I also remember that there was usually a lag between the end of school and the beginning of my summer job. I was fine for a couple of days but then I would quickly get cabin fever. I could not stand laying around the house and not being productive. I enjoyed getting outside and being with my co-workers.

Abusing my back

Unfortunately, I had little regard for my body with regards to lifting properly. I was continually reminded to use my legs and not my back and arms. I did not have great upper body strength so, of course, I used my back. I had no concept of the consequences and had a perverse sense of pride about how much I could lift and for how long.

The perils of parenting

In March of 1985 I was holding my sleeping one-year old son and placed him over the top of the side rail of the crib. It would have made much more sense to lay him down, lower the side rail and then place him in the crib with a relatively straight spine. I was still bulletproof and why would I change my lifting habits now? Just as I was fully leaned over the top of the rail I felt a snap in my back and a searing pain in my left big toe. That was the beginning of a six-week descent into abject misery of constant severe pain. I had thought (incorrectly) that if pain was very localized, that it would be more tolerable. I could not and did not sleep more than two to four hours a night for over six weeks. I still do not know how that is possible and I never had even one full night’s sleep.

My suffering worsened in that I could not eat,  lost 25 pounds, developed kidney failure from taking too many aspirin, experienced ringing in my ears, and I became increasingly irrational. (at least that is what I am told)

I was only able to work half time as the second partner in a private orthopedic practice. I had only debt after just finishing my residency. I was about to begin my spine fellowship training in Minneapolis in 4 months. I finally elected to do the one thing I swore I would never do and that was to have spine surgery. The simple decompression surgery at L5-S1 went well and my great toe pain was gone. I quickly returned to work and was excited about getting on with my training I was ecstatic – until my wounds began to drain about 10 days later. I developed a deep wound infection from being malnourished after losing so much weight. A second operation and six weeks of antibiotics finally resolved it. My spine surgery – and infection

“You’re fired”

I had been through a lot and fortunately I had a remarkably benevolent partner who continued to pay my salary, although I was only about a third functional. I was dealing with it pretty well until my future fellowship directors found out about my infection and promptly informed me that I had been replaced. They did not think I could do the job and I was also not offered a later position.

Somehow that was it. It was the one part of the situation I could not handle – losing my job. I was devastated. That night I sat alone in my car and completely broke down. I cannot verbalize the depth of despair and helplessness that I experienced. I could not care for my family or even myself. I clearly saw how vulnerable you were not being able to fend for yourself in a capitalistic society. I felt like a medieval warrior going to battle without any weapons or armor. It was one of the most painful and enlightening moments of my life.

The “benefits” of being disabled

Physicians are often given the impression that people are generally looking to get off of work. The answer to disability is to tighten the rules and get tougher. They feel that many injured workers just don’t want to work. They also do not realize the implications of taking people off of work. Once a person loses their job the whole nature of the claim changes. It becomes more difficult to get hired by anyone since you now have a track record of missing work. Here are some of of the other “benefits” of being off of work:

• Your income is at least 25% less and is fixed.
• A claims examiner is in charge of your life instead of you.
• You cannot get through to them to get an update on your progress or status and he or she is in charge of your entire life.
• Your disability check can be taken away from you without notice.
• No one believes you are in pain. My battle with NPD
• Life becomes one of surviving rather than thriving.
• Worker’s comp will not cover stress management treatments or provide resources to help you.
• How do you get out of this situation?
• Your providers are not filling out the paperwork and not getting back to your employer.
• There are endless contradictions regarding your care and diagnosis and you often are given bad news.
• Even without the conflicting medical advice, anxiety and frustration usually continue to rise.
• Pain invades every part of your life including many conversations. It is not that interesting after a while.
• What happened to your dreams?
• Research has shown that being off of work is detrimental to your mental and physical health.
• Many people lose their assets, including their home

I remember a moment about five years into my practice when I realized that my Worker’s Comp patients were not doing well because of lack of motivation. It was because  were justifiably angry. The Worker’s Comp system that they expected to help them and allay their anxiety was mostly harassing them. I didn’t blame them for being upset.

Disabled

Life is not better being disabled. Maybe you have been that way for so long that you can no longer understand or appreciate the alternatives. You are so used to being trapped that anger seems normal. Many people don’t even think they are angry. That included me. No one, and I mean no one, is going to help you out of this hole. It is deep and will keep getting deeper. Many Italians choose suicide – People need to work

The only patients I see succeed are those who have made a decision to live a different life and they are not going to live this way anymore. I have watched hundreds of patients become pain free. It is just much more difficult if it involves Worker’s Comp. How do you want to live your life? I had the smallest taste of what it is like to not be able to work and take care of myself. Not only did I not like it, it was the worst part of my ordeal.

