All contents of this presentation remain the cannot be used for any purpose in the absence of Dr. Barth s specific authorization.

Transcription

1 The nature of back pain Robert J. Barth, Ph.D. Chattanooga, TN and Birmingham, AL Parkridge Hospital Plaza Two, Suite McCallie Av. Chattanooga, TN / General Disclaimer (learned from Dr. Melhorn) All contents of this presentation remain the property of Dr. Barth, and cannot be used for any purpose in the absence of Dr. Barth s specific authorization. The nature of back pain Back pain is normal (just like headaches, stomach aches, and fatigue are normal) Significant episodes of back pain are experienced by 80% of Americans 1

2 Back pain is normal Hadler NM. Occupational Musculoskeletal Disorders, 3 rd Edition AMA s Guides to the Evaluation of Disease and Injury Causation. Melhorn and Ackerman, Back pain We are not yet talking about chronic pain What about complaints of new, recent onset back pain? What about the filing of a medical- legal claim for new, recent onset back pain? Back pain What is the best predictor of new, recent onset back pain? (this is not limited to medical legal claims) Depression Jarvik JG, Hollingworth W, Heagerty PJ, Haynor DR, Boyko EJ, Deyo RA. Three-year incidence of low back pain in an initially asymptomatic cohort: clinical and imaging risk factors. Spine Jul 1;30(13):

3 Back pain Bigos SJ, et al. A prospective study of work perceptions and psychological factors affecting the report of back injury. Spine, 1991, 16, 1-6. What are the best predictors of the filing of a new workers compensation claim for back pain? 1. Job Dissatisfaction 2. Scale 3 from the MMPI Back pain Scale 3 of the Minnesota Multiphasic Personality Inventory (MMPI)??? This scale was constructed using patients who exhibited some physical complaints for which no general medical explanation could be established. MMPI-2 Manual Back pain Scale 3 of the Minnesota Multiphasic Personality Inventory (MMPI)??? In other words, the extreme opposite of injury is the best predictor of a workers compensation claim being filed!!!! 3

4 The nature of chronic back pain Chronic back pain For 85-90% of chronic back pain cases, there is no general medical diagnosis that explains the pain For 85-90% of back pain cases, there is no general medical diagnosis that explains the pain This means The overwhelming majority of back claims are not injury-relatedrelated (and, therefore, not work-related) related) 4

5 For 85-90% of back pain cases, there is no general medical diagnosis that explains the pain Deyo RA, et al. Low back pain. JAMA 2001 Feb 1;344(5): For 85-90% of back pain cases, there is no general medical diagnosis that explains the pain AMA Guides, 5 th Edition. AMA s s Physician s s Guide to Return to Work. Talmage and Melhorn, 2005 Chronic Pain claims American Psychiatric Publishing Textbook of Psychiatry, 4 th Edition. there is little correlation between the level of pain and general medical findings 5

6 Chronic Pain claims AMA Guides, 5th ed. Thus, pain can exist without t tissue damage, and tissue damage can exist without pain. Imaging??? Spine imaging almost never provides an explanation for back pain Spine imaging almost never provides an explanation for back pain Carragee E, et al. Are first-time time episodes of serious LBP associated with new MRI findings? Spine J Nov-Dec;6(6): % of new back pain cases had either unchanged or improved MRIs compared to pre-painpain 6

7 Spine imaging almost never provides an explanation for back pain Hadler NM. MRI for regional back pain: need for less imaging, better understanding. JAMA Jun 4;289(21): MRI findings are an example of the general problematic trend toward over-testing and over-treatment No currently available general medical test actually explains back pain complaints No currently available general medical treatment provides demonstrable benefit Back pain sufferers would be better off if they stayed away from doctors Spine imaging almost never provides an explanation for back pain Chou R et al. Imaging strategies for low back pain. Lancet, 2009, MRI for low back pain does not lead to any identifiable benefits MRI was associated with a trend toward worse outcomes (maybe because the irrelevant findings scare patients, and prompt them to avoid exercise and other activity which are the best things that one can do to recover from back pain). Work-relatedness???? relatedness???? The nature of one s work does not change the risk of developing back pain. 7

8 The nature of one s work does not change the risk of developing back pain. Bigos SJ, et al. A prospective study of work perceptions and psychological factors affecting the report of back injury. Spine, 1991, 16, 1-6. The nature of one s work does not change the risk of developing back pain. AMA s Physician s Guide to Return to Work. Talmage and Melhorn, 2005 Chronic Pain claims So if chronic pain does not come from injury, spine imaging i findings, general medical issues, or work, where does it come from? 8

9 Chronic Pain claims Primary issue: Chronic pain is always a psychological issue, but it is not always a general medical* issue >>> Chronic Pain claims IASP Classification of Chronic Pain, 2 nd Edition. (pain) is always a psychological state >>> Chronic Pain claims American Psychiatric Publishing Textbook of Psychiatry, 4 th Edition. The literature supports the importance of psychosocial factors rather than general medical variables in determining whether a person will recover from his or her pain. 9

10 Chronic Pain claims AMA Guides 5th ed. Prospective studies have consistently shown that the onset and chronicity of disabling pain is contingent upon a variety of psychosocial issues. The nature of chronic pain. AMA Guides 5th ed. The role of thoughts, behavior, and/or environmental contingencies have been compellingly demonstrated for chronic pain presentations Classic reference Dr. Alf Nachemson His book reviewed by Dr. Andersson, in the NEJM, as by far the best book ever written on the subject. 10

11 Back AND Neck Pain Textbook review: Nachemson AL, Jonsson E. Neck and Back Pain.. Philadelphia, Pa: Lippincott, Williams, and Wilkins; There is strong evidence that psychosocial variables generally have more impact than biomedical or biomechanical factors. (continued) Back AND Neck Pain psychosocial variables generally have more impact: passive attitude; a tendency to think catastrophically about the pain complaints; depression; anxiety; any other form of emotional distress; a history of sexual and/or physical abuse; a perception of poor health in general. Back pain American Pain Society review: Sanders, S. H. (2000). Risk factors for chronic, disabling low back pain: an update for American Pain Society Bulletin, March/April. Scientifically established risk factors for chronic disabling low back pain 11

12 Risk factors for chronic disabling low back pain* Pre-existing existing Blue collar somatization employment, tendencies, History of Pre-existing existing childhood abuse, depressive tendencies, History of substance abuse, Low activity levels, Claims context of presentation, Job dissatisfaction, Unemployment. Chronic disabling back pain medical-legal legal claims The primary importance of personality disorders Personality Disorders Definition (DSM-IV-TR): A personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood,, is stable over time, and leads to distress or impairment. 12

13 Personality Disorders Paranoid Personality Disorder Schizoid Personality Disorder Schizotypal Personality Disorder Antisocial Personality Disorder Borderline Personality Disorder Histrionic Personality Disorder Narcissistic Personality Disorder Avoidant Personality Disorder Dependent Personality Disorder Obsessive-Compulsive Personality Disorder Personality Disorder Not Otherwise Specified (e.g. Passive Aggressive; Depressive) What is the rate of personality disorders in the general population? 10% - 13% Hales, R. E., Yudofsky, S. C., (2002). The American Psychiatric Publishing Textbook of Clinical Psychiatry, Fourth Edition. American Psychiatric Publishing. How many chronic pain patients have a personality disorder? 31% - 64% Gatchel and Weisberg (2000). Personality Characteristics of Patients With Pain. American Psychological Association. 13

