews and meta-analyses published since the original 2005 guidelines. Key findings include:
- Exercise was the only intervention with a "strong for" recommendation based on meta-analyses showing benefits for pain, fatigue, sleep and functioning.
- A graduated four-stage approach is proposed, beginning with patient education and non-pharmacological therapies. Pharmacological therapies (amitriptyline, pregabalin, cyclobenzaprine, duloxetine, milnacipran) received "weak for" recommendations for severe pain or sleep issues.
- Growth hormone, sodium oxybate, NSAIDs, S
Corticosteroids for sore throat sr ma bmj 2018Mayra Serrano
This systematic review and meta-analysis found that a single low dose of corticosteroids, such as oral dexamethasone up to 10 mg, provides moderate to high quality evidence of pain relief for patients with sore throat. Patients who received corticosteroids were twice as likely to experience pain relief after 24 hours and 1.5 times more likely to have no pain at 48 hours, with no increase in serious adverse effects. The mean time to complete pain resolution was about 11 hours shorter with corticosteroids. Included trials enrolled over 1400 individuals and assessed outcomes up to 48 hours, but did not evaluate risks of repeated corticosteroid use for recurrent sore throats.
- The study compared ocrelizumab (OCR) to placebo in treating primary progressive multiple sclerosis (PPMS) over approximately 3 years. Baseline characteristics were balanced between the treatment groups.
- OCR met the primary endpoint of reducing disability progression confirmed at 12 weeks compared to placebo. Key secondary endpoints including disability progression at 24 weeks, timed walking test, brain lesion volume, and brain volume loss were also significantly improved by OCR compared to placebo.
- Adverse events including infections were more common with OCR, but serious adverse events and discontinuation due to adverse events were similar between groups. Safety analyses are ongoing given a higher number of reported cancers with OCR, but differences must be considered in
Palliative care could help improve the quality of life for Parkinson’s diseas...Δρ. Γιώργος K. Κασάπης
A small study of individuals with Parkinson’s disease finds that adding palliative care to standard care may help raise their quality of life. Half the patients in a 210-person trial were assigned to visit physicians as usual, while the others also received palliative care — a team of a social worker, nurse, palliative medicine specialist, and chaplain visited the patient at home or via telemedicine to discuss symptoms and difficult emotions and offer support to caregivers. Patients in the combination care group had more improvement in their quality of life score (as measured by a survey that assesses physical and mental health).
These patients also scored higher on quality of life measures when their caregivers were surveyed in their stead.
Chemotherapy+with+or+without+gefitinib+in+patients+with+advanced+non small-ce...Mina Max
This meta-analysis examined 12 randomized controlled trials involving 6,844 patients with advanced non-small cell lung cancer (NSCLC). The analysis compared chemotherapy with or without gefitinib. The primary endpoints were overall survival (OS) and progression-free survival (PFS). The meta-analysis found that gefitinib therapy significantly improved PFS compared to chemotherapy alone, but only modestly improved OS and this difference was not statistically significant. Gefitinib therapy was associated with higher objective response rates. The most common adverse events with gefitinib were rash, diarrhea, and dry skin.
Diagnoses from an on-line expert system for chronic pain confirmed by intra-o...Nelson Hendler
The Diagnostic Paradigm from www.MarylandClinicalDiagnostics.com is an on-line expert system, which gives diagnoses with a 96% correlation with diagnoses of Johns Hopkins Hospital doctors. To further confirm the accuracy of the Diagnostic Paradigm, a professor of neurosurgery from the University of Rome found 100% of the time, his intra-operative findings confirmed the diagnoses of the Diagnostic Paradigm. The Diagnostic Paradigm can be used to get pre-authorization for surgery from insurance companies, since it documents medical necessity
An Internet questionnaire to identify Drug seeking behavior in a patient in t...Nelson Hendler
Drug seeking behavior in patients with little or no real pain, has led to the opioid crisis. Until now, there was no reliable method for detecting drug seeking behavior. The Pain Validity Test from www.MarylandClinicalDiagnostics.com can predict with 95% accuracy who will have medical test abnormalities, i.e. who has a valid complaint of pain, and predicts with 85%-100% accuracy who will not have any medical test abnormalities, i.e. who is faking and drug seeking. The Pain Validity Test has been admitted as evidence in over 30 legal cases in 8 states.
Pain Validity Test to detect drug seeking behaviorNelson Hendler
The Pain Validity Test predicts which patient will have medical test abnormalities with 95% accuracy, thereby validating their complaint of pain. The Pain Validity Test also predicts with 85%-100% accuracy who will not have medical test abnormalities, thereby detecting drug seeking behavior, faking and malingering.
This document summarizes the results of moderator analyses from a large randomized controlled trial testing the effectiveness of cognitive behavioral therapy (CBT) for chronic pain from osteoarthritis. The trial compared 10 sessions of Pain Coping Skills Training (PCST), a form of CBT, delivered by nurse practitioners to a usual care control group. Several demographic and clinical variables were examined as potential moderators of treatment response. The analyses found that patients' pain coping style, expectations for treatment, disease severity, age, and education level significantly moderated outcomes, with some subgroups showing stronger responses to PCST. Sex, race, BMI, and depression did not impact treatment response. Specifically, patients with interpersonal pain coping problems did not benefit much from
Work related musculoskeletal disorders in physical therapistsTuğçehan Kara
This study examined work-related musculoskeletal disorders (WMSDs) in physical therapists through a prospective cohort study with 1-year follow up. The study found that 57.5% of physical therapists reported a WMSD in the follow up year, with a 1-year prevalence rate of 28% and incidence rate of 20.7%. Risk factors for low back WMSDs included patient transfers, repositioning, bent/twisted postures, and job strain. Risk factors for wrist/hand WMSDs included soft tissue work, joint mobilization, and manual therapy techniques. The study recommends safer patient handling policies and further research to examine the link between physical therapy exposures and WMSDs.
This study evaluated the impact of preoperative opioid use on pain outcomes following total knee arthroplasty (TKA). The study analyzed data from 156 patients who underwent TKA. Twenty-three percent of patients had used opioids prior to surgery. Patients who used opioids preoperatively experienced less pain relief from TKA, with a mean reduction in pain of 27.0 points compared to 33.6 points for patients who did not use opioids preoperatively. The study concludes that preoperative opioid use is associated with less pain relief from TKA and clinicians should consider limiting opioid prescriptions prior to surgery to optimize outcomes.
Comparisonof Clinical Diagnoses versus Computerized Test Diagnoses Using the ...Nelson Hendler
The Diagnostic Paradigm from www.MarylandClinicalDiagnostics.com was able to help the former Dean of Los Angeles Chiropractic College detect medical diagnoses which he had overlooked, and he later confirmed.
