Case studies

1
Case studies

• Who is
• Disabled for Life
• Ronald Kienitz, D.O.

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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.

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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.

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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.

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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.

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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.

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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

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Illness behavior

• Unconscious symptom exageration

• Psychiatric disorders/
• Malingering

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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

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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
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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)

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Personality Disorders

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

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Personality Disorders

• Antisocial
• Borderline
• Histrionic
• Narcissistic

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Personality Disorders

• Antisocial
• Borderline
• Histrionic
• Narcissistic

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Personality Disorders

• Avoidant
• Dependent
• Obsessive-Compulsive

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Negative affectivity

• Report wide range of psychological symptoms and
  emotional distress
• Low self-esteem, guil, anger, self-consciousness,
  anxiety, hostility
• Negative appraisal of ones 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

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Disorders prone to somatization

• Complaints
• Low back/ neck
• Shoulder
• Hand/wrist (CTS)
• Headache
• Tinnitus
• Vertigo
• Pelvic/Abdominal

• Syndromes
• Fibromyalgia
• Chronic fatigure
• Multiple chemical sensitivity
• Toxic Mold

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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

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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

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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

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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,38707-22,2000

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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

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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???

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Results of disAbility (short term)

• Extended compensated time off work
• Lump sum payment
• Passive, feel-good treatments
• Family concern
• A disabled parking sticker

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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

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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

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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