14 Chronic disabling back pain in workers comp When actually investigated, how many chronic disabling spine pain patients in workers comp are discovered to have a personality disorder? How many chronic disabling spine pain patients in workers comp have a personality disorder? 70% Dersh J, et al. Prevalence of psychiatric disorders in patients with chronic disabling occupational spinal disorders. Spine May 1;31(10): The primary importance of personality disorders 1. General medical investigation of low back pain claims will produce significant findings 10-15% 15% of the time (at the most), but 2. Investigating for a personality disorder will produce significant results 70% of the time for medical- legal claims of chronic low back pain 14

15 The primary importance of personality disorders 1. General medical investigation of low back pain claims will produce significant findings 10-15% 15% of the time (at the most), but 2. Investigating for a personality disorder will produce significant results 70% of the time for medical-legal legal claims of chronic low back pain Rhetorical question: Why are we always doing MRIs and other general medical investigations, while we almost never respond to back claims by evaluating for personality disorders? Mental illnesses that are commonly associated with complaints of pain: Mental illnesses commonly associated with complaints of pain: Somatoform Disorders Mood Disorders Anxiety Disorders Personality Disorders Psychotic Disorders Factitious Disorders Substance-Related Disorders 15

16 Bottom line in regard to medical-legal legal claims of back injury They usually aren t really injuries They usually aren t really injuries Hadler NM, Tait RC, Chibnall JT. Back pain in the workplace. JAMA Apr 11;297(14): Back pain is not an injury The injury-model for back pain is doing more harm than good. They usually aren t really injuries A A history lesson in how backache (something like a headache) transformed into the concept of back injury. Allan DB, Waddell G. An historical perspective on low back pain and disability. Acta Orthop Scand Suppl. 1989;234:

17 Strategy for addressing most back claims, and getting the healthcare on the right track Apply science to the general medical details of this one case to show that there is NOT a general medical explanation for the pain Apply science to the psychosocial details of the case to demonstrate that there ARE non-injury-related related factors that account for the pain complaints Strategy for addressing most back claims, and getting the healthcare on the right track AAOS model - Putting psychological tests in the offices of the general medical doctor, and relying on a psychologist to explain the significance of the results Credible treatment for back pain 17

18 Credible treatment for back pain ODG Treatment in Workers Compensation Graded activity (including modified duty) is more effective than usual care in reducing the number of days of absence from work because of low back pain. Credible treatment for back pain AMA s Physician s Guide to Return to Work. Talmage and Melhorn, Progressively increasing exercise and work activity are recommended as treatment. Today s detailed discussions: Bulging disks Degenerative disk disease 18

19 Bulging disks Bulging Disks Disc bulges are normal They are not an explanation for pain complaints They are not justification for surgery (or for any other treatments). Bulging Disks References that you can start t using right away 19

20 Bulging Disks Jensen MC, Brant-Zawadzki MN, Obuchowski N, et al. Magnetic resonance imaging of the lumbar spine in people without back pain. New England Journal of Medicine Jul 14;331(2): Bulging Disks Jensen MC, et al. NEJM, Specifies the controversial nature of claims that spine imaging is relevant to back pain complaints. Studied spine MRIs of people who do not have back pain Bulging Disks Jensen MC, et al. NEJM, Normal spine MRI results were found for a MINORITY of the people who had no back pain Only 36% of the people without back pain had normal spine imaging findings 20

21 Bulging Disks Jensen MC, et al. NEJM, Most of the people who were free from any pain had at least one disc bulge 52% of the people without back pain had disc bulges Bulging Disks Jensen MC, et al. NEJM, The authors warn: Back pain is common Disk bulges are common When someone with back pain is found to have disk bulges, this might be nothing but a coincidence Bulging Disks Jarvik JJ, Hollingworth W, Heagerty P, Haynor DR, Deyo RA. The Longitudinal Assessment of Imaging and Disability of the Back (LAIDBack) Study: baseline data. Spine May 15;26(10):

22 Bulging Disks Jarvik JJ, et al. Spine Studied spine MRIs of people who do not have back pain Bulging Disks Jarvik JJ, et al. Spine Most of the people who were free from any pain had at least one disc bulge 64% of the people without back pain had disc bulges Bulging Disks Stadnik TW, et al. Annular tears and disk herniation: prevalence and contrast enhancement on MR images in the absence of low back pain or sciatica. Radiology Jan;206(1):

