Case studies

1. Case studies Who is “Disabled for Life” Ronald Kienitz, D.O.

2. Case 1 40 y/o old male with history of injury after clearing beachfront of naupaka. Stated he made several trips carrying 75 lb+ bundles one in each hand, swinging them to try to maneuver through a gait without catching the branches. No initial pain but woke that night with excruciating low back pain, numbness and weakness of the left lower extremity. Despite resting two days, he remained unable to ambulate even short distance. History was positive for prior severe low back pain and sciatica eight years prior that had partially resolved except for intermittent exacerbations. MRI revealed massive L4/5 disc herniation with large, sequestrated fragments impinging L5 nerve root. Sent for micro-discectomy 6 days after the injury event. Post-operatively, continued to exhibit mild to moderate left L5 sensory radiculopathy and some recurrent back pain.

3. Case 2 • 52 y/o male developed low back pain assisting coworker move an ice machine. Sought care 5 days later complaining of increasing back pain during that time. No radicular complaints to the lower extremities. Examination findings show “absolutely full range of motion”. Pain is reported in the lumbar regions L3 to L5 but is not recreated with palpation. Sensation and deep tendon reflexes were found to be intact. Sensation was normal and without dermatomal variance. History of non-work related back strain 20 years prior. Resulted in severe pain and one event of fecal incontinence but largely resolved after 3 to 4 weeks of rest. Experienced intermittent activity related back ache thereafter.

4. Case 2 (cont.d) Care was conservative with NSAIDs, muscle relaxants and physical therapy. When pain continued, he was sent for MRI of the lumbar spine revealing: 1. L4/5 posterior anular tear and disc bulge along with chronic ligamentous and facet hypertrophy causing mild to moderate central stenosis. 2. L5/S1 posterior anular tear and mild bulge without stenosis 3. L3/4 mild diffuse disc bulge along with chronic ligamentous and facet hypertrophy causing mild central stenosis. 4. Multi-level mild to moderate foraminal stenosis He was sent through a 12 week course of exercise rehabilitation therapy. Continued to complain of intermittent back ache.

5. Case 3 48 y/o male complaining of gradually increasing low back pain and limping off of right leg over prior month. Uncertain of specific injury event, but recalls feeling a slight strain of low back as he lifted a heavy suitcase out of his deep taxi trunk. Prior history of on and off back pain for 20 years with occasional severe exacerbations. History of L4/5 discectomy some years prior. Examination findings significant for foot-drop gait and gross weakness of right ankle dorsi-flexion as well as sensory loss to antero-lateral right leg and foot. MRI showed L4/5 disc herniation impinging on right L5 nerve root, degenerative disc narrowing at L5/S1 and mild to moderate central disc bulge at L4/5. Because of prior surgery and multilevel findings, orthopedic consultant recommended and proceeded with L4/5 discectomy and cage fusion with partial lateral allograft fusions at L5/S1 and L3/4. Post-operatively, exhibited good return of ankle dorsi-flexion, but significant L5 sensory loss. Also had significantly reduced range of motion and pain with activities of daily living including some self-care.

6. Case 4 52 year old male injured in cycle accident. Sustained concussion, neck torsion, and significant facial lacerations. Complained of immediate sensory deficit to radial left hand. CT scan of neck revealed no acute fracture but significant underlying degenerative disc disease with multi-level disc-osteophyte foraminal encroachments, moderate to severe at C6/7 and moderate at C5/6. Complained of ongoing significant pain from neck to left arm often affecting sleep. Examination findings later demonstrated tricep weakness and muscle wasting. Symptoms continued in spite of conservative care including NSAIDs, short course of prednisone, physical therapy, and extended exercise rehabilitation. Lyrica provided some benefit for neuropathic pain, but ongoing symptoms continued to impact quality of life. Surgery performed 2 years later with discectomy, fusion, and anterior instrumentation at C5/6 and C6/7. Post-operatively, demonstrated expected mild decrease in cervical range of motion and some residual radial sensory loss but decreased ache and increased strength in spite of continued visible atrophy.

7. Contrast Needlessly disabled Individual perceives self as incapacitiated despite minimal impairment or disorded Exceptionally Abled Individual is productive and interactive despite significant impairment.

8. Traditional medical training often ignores techniques to recognize and deal with illness behavior or to adequately communicate communicate it to patient and colleagues. Iatrogenic disability can result

9. Illness behaviour • Adoption of “sick role” • “the manner in which individuals monitor their bodies, define and interpret symptoms, take remedial action, and utilize sources of help.” The concept of illness behavior. J Chronic Disability 15a, 189-94, 1961

10. Unconscious symptom exageration Psychiatric disorders/ Malingering Illness behavior

11. Symptom magnification • Increased expression of symptoms in excess of that expected (cry for help) • “A conscious or unconscious self-destructive socially reinforced behavioral response pattern consisting of reports or displays of symptoms which function to control the life circumstances of the sufferer.” • Learned pattern of illness behavior • Refugee • Game player • Professional patient • Matheson, LN: Symptom magnification syndrome. • Ind.Rehabil. 4(1),1991

12. Malingering • Intentional claim of false or grossly exagerated symptoms for financial gain, avoidance (e.g., work, military duty, criminal prosecution), or obtaining drugs • Co-Malingering: • Cooperative manipulation of private or public disability system. (Not always intentional) • Often a result of conflicting interests between injured patient, employer, liability carrier

13. Ensalada, LH: The importance of illness behavior in diasability management; Occ Med STAR 15(4);739-54

14. Faking Malingering Exaggeration or fabrication Deny or minimize positive traits/abilities Looking worse Sick Negative

