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					     Case studies

     Who is
“Disabled for Life”
   Ronald Kienitz, D.O.
                                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.
                             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.
                    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.
                                   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.
                                  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.
•Needlessly disabled
  –Individual perceives self as
  incapacitiated despite minimal
  impairment or disorded
•Exceptionally Abled
  –Individual is productive and
  interactive despite significant
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
• 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
 Illness behavior
• Unconscious   • Psychiatric
  symptom         disorders/
                • Malingering
       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
• Learned pattern of illness behavior
   – Refugee
   – Game player
   – Professional patient

                               –   Matheson, LN: Symptom magnification syndrome.
                                                        – Ind.Rehabil. 4(1),1991
• 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
Ensalada, LH: The importance of illness behavior in diasability management; Occ
                          Med STAR 15(4);739-54

                            Expectations Deceptive State           Mental
Comparison of               of           of                        Disorder
Features                    Secondary    Mind
Somatoform Disorder         Yes             No                     Yes
Factitious Disorder         No              Yes                    Yes
Symptom Magnification
                            Yes             No                     No
Symptom Magnification
                            Yes             Yes                    No
“Game player”
Symptom Magnification
                            No              Yes                    No
“Professional patient”

Malingering                 Yes             Yes                    No
•Exaggeration or fabrication
•Deny or minimize positive traits/abilities

                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)
     Personality Disorders
• Paronoid
  – Suspects without basis that others are
    exploitive, harmful, deceitful. Common in
    legal arena
• Schizoid
• Schizotypal
        Personality Disorders
•   Antisocial
•   Borderline
•   Histrionic
•   Narcissistic
        Personality Disorders
•   Antisocial
•   Borderline
•   Histrionic
•   Narcissistic
     Personality Disorders
• Avoidant
• Dependent
• Obsessive-Compulsive
        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
• Behavior produces appearance of
• Mimic culturally permissible expressions
  of distress
  – produce only legitimate symptoms
• Sometimes natural response to
  emotional conflict
         Hysterical epidemics
•   Physician and scientific enthusiast
•   Unhappy, vulnerable patients
•   Supportive cultural enviroments
•   Interactive and evolving process
        Hysterical epidemics
•   Sick building syndrome
•   Ozone
•   Vague chemical or odor exposure
•   Asbestos
      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
 Disorders prone to somatization
Complaints           Syndromes
• Low back/ neck     • Fibromyalgia
• Shoulder           • Chronic fatigure
• Hand/wrist (CTS)   • Multiple chemical
• Headache             sensitivity
• Tinnitus           • Toxic Mold
• Vertigo
• Pelvic/Abdominal
 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
• Media supports of “syndromes” and
 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
• Exaggeration: Profit or revenge
    Illness behavior
• Multiple determinants:
• System
    – Disability systems
    – Work comp, SSA
•   Litigation
•   Cultural context
•   Personality and life experience
•   Response and interaction of health care
       Iatrogenic Disability
• Caused by the health care system by:
  – Incorrect or incomplete clinical assessment
    (miss physical, behavioral, or psychosocial
  – False attribution of etiology of the problem
    (CTS: “Patient uses hands at work”)
  – Fail to recognize or reinforcement of
    dysfunctional behavior
       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
• 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
        Delayed recovery;
       psychosocial factors
• Attitude: Challenge, catastrophe vs.
• Beliefs, expectations, demands (real or
• Loss of control
• Mood
• Coping style, capacity, and skills
• Sum of stressors
Predictors of Disability Injured
• 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
  Occupational and Psychological
 Profiles of People Disabled by Soft
   Tissue Injury - Low Back Pain
• Job dissatisfactin, monotony, stress
• Depression, anxiety, hypochondriasis,
• Legal entanglement

     •    Colledge A, Motivation Determination (Sincerity of Effort), The
         performance APGAR model, Disability Medicine 1(2),5-18,2001
Our Duty

           Hippocrates, 350BC
• 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
         Results of disAbility
              (short term)
•   Extended compensated time off work
•   Lump sum payment
•   Passive, feel-good treatments
•   Family concern
•   A disabled parking sticker
        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
     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
       What would Dr. Stills do?
• Minimal, logical approach to sickness, injury and
• 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