Saying No to Drugs

1. Saying No to Drugs Gabriel Williams MD

2. Address key concepts in interaction, decision making and documentation: • History • Physical • Ways to document this information • Documenting decision making Outline

3. Basics of Pain history: • where, when, how • Equipment: current and prior use, do they have it and is it functional? • Chronos History

4. Weakness, numbness, changes in bowel/bladder, unintentional weight loss, history of cancer, progress decrease in function, fever, systemic symptoms. Red Flags

5. Work history: ask about how many years, what and workman’s comp. • Task specific: anything they cannot do? • Home exercise program: If you suspect they are misrepresenting functional status, ask when was last time they did push ups, dips, back arms, burpies, lunges, water bags… Functional History

6. Sports: last did… • Activities • Fall History • Reports prepared by custody • Asking custody officers of patient activities. Functional History

7. Sleep History • Insomnia • Daytime Somnulence • Substance Abuse History • Prescription, ivdu, alcohol • Duration • Family History of alcohol, drug or sexual abuse. • Psychiatric Disorders • Severity • Date last treated Other Important History

8. PT • HEP: provided written, verbal HEP • Procedures / Operations Treatment Historyand Compliance

9. OSA not on CPAP • COPD • Intolerance to Opioids • Medical noncompliance Pertinent ROS

10. Observation – starts from the moment you can see patient • Cane • Glasses • Attire - cervical collar, additional bracing/wraps/built up • Muscle Bulk. Ask for them to remove their shirts. Examination

11. When patients ask you to repeat questions the increased time allow them to think of an answer. • If patient is not answering your question: Rephrase the question to a simple yes or no or body part answer and ask it again. Repeat asking the same question until answered. Remark how many times you needed to ask the question to get a simple answer. Request they are more forthcoming next time. Behavioral Cues, Evasive History

12. Long pause together with left gaze often imply a creative answer, and an intense adversarial gaze can stand for a premeditated nonfactual answer. • Disclaimers of “to tell you the truth,” or “honestly” should either negate the sentence or consider adding in a negative to make it factually correct. • Count how many times they mention/ask for a specific medication or pain medications. Behavioral cues, Evasive History

13. Not related to a particular skeletal or neuromuscular structure; may be either superficial or nonanatomic: • Superficial - The skin in the lumbar region is tender to light pinch over a wide area not associatedwith the distribution of a posterior primary ramus. • Nonanatornic - Deep tenderness, which is not localized to one structure, is felt over a wide area andoften extends to the thoracic spine, sacrum, or pelvis. Waddell‘s Superficial Tenderness

14. Simulation tests – These tests give the patient the impression that a particular examination is being carried out when in fact it is not. • Axial loading - Low back pain is reported when the examiner presses down on the top of the patient‘s head; neck pain is common and should not be considered indicative of a nonorganic sign. • Rotation - Back pain is reported when the shoulders and pelvis are passively rotated in the same plane as the patient stands relaxed with the feet together; in the presence of root irritation, leg pain may be produced and should not be considered indicative of a nonorganic sign. Waddell’s Simulation

15. Distraction tests A positive physical finding is demonstrated in the routine manner, and this finding is then checked while the patient's attention is distracted; a nonorganic component may bepresent if the finding disappears when the patient is distracted. • Straight leg raising • The examiner lifts the patient's foot as when testing the plantar reflex in the sitting position; a nonorganic component may be present if the leg is lifted higher than when tested in the supine position. Waddell’s Distraction

16. Dysfunction involving a widespread region of body parts in a manner that cannot be explained based on anatomy; care must be taken to distinguish from multiple nerve root involvement. • Motor - Demonstrated on testing by a partial cogwheel "giving way" of many muscle groups that cannot be explained on a localized neurologic basis. • Sensory - Include diminished sensation to light touch, pinprick or other neurologic tests fitting a “stocking" rather than a dermatomal pattern. Waddell’s Regionalization

17. May take the form of disproportionate verbalization, facial expression, muscle tension and tremor, collapsing, or sweating; judgments should be made with caution, minimizing the examiner's own emotional reaction. Waddell’s Overreaction

18. 3 or more positive tests count, 2 or less do not. • Article relates to use of “up-to-date roentgenograms” for diagnosis • Predicted correlation results of chemonucleolysis for prolapsed intervertebral disc: less than 3 signs 74% success, equal or more than 3 signs with 11% success Waddell’s Signs

19. Overreaction has been most contested in the literature since “there are considerable cultural variations, and it is very easy to introduce observer bias.” • False positive nonorganic signs do exist, population identified most at risk is elderly who cannot stand. Waddell’s Signs

20. Reliability 86% for two examiners. • Age, gender, occupation or compensation did not influence results of nonorganic signs. • Correlations with hypochondriasis, depression, and hysteria. • Conflicting evidence regarding nonorganic signs and return to work. • Presence of Waddell’s signs should not preclude work up. Waddell’s Signs

21. Direct versus indirect examination • Specific ones that I look at: ADF direct versus staying on heels versus gait • Seated Hip Flexion versus Supine assisted hip flexion • Spine ROM during direct and indirect exam • MMT: with suboptimal effort, always ask: “are you doing the best you can?” Exam

22. The inverted ankles sign:

23. Not as simple as naming the painful area... • May want to defer a diagnosis because it does not make sense - discrepancies • misrepresentation of functional status - history, noted during exam Should I make a diagnosis?

24. Patient with history of insomnia, claims can only sleep 20 minutes at a time, for a maximum of 2 hours total per 24 hours. Has had this sleep problem for 14 months since morphine was discontinued. • On exam, is alert, talking in complete sentences. Thought process goal oriented. • What do we want to ask next? What should we review? Case

25. Review medications, ask about recent drug abuse, manic episodes, bipolar disorder, psychiatric history. If all ROS is negative, what next? Case

26. Since it is impossible to have such a profound sleep disorder and objective findings on exam lacking drowsiness and/or delirium, documentation should include noncredible historian and misrepresentation of functional status. Case

27. Documentation of Decision Making

28. The risks of constipation, dizziness, nausea, somnulence, respiratory depression, sweating, vomiting, pruritis, urinary retention, overdose, headache, dry mouth, hyperalgesia, fatigue, decreased neuroendocrine axis, triggering addictive behavior outweigh possible benefits of starting/continuing/increasing … given that Documentation of Decision Making

29. there are no functional goals • there is limited evidence of significant impairment • patient has history of abuse or significant risk factors for drug abuse • History of opioid intolerance • History of noncompliance • History of poor relief with opioids

30. Diagnostic studies, • Health care appliance • Accommodation • Activity modification / work restriction • Procedure Current treatment for pain is … and plans for pain management include …

31. Physical therapy • Modalities • Stress management • HEP management including revision/restriction or advancement • Patient Education

32. Psychiatric Patient • Axis I • Axis II • Overtly Manipulative Patient – “In order to be my doctor, you have to prove yourself.” • Angry patient – • Acknowledge frustration and redirect • Rephrase, Repeat, Remark and Request • May have to end encounter Other Difficult Encounters

33. Any Questions?

34. Waddell G, McCulloch JA, Kummel E, Venner RM. Nonorganic physical signs in low-back pain. Spine. 1980;5:117-125. • Scalzitti DA. Screening for psychological factors in patients with low back problems: Waddell’s nonorganic signs. Physical Therapy. 1997;77:306-312. References: