There is Nothing Wrong Not Because - painmuse



There is Nothing Wrong Because

I Feel so

(But Actually Because Nothing Was Done)

Diagnostic Imaging generally has very little role in diagnosing chronic pain and positive results are often ignored. As mentioned in other sections, it is necessary to do specific tests to find certain problems. What follows is a list of conditions I have found are rarely if ever properly diagnosed due to lack of appropriate testing:

Disc problems needing - Discography – NOT SEEN DONE HERE

Facet problems sometimes needing – Facet blocks – rarely done

Sacroiliac Pain – Sacroiliac Injection – NOT SEEN DONE HERE

Nerve Root Pain – Selective Nerve Root Blocks – NOT SEEN DONE (that my colleagues or I know)

Nerve Root Entrapments – diagnostic blocks – NOT SEEN DONE eg:

Thoracic Outlet Syndrome – This syndrome can be common after car accidents. Tests for arterial occlusion poorly done and not reliable. Proper testing requires selective nerve block – NOT SEEN DONE HERE

Thoracic outlet block here

Myofascial Pain Syndromes – diagnosis requires injections and working the muscles to see if they respond; I am the only one I know of that does much of this – NEVER DONE HERE

Complex Regional Pain Syndrome – Rarely even considered. Proper diagnosis and testing requires an anesthetist to do a sympathetic block which is complex therefore this test is rarely done. so NOT SEEN DONE HERE

Tears – Complete Gluteal tears occur in 10% of people as they age and could be traumatically induced. A recent review of this condition found this was never diagnosed. Imaging is difficult by Ultrasound and requires expertise. – NOT SEEN DONE HERE

Shoulder Injuries – sometimes it is necessary to inject various structures to see where the pain is coming from – NOT SEEN DONE

Diagnostic Cortisone Shots - When cortisone injections are done, they are done in isolation. There are usually multiple muscle knots that “grow” around areas of tendonitis. If these are not worked out, then the proper diagnosis will not be realized. – NOT SEEN DONE WELL

Neck instability, facet ruptures, scars and so on only seen on functional MRI – NEVER DONE

This lack of appropriate testing leaves the doctor to decide based on his/her “expertise”; this would be like judging a case on gut feelings rather than evidence. Relying on doctors to appreciate the level of pain and disability of others has in has had a terrible history. This led in the past to tragic under-treatment of cancer pain – again in a situation where cancer patient sitting still he may have looked fine:

“Over 70% of patients with cancer have moderate to severe pain during their illness and many fear pain more than death itself. … Despite this, only a small proportion of patients with cancer pain receive adequate analgesia”

abstract here

The worst person to decide the pain of a patient with chronic pain is an experienced health care professional. They have been shown in many studies to underestimate patients’ pain levels. In fact, untrained university students have better appreciation of patient’s’ pain level.

“Professionals' pain judgments were lower than those of control subjects”

abstract here

“Once you’ve seen a faker, everyone looks like a faker” - unfortunately jades some doctors and leads to misappraisals.

Pain. 2006 Sep;124(1-2):109-16. Epub 2006 May 23. Testing two accounts of pain underestimation. Kappesser J, Williams AC, Prkachin KM

abstract here

“Health care professionals primed to expect cheating underestimated pain”

Experts are more likely to underestimate pain than “inexperienced” doctors:

“Marquié et al. (2003) found that expert physicians (when compared to novice physicians) showed a greater underestimation of a patient's pain. In this study, Marquié et al compared physician and patient ratings of pain, upon entering and leaving the emergency room. When leaving, more experienced physicians showed a greater underrating of patient pain when compared to the residents' assessments. This same study found that the gender of both the doctor and the patient affected pain ratings when the pain had no obvious cause.”

abstract here

“The extent of 'miscalibration' was greater with expert than novice physicians”

Some consultants that work for insurers seem to have their “gut feelings” in one place which puts them in the potential status of “hit men” in the eyes of some family physicians.

Physical findings can be confusing in chronic pain and cannot be relied on. Without selective blocks and other tests, a doctor’s opinion can be of no use. In the unbelievable whiplash cases, two were attributed to psychological problems and one was declared fit for work, much to Dr. Bogduk disgust in his editorial:

“These patients had symptoms and they had pathology. The pathology was perfectly concordant with the symptoms of which they complained. However, these symptoms were dismissed as psychogenic, and the possibility of pathology ignored." (permission to use obtained)



This means, that even when symptoms are apparent, there is a good chance they will be ignored in a MRI-faith environment.