23 Bulging Disks Stadnik TW, et al. Radiology Studied spine MRIs of people e who do not have back pain Bulging Disks Stadnik TW, et al. Radiology Most of the people who were free from any pain had at least one disc bulge 81% 81% of the people without back pain had disc bulges Bulging Disks ACOEM Guidelines (2 nd Edition Revised 2007): bulging is thought to be asymptomatic in nearly all patients. 23

24 Bulging Disks Implications: Disc bulges are normal They are not an explanation for pain complaints They are not justification for surgery (or for any other treatments). Degenerative Disk Disease Degenerative Disk Disease Key Points 24

25 Degenerative Disk Disease DDD is not work- related DDD does not have a demonstrable relationship to pain Degenerative Disk Disease Surgery is not credible treatment for DDD Claims that an accident caused DDD to become symptomatic are not credible generically, and are usually created in a manner that is non-credible at several different levels Degenerative Disk Disease References that you can start t using right away 25

26 Degenerative Disk Disease Battié MC, Videman T, et al. The Twin Spine Study: contributions to a changing view of disc degeneration. Spine J Jan- Feb;9(1): Battié MC, et al. Spine J DDD is not work-related related or injury-relatedrelated Battié MC, et al. Spine J Twin Spine Study 26

27 Battié MC, et al. Spine J Disk degeneration is not correlated with: "wear and tear" mechanical insults Injuries Vibration (e.g., motor vehicles) Battié MC, et al. Spine J In fact, some indications were found that t routine loading may actually have some benefits to the disc. Battié MC, et al. Spine J Disk degeneration is correlated with: Genetics Smoking Body weight 27

28 Degenerative Disk Disease Savage RA, et al. The relationship between the magnetic resonance imaging appearance of the lumbar spine and low back pain, age and occupation in males. Eur Spine J. 1997;6(2): Savage RA, et al. Eur Spine J DDD is not related to pain (or to work) Savage RA, et al. Eur Spine J Compared spine MRIs of -workers who did not have back pain -workers who did have back pain 28

29 Savage RA, et al. Eur Spine J there was no relationship between LBP and disc degeneration DDD is not related to pain AMA s Guides to the Evaluation of Disease and Injury Causation.. Melhorn and Ackerman, DDD is not related to pain AMA s Guides to the Evaluation of Disease and Injury Causation. Degenerative discs and arthritis are not predictive of pain or disability. 29

30 Degenerative Disk Disease Gibson JN, Waddell G. Surgery for degenerative lumbar spondylosis. Cochrane Database Syst Rev Oct 19;(4):CD Gibson JN, Waddell G. Cochrane Database 2005 Surgery is not a credible treatment for DDD Gibson JN, Waddell G. Cochrane Database : There is no scientific evidence on the effectiveness of any form of surgical decompression or fusion for degenerative lumbar spondylosis compared with natural history, placebo, or conservative management. 2000: There is no scientific evidence about the effectiveness of any form of surgical decompression or fusion for degenerative lumbar spondylosis compared with natural history, placebo, or conservative treatment. 2003: There is no scientific evidence about the effectiveness of any form of surgical decompression or fusion for degenerative lumbar spondylosis compared with natural history, placebo, or conservative treatment. 30

31 Gibson JN, Waddell G. Cochrane Database 2005 There is moderate evidence that instrumentation can increase the fusion rate, but any improvement in clinical outcomes is probably marginal. The effectiveness of intra-discal electrotherapy (IDET) remains unproven. Only preliminary results are available on disc replacement and it is not possible to draw any conclusions on this subject. Fusion is not a credible treatment for low back pain Richard Deyo, Alf Nachemson, Sohail Mirza Spinal-Fusion Surgery The Case for Restraint. NEJM, 350;7, February 12, DDD is among the most common reasons cited for performing a fusion But the effectiveness of fusion for any pain complaints in the context of DDD has not been established Fusion is not a credible treatment for low back pain Mirza SK, Deyo RA. Systematic review of randomized trials comparing lumbar fusion surgery to nonoperative care for treatment of chronic back pain. Spine Apr 1;32(7): The results of three scientific trials indicated that fusion is not more effective than 3 weeks of cognitive-behavioral psychotherapy addressing fears about back injury. 31