15. Secondary gain • Contributes to illness behavior • Manipulation of relationships • Sick role (sanctioned dependancy) • Financial gain • Intrapsychic defense mechanisms • Attention of health care providers • Access to “feel good” modalities • Narcotics • Relief from responsibilities (home, work, army)

16. Personality Disorders • Paronoid • Suspects without basis that others are exploitive, harmful, deceitful. Common in legal arena • Schizoid • Schizotypal

17. Personality Disorders • Antisocial • Borderline • Histrionic • Narcissistic

18. Personality Disorders • Antisocial • Borderline • Histrionic • Narcissistic

19. Personality Disorders • Avoidant • Dependent • Obsessive-Compulsive

20. Negative affectivity • Report wide range of psychological symptoms and emotional distress: • Low self-esteem, guil, anger, self-consciousness, anxiety, hostility • Negative appraisal of one’s health

21. Hysteria • Behavior produces appearance of disease • Mimic culturally permissible expressions of distress • produce only legitimate symptoms • Sometimes natural response to emotional conflict

22. Hysterical epidemics • Physician and scientific enthusiast • Unhappy, vulnerable patients • Supportive cultural enviroments • Interactive and evolving process

23. Hysterical epidemics • Sick building syndrome • Ozone • Vague chemical or odor exposure • Asbestos

24. Somatization disorder • Conscious or unconscious use of symptoms for psychological gain • Experience and report somatic symptoms that have no pathophysiolgic explanation • Misattribute symptoms to disease • See Medical attention • 5 to 40% of patient visits • Ford CV,The Somaticizing Disorders: Illness • As a way of life; New York, Elsevier; 1983

25. Complaints Low back/ neck Shoulder Hand/wrist (CTS) Headache Tinnitus Vertigo Pelvic/Abdominal Syndromes Fibromyalgia Chronic fatigure Multiple chemical sensitivity Toxic Mold Disorders prone to somatization

26. The trap: Medicalization of Complaints and/or syndromes • Amplify distress and concern • Feedback encourages more symptoms and complaints • Declining tolerance • Declining threshold for self-limiting symptoms • Media supports of “syndromes” and exposures

27. Illness behavior • Mistaken beliefs • Misattribution and/or refusal to consider alternative explanation of symptoms (CTS, Gout; “I never had it before”) • Falsicification of information or fabrication • Exaggeration: Profit or revenge

28. Illness behavior • Multiple determinants: • System • Disability systems • Work comp, SSA • Litigation • Cultural context • Personality and life experience • Response and interaction of health care system.

29. Iatrogenic Disability • Caused by the health care system by: • Incorrect or incomplete clinical assessment (miss physical, behavioral, or psychosocial interactions) • False attribution of etiology of the problem (CTS: “Patient uses hands at work”) • Fail to recognize or reinforcement of dysfunctional behavior

30. Iatrogenic Disability • Inappropriate or extended treatment and diagnostic interventions • Failure to promote return to function as the goal of treatment • Return to work • Return to ADLs

31. Medicalization • Invoke a diagnosis to explain discomfort not actually caused by disease • Apply medical interventions to treat it. • Labeling of discomforts: • Fibromyalgia • Chronic fatigue syndrome • Multiple chemical sensitivity • Toxic mold • Sick building • Barsky AJ, Boris JF: Somatization and Medicalization in the • era of managed care; JAMA 274(24), 193-4, 1995

32. Delayed recovery; psychosocial factors • Attitude: Challenge, catastrophe vs. negativity • Beliefs, expectations, demands (real or perceived) • Loss of control • Mood • Coping style, capacity, and skills • Sum of stressors

33. Predictors of Disability Injured Workers • Age • Greater reported baseline pain and/or functional disability • Perception of inability to return to work • Dysfunctional personality traits • With back pain, a specific diagosis (e.g., disc disease) vs. “non-specific back pain” • Turner JA,Franklin G,Turk D; Am J Ind Med,38;707-22,2000

34. Occupational and Psychological Profiles of People Disabled by Soft Tissue Injury - Low Back Pain • Job dissatisfactin, monotony, stress • Depression, anxiety, hypochondriasis, hysteria • Legal entanglement • Colledge A, Motivation Determination (Sincerity of Effort), The performance APGAR model, Disability Medicine 1(2),5-18,2001

35. Our Duty Primum non Nocere Hippocrates, 350BC

36. Query • Would the patient with spinal pain or other soft tissue complaint have been finally better off, had he/she never had access to the American medical experience???

37. Results of disAbility (short term) • Extended compensated time off work • Lump sum payment • Passive, feel-good treatments • Family concern • A disabled parking sticker

38. Results of disAbility(in the long run) • Self-perception of worth • Relations with family members • Divorce • Disassociation • Discontinuation of enjoyable activities • Long-term financial strain • Worsening medical conditions associated with inactivity • Drug abuse, Rx and otherwise

39. Physicians often ignore psychosocial influences • Particularly specialists • Hone in only on their pathology of expertise • Providers that benefit from providing palliative, non-curative services • Passive physical therapies for extended periods • Massage • Acupuncture • Chiropractic • OMT • Surgeries and other procedures

40. What would Dr. Stills do? • Minimal, logical approach to sickness, injury and disease • Avoid that which may worsen disease • Holistic: All factors considered • Give the body (and mind) the chance to heal itself • Emphasize function and movement • Lymphatic and arterial basis for tissue healing • Life = Movement • Death = Stasis • QED: Promoting stasis through enabling disAbility destroys health