1. The document describes Resolution Health's Glidepath predictive modeling approach to identify patients who are likely to undergo elective orthopedic surgeries well in advance, in order to provide targeted interventions for informed decision making.
2. Logistic regression models were developed using claims data to predict likelihood of low back surgery and knee replacement. Significant predictors for low back surgery included diagnoses, medications, treatments, and follow-up visits.
3. The models identified patients at various risk levels, achieving sensitivity over 40% and PPV over 16% at standard risk thresholds. This allows targeting interventions appropriately.
Incident opioid abuse and dependence sullivan 2014Paul Coelho, MD
This study investigated the association between prescription opioid exposure and risk of opioid use disorder (OUD) among individuals with chronic noncancer pain (CNCP). The study used claims data from 2000-2005 for over 500,000 individuals with a new CNCP diagnosis and no recent opioid use or OUD. The results showed significantly higher rates of OUD among those prescribed opioids compared to those not prescribed opioids. Risk increased with longer duration of therapy and higher daily doses. Chronic opioid therapy, even at low doses, was associated with substantially increased risk of OUD compared to acute therapy or no opioids. Duration of opioid therapy was more important than daily dose in determining OUD risk.
Comparative evaluation of 2g single dose versus conventional dose azithromycin in uncomplicated skin and skin structure infections. Indian Journal Of Pharmacology. August 2015;Vol. 47; Issue 4
1) The document summarizes several journal articles related to physical medicine and rehabilitation (PMR). It includes abstracts on topics like cognitive communication skills after mild traumatic brain injury, seizure comorbidity and hospital readmissions after traumatic brain injury, effects of traumatic brain injury and spinal cord injury on sexual function, the relationship between white matter hyperintensities and response to language treatment in post-stroke aphasia, using mental imagery therapy to treat neuropathic pain in spinal cord injury patients, and impairments in spatial navigation during walking in younger patients with mild stroke.
2) The editor's preface welcomes readers to the first issue of 2021 and thanks contributors and the recognition from IAPMR. It encourages readers to keep learning with the
The best of_the_pem_literature_in_the_last_year_terry_klassen_presentationtrekkca
This document summarizes several key pediatric emergency medicine studies from 2012-2013. It discusses 10 topics:
1. A randomized controlled trial compared polyethylene glycol 3350 vs enema for fecal disimpaction, finding no significant differences in symptom improvement between groups at day 5.
2. A clinical practice guideline stratified appendicitis risk into low, medium, and high to guide imaging and surgical referral.
3. Two studies examined diagnostic tools and physician accuracy for diagnosing intussusception.
4. An intervention to improve structured pain management in the pediatric ED led to more patients receiving analgesics faster and more frequent reassessment.
5. Studies found that rest improves concussion symptoms and reductions in
Fibromyalgia Over-Diagnosed 97% of the timeNelson Hendler
97% of patients told they have fibromyalgia do not meet the diagnostic criteria for this diagnosis, and have treatable disorders, such as nerve entrapments, thoracic outlet syndrome, discs which do not show on MRI, facet syndromes, etc.
Brain Health: The Importance of Recognizing Cognitive Impairment: An IAGG Con...Nutricia
This document summarizes the conclusions of an expert panel convened by the International Association of Gerontology and Geriatrics to discuss early detection of cognitive impairment. The panel agreed that:
1) Validated screening tests that take 3 to 7 minutes can identify early cognitive impairment.
2) The most effective approach is to use both patient-reported and informant-reported screening tools.
3) Early cognitive impairment may have treatable components, and emerging evidence supports interventions like medical treatment, nutrition changes, and physical/cognitive exercise to delay or reduce decline.
The document provides revised recommendations for the management of fibromyalgia based on a review of evidence from systematic reviews and meta-analyses published since the original 2005 guidelines. Key findings include:
- Exercise is the only therapy strongly recommended based on meta-analyses showing benefit for pain, sleep, and functioning.
- A graduated four-stage approach is proposed, beginning with patient education and non-pharmacological therapies.
- If non-response, further therapies such as psychological therapies, pharmacotherapy, or rehabilitation may be tailored to the individual. However, meta-analyses only found weak evidence for all potential pharmacological therapies.
- Most treatments show relatively modest effects. Future research priorities are identifying who benefits from specific interventions,
The document provides revised recommendations for the management of fibromyalgia based on a review of evidence from systematic reviews and meta-analyses published since the original 2005 guidelines. Key findings include:
- Exercise was the only intervention with a "strong for" recommendation based on meta-analyses showing benefits for pain, fatigue, sleep and functioning.
- A graduated four-stage approach is proposed, beginning with patient education and non-pharmacological therapies. Pharmacological therapies (amitriptyline, pregabalin, cyclobenzaprine, duloxetine, milnacipran) received "weak for" recommendations for severe pain or sleep issues.
- Growth hormone, sodium oxybate, NSAIDs, S
Corticosteroids for sore throat sr ma bmj 2018Mayra Serrano
This systematic review and meta-analysis found that a single low dose of corticosteroids, such as oral dexamethasone up to 10 mg, provides moderate to high quality evidence of pain relief for patients with sore throat. Patients who received corticosteroids were twice as likely to experience pain relief after 24 hours and 1.5 times more likely to have no pain at 48 hours, with no increase in serious adverse effects. The mean time to complete pain resolution was about 11 hours shorter with corticosteroids. Included trials enrolled over 1400 individuals and assessed outcomes up to 48 hours, but did not evaluate risks of repeated corticosteroid use for recurrent sore throats.
- The study compared ocrelizumab (OCR) to placebo in treating primary progressive multiple sclerosis (PPMS) over approximately 3 years. Baseline characteristics were balanced between the treatment groups.
- OCR met the primary endpoint of reducing disability progression confirmed at 12 weeks compared to placebo. Key secondary endpoints including disability progression at 24 weeks, timed walking test, brain lesion volume, and brain volume loss were also significantly improved by OCR compared to placebo.
- Adverse events including infections were more common with OCR, but serious adverse events and discontinuation due to adverse events were similar between groups. Safety analyses are ongoing given a higher number of reported cancers with OCR, but differences must be considered in
Palliative care could help improve the quality of life for Parkinson’s diseas...Δρ. Γιώργος K. Κασάπης
A small study of individuals with Parkinson’s disease finds that adding palliative care to standard care may help raise their quality of life. Half the patients in a 210-person trial were assigned to visit physicians as usual, while the others also received palliative care — a team of a social worker, nurse, palliative medicine specialist, and chaplain visited the patient at home or via telemedicine to discuss symptoms and difficult emotions and offer support to caregivers. Patients in the combination care group had more improvement in their quality of life score (as measured by a survey that assesses physical and mental health).