32 Degenerative Disk Disease Carragee E, et al. Does minor trauma cause serious low back illness? Spine Dec 1;31(25): Carragee E, et al. Spine Claims that an accident caused DDD (or any other imaging finding) to become symptomatic are not credible generically Carragee E, et al. Spine Followed workers, who did not have pain complaints at the beginning of the study, for five years 32

33 Carragee E, et al. Spine Did MRIs on everyone at the beginning (so the people who already had DDD - but no pain could be studied separately) Carragee E, et al. Spine For those with DDD, compared those who did not experience trauma during the five years, to those who did Carragee E, et al. Spine No Difference The rates of new complaints of back pain were the same whether the DDD workers experienced trauma or not 33

34 Carragee E, et al. Spine In general: -rates of new back pain were the same for everyone (not just the DDD group), when people who experienced trauma were compared to people who did not. Carragee E, et al. Spine In general: The severity of trauma was not correlated with whether back pain developed following trauma. Carragee E, et al. Spine In general: The frequency of trauma was not correlated with whether back pain developed following trauma. 34

35 Carragee E, et al. Spine So what did predict the development of new back pain complaints?... What predicted back pain among workers? 1. Psychological test results 2. Smoking 3. Eligibility for compensation Carragee E, et al. Spine Minor trauma was only associated with serious low back pain in a compensation context. 35

36 Carragee E, et al. Spine What about major trauma? Only 25% of the major trauma events led to occupational disability, and any such disability was always short-termterm None of the major trauma events led to long-term occupational disability Final Key Point Claims that an accident caused DDD (or any other imaging finding) to become symptomatic are usually created in a manner that is non-credible at several different levels Claims that an accident caused DDD (or any other imaging finding) to become symptomatic Such claims are obviously based on the report of the claimant/plaintiff Is this a scientifically credible basis for clinical or administrative decision- making?... 36

37 Basing medical opinions on reports from claimants/plaintiffs Not credible!!!! Scientifically tested several times, and the reports from plaintiffs/claimants were found to be unreliable every time Basing medical opinions on reports from claimants/plaintiffs Not credible!!!! Barth RJ. Claimant-Reported History is Not a Credible Basis for Clinical or Administrative Decision-Making. The Guides Newsletter,, September/October, American Medical Association. Claims that an accident caused DDD (or any other imaging finding) to become symptomatic Did the doctors who are making this claim do anything to investigate for malingering? Diagnostic protocols Scientifically validated psychological testing Base rate of malingered pain complaints is around 40% 37

38 Claims that an accident caused DDD (or any other imaging finding) to become symptomatic Did the doctors who are making this claim do anything to investigate for a somatoform disorder (or any other psychological explanation for the pain)? Diagnostic protocols Scientifically validated psychological testing Base rate of somatoform disorders in a medical-legal legal context is around 60% In order to be credible, the treatment rehabilitation plan has to include WORK. References: Barth, RJ, and Roth, VS. (2003). Health Benefits of Returning to Work. Occupational and Environmental Medicine Report, 17, 3, March, 2003, p Talmage J, and Melhorn M. A Physician s Guide to Return to Work. American Medical Association, Waddell GE, Burton AK. Is work good for your health and well-being? The Stationery Office, London >>> There is little clinical or scientific justification for ever asking the question, Can this patient return to work? When doctors are asked, Can this patient return to work?, the answer should be: He (or she) MUST return to work for the sake of his (or her) health. >>> 38