This however all begs the question – It has been established that chronic pain of undetermined cause cannot be treated any differently than chronic pain from a “known” cause.

There was already a precedent for this in 2001:

LIMA v. CANADA (MINISTER OF HUMAN RESOURCES DEVELOPMENT)

Federal Court, Trial Division

Judge Marc Nadon

February 16, 2001



IN:

Pension and Benefit Law Reporter March/April, 2001

“Objective medical evidence not necessary to establish chronic pain

…..In reaching its conclusion, the Tribunal put particular weight on the fact that objective medical evidence could not explain the degree of disability that Lima claimed to be experiencing.

….Judge Marc Nadon allowed Lima’s judicial review application. Nadon pointed out that Lima did not dispute the fact that objective medical evidence was lacking. “[B]y definition, chronic pain syndrome cannot be explained by objective medical evidence,” he said. As an example of a more appropriate approach in such cases, he cited a previous decision of the Pension Appeals Board in which it had merely required a chronic pain sufferer to show that treatment was sought and that efforts were made to cope with the pain. In that case, the judge noted, the Board had opined that it was desirable though not essential that psychiatric or psychological expert evidence be adduced to support these kinds of claims.

In the present case, the judge held, the Board did not ask the proper question, namely, “whether the applicant had an arguable case that he is suffering from chronic back pain syndrome and … can no longer pursue a substantially gainful occupation.” In the result, he remitted the matter to the Board for reconsideration.”

Subsequent to this ruling was the ruling of the Supreme Court in a Nova Scotia Case in 2003.

NOVA SCOTIA (WORKERS’ COMPENSATION BOARD) v. MARTIN

Supreme Court of Canada

Justices Charles Gonthier, Beverley McLachlin, Frank Iacobucci, John Major, Michel Bastarache, Ian Binnie, Louise Arbour, Louis LeBel, and Marie Deschamps

Kenneth LeBlanc, Anne Clark, Anne Derrick, and Patricia Wilson, Counsel for the Appellants

Brian Crane, David Farrar, and Janet Curry, Counsel for the Workers' Compensation Board of Nova Scotia

Catherine Lunn, Counsel for the Attorney General of Nova Scotia

October 3, 2003

There was a two track system for WCB – Patient’s whose pain was of a medically determine source were given 5 weeks of rehabilitation followed by continued coverage, while those with pain of undetermined origin were given 5 weeks of rehab and then cut off. Though WCB here claims to handle things on a cases to case basis, in my opinion, this policy continues to some extent here.

The Supreme Court ruled this was a human rights violation and in effect decided that again, objective findings were not necessary for continued designation of disability. This caused WCB boards across the country to scramble and change their protocols.

IN:

Health & Safety/Workers' Compensation Law Reporter September/October, 2003

“Justice Gonthier defined chronic pain as “pain that persists beyond the normal healing time for the underlying injury or is disproportionate to such injury, and whose existence is not supported by objective findings at the site of the injury under current medical techniques.” While pointing out that the disability is real, and that there is no doubt that chronic pain patients are suffering and in distress, Justice Gonthier noted that victims of the condition “have been subjected to persistent suspicions of malingering on the part of employers, compensation officials and even physicians.”

According to Gonthier, the separate, limited regime established for chronic pain victims deprives them of a personalized evaluation of their needs and circumstances, and restricts the benefits they can receive to a uniform and strictly limited program. … “[It] not only removes the appellants’ ability to seek compensation in civil actions, but also excludes chronic pain sufferers from the protection available to other injured workers. It also ignores the real needs of workers who are permanently disabled by chronic pain by denying them any long-term benefits and by excluding them from the duty imposed upon employers to take back and accommodate injured workers. The Act thus sends a clear message that chronic pain sufferers are not equally valued and deserving of respect as members of Canadian society.”

While the legislature’s concern “to efficiently allocate resources within the workers’ compensation system so as to give priority to the most severe cases is laudable,” Gonthier observed, “it cannot serve to shield an outright failure to recognize the actual needs of an entire category of injured workers from Charter scrutiny.”