These patients also scored higher on quality of life measures when their caregivers were surveyed in their stead.
Chemotherapy+with+or+without+gefitinib+in+patients+with+advanced+non small-ce...Mina Max
This meta-analysis examined 12 randomized controlled trials involving 6,844 patients with advanced non-small cell lung cancer (NSCLC). The analysis compared chemotherapy with or without gefitinib. The primary endpoints were overall survival (OS) and progression-free survival (PFS). The meta-analysis found that gefitinib therapy significantly improved PFS compared to chemotherapy alone, but only modestly improved OS and this difference was not statistically significant. Gefitinib therapy was associated with higher objective response rates. The most common adverse events with gefitinib were rash, diarrhea, and dry skin.
Diagnoses from an on-line expert system for chronic pain confirmed by intra-o...Nelson Hendler
The Diagnostic Paradigm from www.MarylandClinicalDiagnostics.com is an on-line expert system, which gives diagnoses with a 96% correlation with diagnoses of Johns Hopkins Hospital doctors. To further confirm the accuracy of the Diagnostic Paradigm, a professor of neurosurgery from the University of Rome found 100% of the time, his intra-operative findings confirmed the diagnoses of the Diagnostic Paradigm. The Diagnostic Paradigm can be used to get pre-authorization for surgery from insurance companies, since it documents medical necessity
An Internet questionnaire to identify Drug seeking behavior in a patient in t...Nelson Hendler
Drug seeking behavior in patients with little or no real pain, has led to the opioid crisis. Until now, there was no reliable method for detecting drug seeking behavior. The Pain Validity Test from www.MarylandClinicalDiagnostics.com can predict with 95% accuracy who will have medical test abnormalities, i.e. who has a valid complaint of pain, and predicts with 85%-100% accuracy who will not have any medical test abnormalities, i.e. who is faking and drug seeking. The Pain Validity Test has been admitted as evidence in over 30 legal cases in 8 states.
Pain Validity Test to detect drug seeking behaviorNelson Hendler
The Pain Validity Test predicts which patient will have medical test abnormalities with 95% accuracy, thereby validating their complaint of pain. The Pain Validity Test also predicts with 85%-100% accuracy who will not have medical test abnormalities, thereby detecting drug seeking behavior, faking and malingering.
This document summarizes the results of moderator analyses from a large randomized controlled trial testing the effectiveness of cognitive behavioral therapy (CBT) for chronic pain from osteoarthritis. The trial compared 10 sessions of Pain Coping Skills Training (PCST), a form of CBT, delivered by nurse practitioners to a usual care control group. Several demographic and clinical variables were examined as potential moderators of treatment response. The analyses found that patients' pain coping style, expectations for treatment, disease severity, age, and education level significantly moderated outcomes, with some subgroups showing stronger responses to PCST. Sex, race, BMI, and depression did not impact treatment response. Specifically, patients with interpersonal pain coping problems did not benefit much from
Work related musculoskeletal disorders in physical therapistsTuğçehan Kara
This study examined work-related musculoskeletal disorders (WMSDs) in physical therapists through a prospective cohort study with 1-year follow up. The study found that 57.5% of physical therapists reported a WMSD in the follow up year, with a 1-year prevalence rate of 28% and incidence rate of 20.7%. Risk factors for low back WMSDs included patient transfers, repositioning, bent/twisted postures, and job strain. Risk factors for wrist/hand WMSDs included soft tissue work, joint mobilization, and manual therapy techniques. The study recommends safer patient handling policies and further research to examine the link between physical therapy exposures and WMSDs.
The paper lists the correct method of diagnosing chronic pain, and matching the proper medication to tissue damage without the use of narcotics or opioids.
Johns Hopkins Hospital doctors report that 40%-80% of chronic pain patient are misdiagnosed, and that MRIs and CTs miss pathology 56%-78% of the time, Therefore, during extensive chart reviews of current medical data will produce a classic case of GIGO-garbage in giving garbage out. The need for accurate diagnoses and testing is critical for AI to work.
Evaluating Chronic Pain Patients Using Methods from Johns Hopkins Hospital Ph...Nelson Hendler
This article describes the use of physiological testing, instead of anatomical testing, to evaluate chronic pain. The efficacy of this approach is documented by published outcome studies.,, Patient require surgery 50%-63% of the time to improve.
The document summarizes a study that reviewed charts of 86 patients discharged from an Opioid Renewal Clinic (ORC) over 22 months to examine outcomes two years after discharge. The most common reason for discharge was recurrent positive urine drug screens for illicit substances (47%). Only 17% received addiction treatment in the two years after discharge. 41% were prescribed opioids within two years of discharge, and those prescribed opioids tended to have longer stays in the ORC and more primary care visits after discharge. The outcomes reveal a need to improve addiction management for this patient population.
The role of illness perceptions and medicine beliefs in adherence to chronic ...epicyclops
Presentation given by Dr Leanne Ramsay & Dr Martin Dunbar to the West of Scotland Pain Group on 7th October 2008 at the Royal College of Physicians and Surgeons of Glasgow.
This study examined whether higher scores on a fibromyalgia survey were associated with increased opioid consumption after hysterectomy, while accounting for known risk factors. The study found:
1) Higher scores on the fibromyalgia survey were independently associated with greater postoperative opioid use, with opioid consumption increasing by 7 mg of oral morphine equivalents for every 1-point increase on the 31-point survey scale.
2) In addition to fibromyalgia survey scores, factors like more severe medical comorbidities, greater catastrophizing, laparotomy surgical approach, and preoperative opioid use predicted increased postoperative opioid needs.
3) These results suggest that the fibromyalgia survey may help identify patients at high risk for needing more opioids after surgery, and that
1. The document describes a study that examined the effects of a 6-month exercise intervention on inflammatory markers in sedentary middle-aged men. 152 men were screened and eligible sedentary men were randomly assigned to an exercise group or control group.
2. Blood samples were taken at regular intervals to measure inflammatory markers like IL-6 and CRP. The results showed that regular exercise over 6 months can positively impact systemic markers of chronic inflammation.
3. The study provides causal evidence that exercise interventions can reduce inflammation, filling gaps in previous research that had inconsistent or limited findings. It establishes a dose-response relationship and controls for compliance through activity monitors.
Au Psy492 M6 A3 Ssal Smith Marcanne Research Skillsmarcanne
The document summarizes a student's self-appraisal of their learning related to research skills. It describes a quasi-experimental study the student designed to examine the effects of patient-controlled analgesia versus conventional pain management after surgery. The study has threats to validity due to the non-random assignment of patients to treatment groups and lack of control for factors like pain tolerance and medical history. The student recommends adding pretesting and placebo treatments to help control for these threats.
A randomized, double-blind, placebo-controlled pilot study was conducted to determine if preoperative modafinil improved recovery after general anesthesia in patients with obstructive sleep apnea (OSA). 102 patients with OSA were given either 200mg of modafinil or placebo before surgery. The primary outcome of length of stay in the post-anesthesia care unit (PACU) showed no difference between groups. Secondary measures of emergence and recovery also did not differ significantly. While respiratory rate was higher and blood pressure lower in the modafinil group in the PACU, the study results suggest single-dose preoperative modafinil does not improve functional recovery after general anesthesia in patients with OSA.
This study aimed to develop abbreviated versions of the Pain Catastrophizing Scale (PCS) and Short Health Anxiety Inventory (SHAI) for use in busy orthopedic settings. The researchers analyzed data from 164 patients and identified questions from the original scales that highly correlated with each other and the full scales. For the PCS, questions 3, 6, 8 and 11 were selected, creating the PCS-4. For the SHAI, questions 2, 3, 12, 15 and 17 were chosen, forming the SHAI-5. Both the PCS-4 and SHAI-5 showed good internal consistency and correlated highly with the original full scales. The abbreviated scales also correlated equally well with measures of disability,
ORIGINAL ARTICLE HIP - ANESTHESIAA randomized controlled.docxgerardkortney
ORIGINAL ARTICLE � HIP - ANESTHESIA
A randomized controlled trial of postoperative analgesia following
total knee replacement: transdermal Fentanyl patches
versus patient controlled analgesia (PCA)
M. J. Hall1 • S. M. Dixon2 • M. Bracey3 • P. MacIntyre4 • R. J. Powell3 •
A. D. Toms3
Received: 13 November 2014 / Accepted: 12 February 2015 / Published online: 11 March 2015
� Springer-Verlag France 2015
Abstract
Background This randomized controlled trial compared a
standard patient controlled analgesic (PCA) regime with a
transdermal and oral Fentanyl regime for post-operative
pain management in patients undergoing total knee
replacement.
Methods One hundred and ninety-six patients undergoing
total knee replacement were recruited. Pre- and post-op-
eratively Visual Analogue Score (VAS), Oxford Knee
Score, Health Anxiety and Depression Score and Brief Pain
Inventory Score were completed. According to the day 1,
VAS score patients were randomly allocated to either a
PCA regime or a Fentanyl transdermal/oral regime. Patient
reported outcomes were measured until the patients were
discharged.
Results The results demonstrate that in terms of analgesic
effect, day of discharge and side effect profile the two
regimes are comparable.
Conclusions We conclude that a Fentanyl transdermal
regime provides adequate analgesic effect comparable to a
standard PCA regime in conjunction with a low side effect
profile. Using a transdermal analgesic system provides ef-
ficient continuous delivery enabling a smooth transition
from hospital to home within the first week. Transdermal
Fentanyl provides an alternative analgesic regime that can
provide an equivalent analgesic effect so as to enable a
satisfactory outcome for the patient in terms of function
and pain.
Level of evidence II.
Keywords Total knee replacement � Post-operative
analgesia � Patient controlled analgesia � Fentanyl patches
Introduction
Knee replacement surgery has proved a successful and
cost-effective method for relieving pain and restoring
function in patients with osteoarthritis [1]. However, pain
management after knee replacement surgery remains a
significant problem, with patients reporting this as a major
concern prior to surgery [2]. Implementing relevant pre-
operative screening methods may facilitate the identifica-
tion of individuals at high risk of experiencing high post-
operative pain [3]. Despite recent advances in the aetiology
of pain, improved pain treatments and the development of
clinical guidelines for pain assessment, the under-treatment
of post-operative pain remains a challenge to both surgeon
and anaesthetist. Recent studies have clearly demonstrated
that patient satisfaction following total knee replacement is
multifactorial with the most significant predictor of dis-
satisfaction being a painful total knee replacement [1].
Providing effective pain relief in the post-operative pe-
riod is essential to enable early mobili.
This study assessed long-term outcomes of surgical versus nonsurgical treatment of sciatica caused by a herniated lumbar disc. Over 10 years:
- 69% of surgically treated patients reported improved symptoms versus 61% nonsurgically treated, and 56% of surgical patients reported much better or resolved leg and back pain versus 40% nonsurgical.
- Surgically treated patients also reported greater satisfaction and improved functional status compared to nonsurgical patients, though work disability outcomes were similar between groups.
- By 10 years, 25% of each group had additional lumbar spine surgeries, though surgical patients initially had worse symptoms and findings.
Pilot Study of Massage in Veterans with Knee OsteoarthritisMichael Juberg
This pilot study assessed the feasibility and preliminary efficacy of Swedish massage therapy for 25 veterans with knee osteoarthritis. The study found high retention and adherence rates, suggesting massage was feasible and acceptable for veterans. Veterans receiving 8 weekly one-hour massage sessions experienced statistically significant improvements in self-reported knee pain, stiffness, function, and quality of life, as well as trends toward improved range of motion. The results support further study of massage as a treatment approach for knee osteoarthritis in veterans.
For this assignment activity, I want you to answer the questions beLilianaJohansen814
For this assignment activity, I want you to answer the questions below. Refer to module and text book readings.
Give rationales for all of your answers.
Identify and define the
most commonly used
data collection methods for qualitative research?
What are the most commonly used data collection methods used for each of the following qualitative research traditions:
Ethnography
Phenomenology
Grounded Theory
Relative to the Heikkinen et al. article, answer the following questions and include supporting rationales.
What data collection methods were used (be sure to include nurse measures, patient measures, and physiologic measures)?
What are the strengths and weaknesses of each data collection method?
"BELOW IS THE ARTICLE"
ISSUES AND INNOVATIONS IN NURSING PRACTICE
Prostatectomy patients’ postoperative pain assessment in the recovery room
Katja Heikkinen MNSc RN
Lecturer, Turku Polytechnic and Department of Nursing, University of Turku, Turku, Finland
Sanna Salantera¨ PhD RN
Adjunct Professor, Department of Nursing, University of Turku, Turku, Finland
Marjaana Kettu RN
Head of Department, Ophtalmology Clinic, Turku University Central Hospital, Turku, Finland
Markku Taittonen MD PhD
Consultant Anaesthesiologist, Department of Anaesthesiology and Intensive Care, Turku University Central Hospital, Turku,
Finalnd
Accepted for publication 16 February 2005
Correspondence:
Katja Heikkinen,
Department of Nursing,
University of Turku,
FIN – 20014,
Turku,
Finland.
E-mail:
[email protected]
HEIKKINEN K., SALANTERA¨ S., KETTU M. & TAITTONEN M. (2005) Journal of Advanced Nursing 52(6), 592–600
Prostatectomy patients’ postoperative pain assessment in the recovery room
Aim. This paper reports a study to assess the usability and use of different pain assessment tools and to compare patients’ and nurses’ pain assessments in the recovery room after prostatectomy.
Background. Pain assessment is the first step towards providing adequate pain relief but poses problems because of the subjective nature of the pain experience and the lack of quantifiable measurements. Pain tools have been tested in several clinical settings, but not in the recovery room.
Methods. Data were collected in the recovery room from 45 consecutive patients who had undergone prostatectomy by asking them to evaluate their pain intensity using visual analogue scale, numeric rating scale and verbal expressions. One of two research nurses measured patients’ pain at regular intervals and at the same time as the patients. Physiological parameters were also evaluated. Data were analysed as frequencies and percentages. Sum variables were formed and results were analysed using Spearman’s rank correlation, Pearson’s correlation and with multiple regression analysis.
Results. Patients varied in their ability to assess the intensity of their pain using different tools, but assessments were correlated with each o ...
This document provides instructions and questions for an assignment on clinical epidemiology and chronic disease epidemiology. It includes 7 questions assessing understanding of key epidemiological concepts like determinants of disease, epidemiological study designs, and interpreting results. Students are asked to apply their knowledge to analyze specific chronic diseases and epidemiological studies, as well as propose public health interventions.
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Reports from Johns Hopkins Hospital doctors document that 40%-80% of patients labeled as soft tissue injury, whiplash, sprain or strain are misdiagnosed. Use of an Internet expert system provides diagnoses with a 96% correlation with diagnoses of former Johns Hopkins Hospital doctors, resulting in a 192% increase in interventional testing, and a 50%-63% increase in surgery in previously misdiagnosed patients, 93% of whom report good to excellent improvement after surgery. .
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Predicting Medical Test Results and Intra-Operative Findings in Chronic Pain Patients Using the On-Line "Pain Validity Test"
1. Journal of ISSN: 2373-6437JACCOA
Anesthesia & Critical Care: Open Access
Research Article
Volume 5 Issue 1 - 2016
Predicting Medical Test Results and Intra-Operative Findings in Chronic Pain
Patients Using the On-Line “Pain Validity Test”
Reginald Davis1, Nelson Hendler2* and Allison Baker3
1Assistant Professor of Neurosurgery, Johns Hopkins University School of Medicine and Chief of Neurosurgery, Greater Baltimore Medical Center, USA
2Former Assistant Professor of Neurosurgery, Johns Hopkins University School of Medicine, USA
3School of Social Science Research, USA
Received: May 04, 2016| Published: June 15, 2016
*Corresponding author: Nelson Hendler, Former Assistant Professor of Neurosurgery, Johns Hopkins University School of Medicine, 117 Willis St., Cambridge,
Maryland, 21613, USA, Tel: 443-277-0306; Email:
Citation: Davis R, Hendler N, Baker A (2016) Predicting Medical Test Results and Intra-Operative Findings in Chronic Pain Patients Using the On-Line “Pain Validity
Test”. J Anesth Crit Care Open Access 5(1): 00174. DOI:10.15406/jaccoa.2016.05.00174
Download PDF
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Abstract
Previous reports indicated The Pain Validity Test (PVT) can predict the presence of abnormalities on the correct medical testing, with 94% accuracy, and the
absence of abnormalities on the correct medical testing with 85% accuracy, in patients with chronic back, neck or limb pain. However, 40%-71% of chronic
pain patients are misdiagnosed, primarily because physicians use the wrong medical tests, or use tests, such as the MRI, which have a false negative rate as
high as 78%. Rather than rely on inaccurate medical testing which is typically used, we conducted research to see if the Pain Validity Test could predict a
more reliable and irrefutable indication of pathology, i.e. intra-operative findings. Prior to surgery, the Pain Validity Test (PVT) correctly predicted which
patients had abnormal results on the correct medical tests with 94% accuracy, (r = 0.554; p < .0001). Of the original 149 patient studied in the original
report, 74 patients had surgery. In the 71 patients with abnormal medical testing, the Pain Validity Test correctly predicted that 69 patients would have
abnormal testing (97.1 %). Of the 74 patients with intra-operative pathology, the Pain Validity Test predicted 69 would have pathology (93.2%). Of the 69
patients predicted to have abnormal medical testing, 69 of the 69 had moderate or severe intra-operative pathology (100%), so there were no false
positives. Two of the remaining 5 patients in whom the Pain Validity Test predicted no pathology, did have abnormal medical testing, and intra-operatively
did have pathology. Three of the remaining 5 patients in whom the Pain Validity Test predicted no abnormal medical testing did not have abnormal testing,
but intra-operatively, were found to have moderate pathology. Therefore, The Pain Validity Test can predict who will have a) abnormal medical testing with
97.1% accuracy (69/71) and b) regardless of pre-operative testing, will predict who will have intra-operative pathology if surgery is indicated with 93%
accuracy (69/74).
Keywords: MMPI; Intra-operative findings; Psychological tests for pain; Back pain; Neck pain; Measuring pain; Validating pain; Predicting organic
pathology; Misdiagnosis of chronic pain; Arm pain; Leg pain
Go to...
Introduction
A surgeon is often faced with multi-factorial challenges when evaluating a patient with chronic pain problems. Chronic pain is defined as a constant pain
lasting 6 months or longer and often causes psychological problems, which interferes with accurate medical assessment [1]. X-ray studies, Electro
Myelograms (EMG), nerve conduction velocity studies and EMG [2-4] may document an organic basis of chronic back pain, but some pain problems cannot
be identified by objective tests, since there are many false negative and false positive results on “objective” medical testing [5]. Physician prejudice against
woman patients can result in a significantly less extensive evaluation of their complaints of back pain [6]. Litigation may influence symptoms [7] and the
type of litigation may influence outcomes [8]. For that reason, there is a need to differentiate between “organic” (valid) and “functional” (negative physical
2. and laboratory examination) back, neck and limb pain, before undertaking an extensive medical evaluation, prescribing narcotic medication, or performing
surgery [9].
