Assessing Disability in the Pain Patient

In a newly published textbook, Comprehensive Treatment of Chronic Pain by Medical, Interventional, and Behavioral Approaches: The AMERICAN ACADEMY OF PAIN MEDICINE Textbook on Patient Management. March 2013 (Springer Science+Business Media) there are two Chapters that may be of interest and which I can provide on a limited basis for educational purposes if requested.

Assessing Disability in the Pain Patient (Feinberg, S.D. & Brigham, C.R.)

Key Points

• Assessing disability in the pain patient is often difficult due to both administrative and clinical issues, yet this assessment is essential.
• Clinically, quantifying pain remains problematic as chronic pain is a subjective phenomenon, often associated with confounding behavioral, characterological, personality, and psychological issues.
• Typically, the physician does not define “disability”; rather, the physician defines clinical issues, functional deficits, and, when requested, impairment. Disability is most often an administrative determination.
• The assessment of disability associated with chronic pain is complex, and the evaluator must approach the clinical evaluation with recognition of the many factors associated with the experience of pain and disability.
• The treating physician who has a doctor–patient relationship with the claimant may have a different perspective than the “independent” disability evaluator.
• While an independent medical evaluation has some similarities to a comprehensive medical consultation, there are significant differences.

Interdisciplinary Functional Restoration and Chronic Pain Programs (Feinberg, S.D., Gatchel, R., Stanos, S., Feinberg, R., & Johnston-Montieth, V.)

Key Points

• An interdisciplinary functional restoration approach to pain management has been empirically shown to be therapeutically and cost-effective.
• The biopsychosocial model of diagnosis and treatment operates on the idea that illness and disability is the result of, and influences, diverse areas of an individual’s life, including the biological, psychological, social, environmental, and cultural components of their existence.
• It is important to identify those individuals at risk for delayed recovery and transitioning from an acute pain episode to a chronic pain condition.
• Functional restoration programs emphasize a biopsychosocial approach including different disciplines and anticipating an individual’s gradual progression to a normal lifestyle.
• Treatment approaches include medication optimization, normalization of function, education, physical reactivation, cognitive-behavioral therapy, various mind-body techniques to manage chronic pain, and return of new functional activities.

Please hit REPLY if and let me know if you would like a copy of one or both of the above articles for educational purposes.

Real Help and Red Herrings in Spinal Imaging

There is nothing more compelling than seeing an abnormality on an MRI – “seeing is believing” to assure the doctor and the patient that the cause (lesion) of a problem has been identified. Medical treatment decisions often rest on these findings and result in surgery. But how often does that 2^nd, 3^rd or 4^th surgery prove efficacious?

While seeing an “abnormality” and operating on it may be seductive, the fact is that modern imaging uncovers things that are alarming but of no clinical consequence. There is ample scientific evidence that adults with no back pain or sciatica routinely have worrisome imaging findings. Such findings may distract attention from the actual medical problem while initiating more tests or invasive interventions with occasional risks.

This topic is discussed in the March 14, 2013 issue of the New England Journal of Medicine in an editorial, “Real Help and Red Herrings in Spinal Imaging” by Dr. Richard A. Deyo regarding an article in that issue titled “Magnetic Resonance Imaging in Follow-up Assessment of Sciatica” by Abdelilah el Barzouhi, M.D., and colleagues. In this study of patients with symptomatic lumbar disk herniation at baseline who were treated with either surgery or conservative treatment and followed for 1 year, the presence of disk herniation on MRI at 1-year follow-up did not distinguish patients with a favorable clinical outcome from those with an unfavorable outcome.

Dr. Deyo provides a good summary of the pitfalls of overzealous interpretation of imaging and the article by el Barzouhi et al. add further cautions regarding the use of spinal MRI, even in circumstances in which intuitively it might seem quite valuable. The investigators provide 1-year imaging follow-up of 267 patients enrolled in a randomized trial of surgical versus nonsurgical care for patients with a herniated disk and sciatica. Although MRI evidence of a herniated disk or nerve-root compression was found at 1-year follow-up more often in the patients who received conservative treatment than in those treated surgically, the findings were not associated with a poor outcome. The presence of scar tissue surrounding nerve roots was also not associated with patient outcome. Yet such findings may lead to unnecessary further imaging and surgery. Thus, postoperatively, clinicians should be slow to ascribe persistent or recurrent symptoms to the presence of either disk herniation or scar tissue on imaging.