As for the argument that the effect on chronic pain claimants was only economic, Gonthier stated:

“In my view, given the circumstances of injured workers, particularly those who may be permanently impaired by chronic pain and have no source of support other than the provincial compensation scheme, it cannot be said that the loss of financial benefits here is a trivial matter. More importantly, I cannot agree that the interest affected by the chronic pain provisions is purely, or even primarily economic. Beyond the financial benefits at stake, injured workers suffering from chronic pain are also denied an opportunity to access the compensation scheme available to other injured workers in the province, on the basis of the nature of their disability. They are also deprived of ameliorative benefits, such as vocational rehabilitation services, medical aid and a right to accommodation, which would clearly assist them in preserving and improving their dignity by returning to work when possible. Our Court has consistently emphasized the crucial importance of work and employment as elements of essential human dignity under s.15(1) of the Charter .”…

Gonthier continued: “far from dispelling the negative assumptions about chronic pain sufferers, the scheme actually reinforces them by sending the message that this condition is not ‘real,’ in the sense that it does not warrant individual assessment or adequate compensation. Chronic pain sufferers are thus deprived of recognition of the reality of their pain and impairment, as well as of a chance to establish their eligibility for benefits on an equal footing with others.”

Gonthier also said “budgetary considerations in and of themselves cannot justify violating a Charter right, although they may be relevant in determining the appropriate degree of deference to governmental choices based on a non-financial objective.”

[Author’s note - This is a key point – WCB would say it would costs too much to give people the benefit of the doubt and it’s OK to “hang” some patients with chronic pain in the pursuit of savings. This attitude is now considered illegal, but may explain why they are able to make profits. ]

Gonthier also said:

“[I]t is obvious that the blanket exclusion of chronic pain from the workers’ compensation system does not minimally impair the rights of chronic pain sufferers. The challenged provisions make no attempt whatsoever to determine who is genuinely suffering and needs compensation and who may be abusing the system.” (emphasis added by author)

[author’s note – the pathetic lack of any of the above tests I mentioned gives full credibility to this remark]

cont’d quote:

“They ignore the very real needs of the many workers who are in fact impaired by chronic pain and whose condition is not appropriately remedied by the four-week Functional Restoration Program. “

Physician Bias in WCB

In Saskatchewan, there are physicians who will decide for WCB that due to lack of objective findings, the patient must be able to return to work. Case workers, without any repercussions for their actions, will also automatically terminate patients in what I call is “the shakedown” (see later). Poorly educated and overly sick subjects can be easily eliminated that way because they are in no shape to fight back. The worker’s advocate is too overloaded to respond, and lacks medical expertise to be of much help (in my opinion). Specialists will often not defend patients whose MRI is “normal”, and when they do, it can be a vague “one liner” about some evidence of cervical canal narrowing or Hyper-intense image in the disc. Interpretation however, is in essence is left to the case worker to do what s/he wants.

The lack of help by some doctors and I have questioned why they do that. Some possibilities include:

1) Over-confidence in their technology and abilities

2) Health professionals do not like to admit that they do not have the knowledge/technology to know for certain what is going on.

3) Knee jerk “rule of life” that if evidence is not forthcoming, it is automatically psychological. This is a misuse of the biopsychosocial model. The model is meant to insure that all areas of life are taken into account, and to stress the interconnection between these areas. However, some insurance companies take a more ‘dualist’ approach, whereby if medical reasons are not forthcoming, claimant’s problems are automatically assumed to be psychological.

4) Being asked to make decisions by WCB at times when it is inappropriate. Generally, decisions can only validly be made on an individual when they have reached “Maximal Medical Improvement - MMI”. Often Chronic pain cases are a “work in progress” and any comments on them would be of poor quality – so reports are vague and short as possible.

5) Doctors HATE forms and are already overworked. They are also aware that the information in the forms may be ignored anyway. This was the case with one patient, where both the physiotherapist and doctor wrote that the patient was not only in no shape to return to work (also in no shape to even do an FCE) - but case worker on basis of an off remark from a WCB reviewer who said subject should be “boarded” decided to terminate coverage.

6) But there is a more serious issue that generates considerable problem. The chronic pain patient has been trivialized, unbelieved, had his benefits and future threatened, told that it is his fault he has this problems (nuts, too deconditioned and so on) by people they know do not necessarily have their best interests at heart. - in short victimized to the point that he will go out of his way to be at least taken a bit seriously. I call this “desperation” to be taken seriously while others have called it “Pain Behavior”

Bigos et al. Bigos SJ, Baker R, Lee S: A definition and approach to helping the patient with a return to work predicament.

Phys Med Rehabil Clin North Am 1993, 4:109–123.

“Pain behavior is but a higher level of the behavioral changes observed in a threatened animal. These patients feel “trapped” without options in a system in which everyone seems to be trying to force them to face failure... pain behavior that continues at a high level after 4 to 6 weeks of care probably indicates that the patient is not convinced that we truly have his or her best interest in mind.”