Personality disorders, and organic disease are independent of each other, yet doctors often do not recognize this independence [10,11]. Chronic pain creates
psychological changes over time [1,12,13]. Psychological tests, of different varieties, have been used to evaluate the validity of the complaint of pain [9]. A
frequently used test is the Minnesota Multiphasic Personality Inventory (MMPI), Researchers have identified several clusters of personality traits which
occur commonly in chronic pain patients [14-17]. In fact, one scale, the “Fake Bad Scale” provides such inaccurate information that researchers from the
Department of Psychology, University of Minnesota, where the MMPI was developed, recommended that this scale not be used [17]. Only one study from the
Mayo Clinic, reported on patients with chronic pain on a longitudinal basis after MMPI administration, and found that it had no predictive value [18].
“Functional” pain is defined as a pain for which there is no organic pathology, while “organic” pain is defined as pain that does have a medical explanation.
The MMPI had been used to differentiate between “organic” and “functional” groups of chronic back pain patients with varying degrees of accuracy [19-21],
and specifically developed subtests of the MMPI were also unreliable [21-23]. One group of researchers tried to correlate MMPI findings with the presence
or absence of objective physical findings [24-26]. These researchers found scale 2 (depression) had a slight correlation with physical findings in men and, in
a combined study, found that the F scale (faking) correlated with physical findings, but these findings were not consistent [24-26].
The Pain Validity Test (PVT) was developed by a group of researchers from Johns Hopkins Hospital. The questions address medical, psychological and social
issues in a patient’s life. It was based on normative responses to medical, psychological and social issues in patients with documented chronic back, neck and
limb pain regardless of any pre-existing personality disorder, or co-existing psychiatric problem [27]. Multi-center studies found that the test could reliably
predict the presence or absence of abnormalities on objective medical tests [24-26,28]. The most recent study showed the Internet version of the Pain
Validity Test (PVT), not subject to inter-rater reliability problems, could predict the presence of organic pathology 94% of the time, and the absence of
organic pathology 85% of the time [29]. The Pain Validity Test is a 32 question test, available in English and Spanish over the Internet at
www.MarylandClinicalDiagnostics.com. Results are emailed back to physicians in 5 minutes after completion of the test.
However, medical tests very often have false positive and false negative results, which confound the decision to perform surgery. The real concern is not
whether a patient has an abnormal test. This real issue is the presence or absence of intra-operative pathology, i.e. was the surgery warranted. Therefore, a
verbal test which could predict intra-operative findings would be a valuable screening tool for non-medical professionals, such as psychologists, insurance
carriers, or attorneys. It would help them decide if expensive medical tests should be ordered, and if the surgeon should obtain more extensive testing, or
rely on erroneous testing results, such as the MRI of discs, in which the false negative rate could reach as high as a 78%. This is particularly valuable in
chronic pain patients, who have pre-existing or co-existing psychological issues.
The present study is designed to investigate the usefulness of PVT for predicting the presence or absence of intra-operatively documented organic
pathological conditions in patients with chronic back, neck and/or limb pain. This research is an attempt to determine if a properly designed questionnaire
can predict the actual intra-operative findings using predictive analytic techniques.
Go to...
Methods
Patients
One hundred and forty-nine patient charts were reviewed. As reported in previous articles, the PVT was administered over a computer, with an Internet
connection. A number of patients expressed concerns about their skills with a computer, and several times entered the wrong answers to the Pain Validity
Test, and wanted to correct their answers. Unfortunately, due to programming restrictions, the patients are unable to reverse the page sequence of the test,
in order to correct their answers, which may lead to entry of erroneous answers. Despite these problems, the Internet version of the Pain Validity Test is able
to predict medical test abnormalities with 94% accuracy and the absence of organic pathology with 85% accuracy [29]. Of these 149 patients, 74 received
surgery. Seventy-three percent of these 74 patients were from outside the State of Maryland, while the remainders were from the State of Maryland. Since
PVT was designed only to assess the impact of the complaint of chronic back, neck and limb pain, only patients with the chief complaint of consistent pain in
the back, back and legs(s), neck, neck and arm(s) or all the combinations thereof of six months’ duration or longer were included in the study. In addition,
only those patients who had received the appropriate objective physical tests (see below) were included. Excluded from the study were patients with too
few tests, pain of less than six months’ duration and inappropriate location of the pain (headache, gastrointestinal pain, genital pain, facial pain, etc.)
For the 74 patients, demographic data was derived from chart review, if the information was available. The average age of all patients was 41.4 years (n = 74
range 23-61). There were 45 males and 29 females in the study.
Physical tests
Objective physical tests were divided into two groups based on the ability of these tests to assist in the diagnosis of chronic back and/or back and limb pain.
The first group, which was comprised of physiological tests, consisted of electromyography, nerve conduction studies, facet blocks, root blocks, peripheral
nerve blocks, current perception threshold testing, quantitative flow-meter studies (Doppler), provocative discometry, bone scan, gallium scan or Indium III
scan. The second group, which was comprised of anatomical tests, consisted of myelogram and/or iohexol-enhanced CT of the back, or a combination of the
two tests, MRI, with or without gadolinium enhancement, 3D-CT, CT, and flexion-extension X-rays with obliques. A patient had to receive at least two tests in
the first group or two or more tests in the second group to be included in the study.
3.
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Results
Analysis of physical test results
The medical charts were graded for the severity of physical findings based on a simplified ranking system. The charts were blindly reviewed, i.e. the
researchers did not know the score on the Pain Validity Test. Physical tests in which there were no abnormal findings were assigned a score of 0; those with
equivocal and minimal findings were scored as a 1. Tests interpreted as moderate or severe were given scores of 2 or 3 respectively. The ratings were based
on the reported results from the various laboratories in which the objective tests were performed. Assessing the physical values for the objective tests was
standardized, as previously reported [29].
Analysis of intra-operative findings
The operative note from each patient who received surgery was blindly reviewed by a researcher who did not perform the surgery. Findings were
considered normal if pathology reports and intra-operative notes indicated no pathology. Findings were considered mild if pathology reports and intra-
operative notes found “mild scaring of a nerve root,” or “mild scarring of a peripheral nerve” or “mild neural foraminal stenosis,” or “mild compression of a
vessel.” Likewise, if the reports or note contained the word moderate or severe, then the pathology was considered moderate or severe.
Various surgeries were performed, including rotator cuff repair, 360 degree fusions, artificial disc implants, resection of the first rib for thoracic outlet
syndrome, decompression of peripheral nerves and others. Table 1 lists the various surgeries for which intra-operative findings were reviewed.