The post The “Benefits” of Becoming Disabled first appeared on Back in Control.

The post The “Benefits” of Becoming Disabled appeared first on Back in Control.

Chronic pain is dangerous. When you are trapped by anything in life, especially pain, you’ll become angry. When you’re angry, everything is completely about you and your efforts to escape. You can no longer see the needs of those around you, much less respond to them. The essence of abuse is being unaware. Anger destroys awareness to the point that you can’t recognize your unawareness. Pain = anger = abuse

“But I would never be abusive”

You might not like hearing the word “abusive” even mentioned, much less think that it might in some way apply to you. There are many barriers to waking up to the possibility that the word does pertain to you.

• The most common barrier is this: many people are so used to being “frustrated” that negative emotions become a baseline. These people cannot perceive themselves as angry. For them, their anger is just a normal state to be in.
  • In the world of chronic pain, frustration and anger are synonyms. However, frustration is anger.
  • When you are upset, you feel so right that you cannot imagine someone not seeing your viewpoint. However, your anger blocks you from seeing the perspective of others.
    • This is particularly true when you are dealing with your children.

Chronic pain doesn’t elicit peace and joy

Everyone with significant chronic pain is angry. It is only a matter of how connected you allow yourself to be with your anger. If you are finding yourself upset this very moment while reading this, then this statement particularly applies to you.

I have seen hundreds of patients become pain free, and it doesn’t really happen until anger is acknowledged and addressed.

• Anger and pain are linked neurological circuits.
• They feed off of each other

I recognize abuse daily

For many years, I never put pain and abuse in the same sentence. I didn’t see the link. Now, it’s more than clear.

• Almost every time I mention how difficult it must be to live with someone in chronic pain, the patient’s spouse begins to involuntarily nod.
  • Many start crying.
  • I ask my patients to think about what it must be like for their children when they’re angry. They invariably get a wide-eyed look and take a deep breath.
  • I watch patients snap at their children in clinic. They seem to think it’s OK.

You won’t be able to see your own abuse

Few people wake up in the morning and think about the ways they can make their families miserable. Even those who are making their families unhappy, don’t realize they’re doing so. They are too busy thinking about themselves to notice. If you are in significant chronic pain, you can only partially see the needs of those around you. You have to make some stopgap rules. Here are some that I have suggested with some success.

The family rules of anger

1) When you’re upset, just disengage.

• Stop and take your own “time-out.”
• No relationship is improved with interactions based on anger–EVER!
• Have a family meeting and ask your children and spouse/significant other what it’s like to be around you when you are angry.
  • The answers aren’t pleasant.

2) The apologies later don’t work or make up for anything.

• Ask your family.

3) Imagine that you are your child watching you walk through the front door after just having an argument with your boss or claims examiner.

• Would you be excited or full of dread?

4) How attractive is your partner when he or she is angry? Compare that to when they are smiling.

• So how attractive do you think you look when you are upset?
• ANGER ISN’T ATTRACTIVE!

5) Listen–only listen for at least a month.

• Do not give ANY advice to your children or partner for at least a month.
• It should preferably last indefinitely.
• Advice should only be given when asked for.

6) Your opinion of your children’s “values” is not helpful.

• Find out who they are.
• They are more interesting than you think.

7) Make a commitment to be a source of inspiration and joy to your family–not a nightmare.

• Your family dynamic will change within weeks.

Don’t delay taking action

Anger is a major family problem. You love your family and the last people you would want to hurt would be them. Yet when you are angry, you are destroying them.

Not only do love your family but you also need their support. Don’t drive them away.

Protect them from your pain—NOW!

BF

The post Protect Your Family from Your Pain first appeared on Back in Control.

The post Protect Your Family from Your Pain appeared first on Back in Control.

• Without the distractions of work, pain is more noticeable.
• It’s usually not known when the patient can go back to work, which is anxiety-inducing.
• Being labeled a “chronic pain patient” by everyone, including the medical profession, begins early.

NBC News Post

NBC News last week reported that with the recent economic downturn, many Italians are committing suicide. Here are excerpts from the notes left by the victims:

• “I decided to end it because I am a failure. I can’t live without work.”
• “I can’t live without a job.”