Feldman(1998) puts it very well:

System Factors

The effects of industrial compensation systems on the work-injured patient comprise another major theme in the literature. It is an adversarial system designed to provide “care” for patients, with negative attitudes concerning injured workers prevalent among insurance providers and, all too often, professional caregivers. Bigos et al. [2•], citing

the work of Guest and Drummond [24], have most thoroughly and persuasively argued that this system is inherently harmful to individuals trapped within it:

The creation of the term industrial back pain apparently fostered the development of adversarial attitudes and expensive systems that have only worsened the burden by expanding costs without returning the injured worker to productivity. “Adversarial help” seems, and mostly is, a contradiction in terms. In any event, this “adversarial help” system, although a growing expense, has had little effect in aiding the worker or society by reaching the goal of keeping our populous productive until retirement age. Individuals often focus on their pain in an effort to legitimize their injury and themselves when under the stress of facing an adversarial system in which employers, insurance case managers, and health professionals often view them as malingerers. Patients tend to express their emotional stress and the frustration of feeling trapped via what is generally termed pain behavior. They are attempting to communicate:

“I really am hurting; There really is something wrong; I am not faking; It is not all in my head” (see [12]). Unfortunately, this mode of expressing distress via symptom amplification only predisposes physicians and other health care providers to view such patients more negatively. (emphasis added)

Gallagher et al. [8] demonstrated that emotional distress reduced the probability of receiving compensation, after controlling for severity of spinal dysfunction. The industrial compensation system simultaneously fosters and condemns the internalized victim role for those injured persons receiving workers’ compensation. Patients are impelled to focus on the physical symptoms because psychologic or psychiatric diagnoses are considerably weaker metaphorically than are physiologic diagnoses [25]. Psychologic or psychiatric diagnoses also tend to infer the strong possibility of patients contributing to their condition as a result of hypochondriacal or psychosomatic tendencies, or even worse, malingering [25]. Physicians often assume hypochondriasis or malingering on the part of patients who behaviorally express stress owing to their physical condition. Patients who perceive professionals viewing them as hypochondriacal become increasingly distressed, which is most often evidenced by further amplification of pain behavior.

The is very much like the paradox Dr. David Burns (eminent psychotherapist) talks about in psychotherapy: Protest that you are sick will actually prove the opposite. This means that chronic pain patients invite misappraisal from doctors who do not know any better.

A one time examination by a doctor can only give an impression of the problem; I have worked with some cases for a prolonged periods of time (sometimes years) before all the patient’s problems became evident. With very limited access to investigations (none for discograms), it is easy for a one time consultant to assume it is psychological. One time assessments of complex cases are not helpful and seem inappropriate.

Case in point – (my case - not WCB)Being so sick of specialists missing critical factors, I took it upon myself to actually go to the specialist’s office to help emphasize critical factors. The patient had neck and upper thoracic back pain, unresponsive to any treatments. I explained the problem and the specialist was willing to order an MRI. He ordered the neck MRI which showed some positive findings (cervical stenosis), but despite this failed to arrange the thoracic one. This area flared badly with excessive work; and has not yet been scheduled despite reminders. You see, I, as a general Practitioner, am not allowed to order MRI’s… While working on this patient, to my dismay, have found his left upper cervical joint will “pop” with slight traction on occasion – suggesting instability at that level and is concordant with the severe pains he has in the area. This would fit very nicely with his episodic fainting /faintness spells, suggesting the blood vessels in the neck are being compromised by certain neck movements. This sounds so much like the recent study finding results on fancy fMRI– Unfortunately as seen from these published MRI cases, this cannot be seen on static MRI’s and so in the eyes of a specialist does not exist.

This same patient had his chart reviewed by a “pain specialist” for a huge amount of money paid by SGI. This specialist claimed that there was nothing wrong with the patient, and the patient was forced to settle for nothing. After the MRI results were positive, I saw this specialist at a Canadian Pain Society meeting and confronted him with the positive MRI findings. His rebuttal was that he made a one liner remark to the effect this could be in error, but the weight of his well paid opinion had done its damage at a point where the court decision could not be reversed.