Surgery Finding
Thoracic outlet first rib removal Dense scarring of the brachial plexus, and artery
Anterior cervical fusion Reduced disc space height, and degenerated disc
Ulnar nerve decompression Dense scarring of the ulnar nerve at the elbow
Foraminotomy Severe neural foraminal stenosis
Radial nerve decompression Dense scarring of the radial nerve in the radial groove
Lumbar disc herniation
Protrusion of the nucleus polposa with compression
of a nerve root or thecal sac
Cervical disc herniation
Protrusion of the nucleus polposa with compression
of a nerve root or spinal cord.
Saphenous nerve entrapment Dense scarring of the saphenous nerve at the knee
Tibial nerve entrapment Dense scarring of the tibial nerve at the ankle
Peroneal nerve entrapment Dense scarring of the peroneal nerve at the knee
Complex regional pain syndrome Scarring of the sympathetic chain
Anteriolysthesis Break and dislocation of the pars interarticularis
Rotator cuff tear Tear of the rotator cuff
Labral tear Tear of the labrum
Acromo-clavicular impingement Hypertrophy of the acromo-clavicular joint.
Medial meniscus tear Tear of the medial meniscus
Fracture of the lateral maleolus Fracture of the lateral maleolus
Carpel tunnel syndrome Dense scarring of the median nerve at the wrist
4. Radial nerve entrapment Moderate or dense scarring of radial nerve
Ulnar nerve entrapment Moderate or dense scarring of ulnar nerve
Table 1: Various surgeries performed and intra-operative findings.
Test Interpretation
In this study, inter-rater reliability for the Pain Validity Test was not a factor, since every testing encounter was consistent. The questions were always the
same questions, and answers were multiple choice answers administered over the Internet. The score calculated by a computer.
The patients scoring as objective pain patients on the Pain Validity Test, and only having 1 or 0 points rating their physical abnormalities, could have errors
that were the result of incomplete medical evaluations, false negative results on medical testing, and absence of exhaustive physical testing. However, to off-
set this type of error, the actual intra-operative finding was considered more reliable than medical testing, since false negatives and false positives occur
with medical testing [5].
Patients who scored as exaggerating pain patients, on the Pain Validity Test, but who had 2 or 3 points rating their physical abnormalities could have severe
pre-existing psychopathology. This skews the results of the Pain Validity Test. If medical testing was moderately or severely abnormal, surgery was
warranted, regardless of pre-existing or co-existing psychopathology. Usually, these patients presented as management problems pre and post operatively,
due to their psychopathology, but clearly, they were not malingering, nor faking their organic pathology, as documented by abnormal medical testing.
Data analysis
Of the original 149 patient studied in the original report, 74 patients had surgery. In the 71 patients with abnormal medical testing pre-operatively, the Pain
Validity Test correctly predicted that 69 patients would have abnormal testing (97.1 %). Of the 74 patients with intra-operative pathology, the Pain Validity
Test predicted 69 would have pathology (93.2%). Of the 69 patients predicted to have abnormal medical testing, 69 of the 69 had moderate or severe intra-
operative pathology (100%), so there were no false positives. Two of the remaining 5 patients in whom the Pain Validity Test predicted no pathology, did
have abnormal medical testing, and intra-operatively did have pathology. Three of the remaining 5 patients in whom the Pain Validity Test predicted no
abnormal medical testing did not have abnormal testing, but intra-operatively, were found to have moderate pathology. Therefore, The Pain Validity Test
can predict who will have a) abnormal medical testing with 97.1% accuracy (69/71) and b) regardless of pre-operative testing, will predict who will have
intra-operative pathology if surgery is indicated with 93% accuracy (69/74).
A correlation coefficient, using the Pearson Product Moment Correlation Test (R Test), was computed between the severity rating of intra-operative findings
of each patient and The Pain Validity Test score. Scattergrams are plotted for the Pain Validity Test versus the severity of intra-operative findings. A Chi-
Square test was used to analyze the significance of the frequency distribution of the scattergram, despite its limitations.
The scattergram for PVT scores compared with the severity of intra-operative findings is shown in Figure 1. PVT score for each patient was compared with
their score for the most severe intra-operative finding. A correlation of r = 0.413 was obtained, which is significant at the level of p<0.0001.
Figure 1: Scattergram of Computer Scored Pain Validity Test Vs Severity of Intra-Operative Findings.
Figure 2 shows tabulation of the Chi-square test for The Pain Validity Test versus the severity of abnormal medical test findings. The Chi-square test result
was 56.25 which was significant at p<0.0001. On PVT the cut off score considered to be an objective pain patient is 17 points or less. If a patient had 17
points or less, 94.4% of the time he or she had an intra-operative abnormality that could be documented using objective testing described under Physical
tests (103/109). A score between 18 and 20 points, inclusively, was considered a mixed objective-exaggerating pain patient, and 74.1% % of the time these
patients had objective physical findings (20/27). This group may represent patients with a poor pre-morbid physiological adjustment, who had documented
physical pathological conditions. If a patient scored 21 points to 29 points, inclusively, on PVT, he or she was considered an exaggerating pain patient, and
5. 84.6% of the time had only mild findings on objective tests of organic pathology, or no test was positive (11/13). However, the group consisted of patients
with definable organic syndromes, with only mildly abnormal or absent objective findings, such as found in myofascial syndrome or facet syndrome.
Figure 2: Scattergram of Computer Scored Pain Validity Test v Findings on Laboratory Tests.
Earlier research indicated that between 50% to 55% of properly diagnosed chronic pain patients were referred for surgery. In this report 74 of 149 patients
(49.6%) of patients were referred for surgery, based on their diagnosis, and laboratory testing results. Of the 74 patients who received surgery, only 5
patients scored in the Exaggerating Pain Patient Category, and 69 were in the Objective, or Mixed Objective Exaggerating Pain Patient Category. All 69
patients in the latter two categories had moderate or severe abnormities on pre-operative medical testing, and moderate or severe abnormalities were
found intra-operatively. Five of the Exaggerating Pain Patients had moderate or severe abnormities on pre-operative medical testing, and moderate or
severe abnormalities were found intra-operative. Therefore, the Pain Validity Test accurately predicted that 93% of the patients (69/74) would have
moderate or severe intra-operative findings, and had a 7% false negative rate, i.e. indicated that 5 of the 74 patients would not have moderate or severe
intra-operative findings, when in fact they did.
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Discussion
Surgeons may encounter a patient who is demanding, histrionic in their behavior, or have negative radiological studies [10,11]. Due to the increased amount
of time required to deal with these patients, and other management issues, the surgeons often ask for a psychiatric evaluation for these patients. Often, this
evaluation is conducted by a non-medical clinician, such as a psychologist or social worker, who may use the MMPI to assist them in the evaluation of the
patient. The lack of medical training, coupled with the use of a psychological test which is inappropriate to determine the validity of the complaint of pain,
leads to misdiagnosis.
The failure to recognize that organic pathology and psychiatric disorders may exist independently leads to confusion in the diagnosis of chronic pain
patients and do not necessarily have a cause and effect relationship [10]. The incidence of psychiatric disorders presenting as pain problems had never been
defined [30-32]. However, the clinician must consider that chronic pain may create anxiety and depression [31]. In a study conducted by the psychiatry
department of Johns Hopkins Hospital, 80% of the 67 patients admitted to a psychiatry ward because of their complaint of chronic pain had physical
abnormalities to explain their complaints [34]. Rosenthal also lends credence to the concept that pain complaints and psychiatric disturbance exists on two
separate axes [35].
The F scales of the MMPI correlated with the severity of objective organic pathologic conditions [27]. However, in two other test populations, it was found
that either the depression scale (scale 2) of the MMPI negatively correlated with physical pathology [26] or that none of the scales of the MMPI correlated
with the severity of objective organic pathological conditions [25]. The variability in MMPI results suggests this test is unreliable for determine the validity of
physical complaints.
From a preoperative sample of 50,000 MMPIs, Hageron and his colleagues at the Mayo Clinic found 59 patients who subsequently had back surgery over a
20-year follow-up [18]. This group concluded that the MMPI abnormalities noted after the onset of back pain were the result of pain “rather than a reflection
of pre-existing personality traits” [18]. In the absence of longitudinal studies, one cannot determine whether or not the MMPI scales are elevated prior to or
as a result of the chronic pain syndrome [36].
6. In summary, it seems that the MMPI is not able to differentiate organic from functional low back pain with any degree of validity or reliability. In addition, it
would be imprudent and irresponsible for a clinician to label as functional any chronic pain patient who happens to have elevations of MMPI scales as has
been done by one author [37] since the MMPI cannot predict the presence or absence of an organic pathological condition with any degree of certainty in
patients with chronic back pain [24-26]. Additionally, elevated MMPI scores in pain patients seem to be the result of pain rather than the cause of the
complaint [18,31].
The DSM IV (providing definitions and ICD codes for psychiatric disorders) defines “somatization disorder” as a disorder that occurs in patients whose
“multiple somatic complaints cannot be fully explained by any known general medical condition…” [38]. However, this definition suffers from circular logic
since many patients with concurrent psychiatric disease and chronic pain receive inadequate physical evaluations and are medically misdiagnosed 40% to
71% of the time [39,40,41].
Only two other tests in the medical literature try to correlate the verbal history with actual findings on medical testing. The Ottawa ankle rules and the
Ottawa knee rules were found to correlate with the presence and absence of organic pathology, and these tests resulted in cost savings of over $50,000,000 a
year in preventing needless X-rays the Ottawa province of Canada [42-44]. The PVT differs from these two verbal tests, since it can be used to predict the
presence or the absence of abnormal laboratory tests, of all types, not just X-rays, in patients with back, neck and limb pain. This could result in even larger
savings for health care systems.
California State Auditor Elaine Howle [45] says the $30,000,000 annual assessment to combat workers compensation fraud in California may be wasted. The
insurance carriers cannot measure the effectiveness of their efforts. The fraud division publishes statistics showing the number of investigations, arrests,
convictions, and restitution, but cannot show if anti-fraud efforts are cost-effective [45]. The Pain Validity Test, a 31 question, self administered test available
on the Internet (www.Need IME website.com) was designed to tell an insurance adjustor if a claimant has a valid complaint of pain. It can predict that a
claimant will have organic pathology detected by objective testing 94% of the time, and predict that a claimant will not have organic pathology 85% of the
time [29]. Earlier research reports that only 6% to 13% of chronic pain patients are exaggerating their symptoms, while 87% to 94% of patients have a valid
complaint of pain [24-27]. Unfortunately the patients with valid pain are misdiagnosed 40%-71% of the time [39-41]. Using the Pain Validity Test, which
costs $300, saved a major insurance carrier an average of $1,554 per claim, by eliminating the need for independent medical examinations (IMEs), nurse
case reviewers, and surveillance [46]. This allowed the insurance adjustor to focus the surveillance and independent medical examinations on the patients
who were exaggerating their claims. It also gives the insurance adjustor an indication of which claimants need better diagnosis and proper treatment.
Until now, no verbal test has ever been reported to predict the presence of intra-operative pathology. The Pain Validity Test does predict medical testing
abnormalities, but this approach to verifying pain still has problems, due to the false negative and false positive rates of most medical tests. As an example,
the false positive rate for detecting disc pathology for the MRI is 29% [47] while the false negative rate is between 76% to 79% [48,49]. Therefore, a test that
predicts abnormal medical tests is less valuable than a test that can predict the real pathology, i.e. intra-operative findings.
Several tests have been used to predict surgical outcome, which is a different issue than predicting the more objective findings of the presence or absence of
organic pathology, or actual intra-operative findings [50-52]. These articles on surgical outcome recognize that multiple factors influence results, including
legal, social, medical and psychological factors.
Current methods of evaluating the validity of a patient’s complaint, using the MMPI, have little chance of meeting the Daubert criteria since they do “not meet
the applicable ‘general acceptance’ standard for the admission of expert testimony” [53]. Furthermore “expert opinion based on a scientific technique is
inadmissible unless the technique is ‘generally accepted’ as reliable in the relevant scientific community” [53]. The Pain Validity Test has seven published
articles in peer reviewed medical journals describing its accuracy. Therefore, medical evaluations utilizing the Pain Validity Test are more likely to be
accepted than just a medical evaluation alone or those that employ the MMPI. Additionally, the PVT may provide cost savings for insurance carriers in the
same fashion as the Ottawa ankle and knee rules do, while improving the quality of health care. By employing a multidisciplinary model rather than just a
medical or psychological model for diagnosing chronic pain patients, a clinician may improve the accuracy of his or her evaluation, to the benefit of all
parties involved in the health care process.
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Conclusion
i. The MMPI is a verbal psychological test that cannot predict the results of objective medical testing.
ii. Very often, psychological assessments are done by non-medical personnel.
iii. The PVT is a verbal medical-psycho-social test which can predict which patient will have moderate or severe abnormalities on objective medical testing
with 94% accuracy, and which patient will have negative or minimally abnormal objective medical testing with 85% accuracy. The PVT should be used be
used to supplement, but not replace clinical assessments.
iv. The PVT is a verbal medical-psycho-social test which can predict which patient will have moderate or severe intra-operative pathology with 93%
accuracy. The intra-operative pathology is proof positive of real organic problems, and directly answers the question about the origin of pain.
7. Go to...
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