In the United States, apparently 50% of pain patients ask to be referred to a pain specialist. These specialists will help do the necessary tests to determine the origin of the pain. This option is not available here. Dr. Bogduk made it clear that 80% of neck and back chronic pain cases cannot be diagnosed without discograms, facet and sacroiliac blocks and perhaps selective nerve root blocks and so on. Given that these are not done here, the patient needs to be given the benefit of the doubt in every case. Physician’s “feelings” on the matter will give the worst perspective on the case and should not be accepted. These “feelings” are based on objective findings which are not evident to people with chronic pain that have doctors and specialists that have not bothered to do the necessary above investigations.

Doctors working for WCB should not be allowed to make flippant decisions that someone should be “boarded” based on “gut” feelings on the matter. It has now been established that such decisions if without sufficient “objective” reasons should allow the doctor to be cross examined at appeals:

EMERY v. ALBERTA (WORKERS’ COMPENSATION BOARD, APPEALS COMMISSION)

Alberta Court of Queen’s Bench

Judge Melvyn Binder

Kenneth Penonzek, Counsel for Emery

Sandra Hermiston, Counsel for the Board

October 10, 2000

AT:



“An Alberta judge has ruled that the Appeals Commission of the province’s Workers’ Compensation Board breached the principles of natural justice when it did not allow a claimant to cross-examine the Board’s medical experts” Health & Safety/Workers' Compensation Law Reporter January/February, 2001

The review committee needs to set up very definite limits on what can be used to decide termination of coverage in this pathetic investigative environment.

In the USA, I was able to come across this reference to how decisions were reached re terminating coverage:

abstract here

( re Injured Worker = IW)

The claims adjuster can terminate workers' compensation benefits for only three reasons:

a) The IW reached maximum medical benefit.

b) The IW unreasonably refused medical treatment or examination,13, 14

c) The IW refused vocational rehabilitation without a court order.15, 16

This medical treatment, examination, and rehabilitation must be under the control of the patient’s doctor. Currently, a “shakedown situation” of inappropriate rehabilitation could be foisted on the pain patient at any time as an endurance contest to see if they can be eliminated for non-compliance. In Canada, the patient has the right to refuse toxic rehabilitation but claimants are unaware their termination for non-compliance is illegal. I suspect any non-compliance with rehabilitation is based on fact it causes to much suffering.

Referral of cases to doctors who are regularly paid by an insurer or have a negative perspective of patients with chronic pain in general is a conflict of interest. The family doctor should have the right to cancel such referrals and have someone with the expertise to suggest what is appropriate (maybe worker’s advocate can provide a list). In the past, lawyers knew who could give a more unbiased review; I am having trouble finding physicians who are not in a conflict of interest situation. I could remember one young physiatrist from Ontario talking to a colleague (at a Botox use meeting) about how he was going to make big money doing assessments. Some unbiased orthopedic medicine physicians that I know are so sick of how WCB operates, they won’t even see WCB cases.

Worth repeating, - the patient has the right to refuse to submit to a rehab program that is inappropriate for their pains.

IN:

OSMOND vs. NEWFOUNDLAND WORKER’S COMPENSATION COMMISSION

Newfoundland Supreme Court of Appeal

April 26, 2001

L.C.C. No. 3443

Several points taken from Health & Safety/Worker’s Compensation Law Reporter July/August, 2001

1) The feeling of WCB that they have “the authority to deem a person capable of earning a salary associated with a job which we feel an injured worker is capable of performing” is incorrect:

• “In the first place s. 74 does not authorize “deeming”, it merely allows for the availability of appropriate rehabilitation to be taken into account in deciding future earning capacity”

• “Commission did not have the authority to deem a worker capable of work simply because the worker declined an offer of rehabilitation.”

2) “Secondly, it is not enough to take account of refused rehabilitation simply because “we feel an injured worker is capable of performing.” There must be, to use the Commission staff’s well-worn expression, “objective evidence” supporting any “feeling” by the Commission that the claimant can productively avail of the offered rehabilitation. The Policies themselves, properly interpreted, recognize this. They require the Commission to engage in an analysis that involves identifying an appropriate alternate occupation, determining whether the claimant is “physically capable” of performing the identified occupation and determining whether she is “able to become qualified with appropriate rehabilitation” for that occupation. If there is no relevant evidence that the claimant can undertake the offered rehabilitation, then the Commission cannot “deem” her capable of performing in any alternative employment on the basis of her refusal or failure to try the rehabilitation.”

Conclusion – By law, chronic pain sufferers need to be given the benefit of the doubt. Injured workers DO NOT need objective findings for chronic pain but any dismissal has to be based upon objective findings that will stand up to cross-examination by an appeal committee.

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