This feeling of failure and loneliness is at the heart of acts of desperation among the business community in Italy. These messages left are the same mantra repeated by workers and businessmen who either tried to kill themselves and lived to tell the tale or by those who thought about trying, but found other reasons to live.

Another excerpt:

• “My business is like my family. I feel responsible for each of my employees. If my business fails, I fail with it.”

(This article was called, “In debt or jobless, many Italians choose suicide,” by  Claudio Lavanga. NBC News World Blog, May 9^th, 2012)

My old attitudes

I can speak only for myself in mentioning some of my old perspectives. However, my old attitude might generalize to how some physicians currently think about this issue.

• I had the impression that many patients wanted to stop working.
  • Only some wanted to stop working.
    • Most did not.
• I did not understand how devastating it was to a patient and his/her family to lose a job.
• The mental health consequences of being home and disabled are severe.
  • Social isolation creates the same symptoms as chronic pain
• It is often easier for me just to take a person off of work.
  • It’s time-consuming to go into the details of light duty, etc.

My approach changed

• There are major implications of losing a job.
• Being out of work creates further health problems.
• Any time off work should be for as short a duration as possible with specific dates prescribed to return to work.
• If a patient is already off of work, broach the subject of returning to work very quickly.
• If they have no intention of returning to work, the issue has to be clearly discussed and an alternate plan implemented.

People inherently want to be a part of society and contribute. Being active in the workforce is an important part of that need.

The post “Many Italians Choose Suicide” – People Need to Work first appeared on Back in Control.

The post “Many Italians Choose Suicide” – People Need to Work appeared first on Back in Control.

Anger

It is my observation that the whole system of care ignores the most significant factor that contributes to the development of chronic pain—anger. Anger is universal and part of the human experience. Some argue for the necessity of anger. In any case, it is not going away any time soon. Anger provides a useful survival mechanism. When you are threatened and feel anxiety, you will take evasive or avoidance action. When that ability to escape is lost, you will become angry, which increases your body’s physical reaction and mental focus to solve the problem.

Control

The antidote to anxiety is control.

Loss of control = anger.

The current disability system strips the worker of control. Additionally, at least in Washington State, the injured worker is at the mercy of a medically unsophisticated claims examiner. That examiner has final say in everything. As “enlightened” as I am, I cannot discuss a case with an examiner for more than a few minutes before I feel like I am losing my mind. I cannot imagine having my well being, as well as my livelihood, at the mercy of this system.

Dealing with the Anger

It will not matter what systems are designed to “incentivize” workers to return to work, unless this core issue of anger is addressed. You don’t have to incentivize any living creature to jump out of a cage. You just have to the door. Anger not only traps workers so they cannot fully engage in their care, but it also robs them of the ability or motivation to become engaged.

Although anger can be a useful survival mechanism, it is usually destructive to you and everyone around you.  Your anger imposes its own will on the immediate surroundings, and you lose all ability to rationally interact with your environment. The consequences are often disastrous. The most well designed programs are not going to be effective unless the wall of anger can be penetrated.

Anger and Frustration with Workers Compensation 

The post Anger and Workers’ Comp Webinar first appeared on Back in Control.

The post Anger and Workers’ Comp Webinar appeared first on Back in Control.

Dear Dr. Hanscom:

You may not receive these kinds of letters from nurse case managers very often.

I thought I would advise you of the above captioned patient that you performed a redo L5-S1 microdiscectomy about a year ago.  Ron got quite discouraged when he did not improve.  He was almost done with your book, Back in Control when he got off the couch, got motivated, moved forward, and we saw a dramatic change in his attitude. He worked through his pain, eventually stopped all medications, completed PT, and work conditioning programs. He was recently declared fixed and stable and was released to his job of injury as a sorter. (One of the hardest jobs around, believe me!)  He is back on the job and doing very well!!

Please thank your assistant for all of her help.

Thank you for all you have done for Ron.

Sincerely,

_____________, RN, BSN,  Medical Case Manager

Ron’s story

Ron was only in his early twenties when he ruptured his lowest disc, L5-S1, while on the job a couple of years earlier. A prior surgical attempt to remove the disc had not given him lasting relief. When I first saw him, he was experiencing ongoing severe sciatica down the back of his leg. His MRI scan showed a large ruptured disc. It had probably re-ruptured relatively soon after his first surgery.

Lower back pain

I am always clear about the goals of surgery and what I can and cannot accomplish with a given operation. He had a significant amount of lower back pain (LBP) in addition to his sciatica. There is not an operation that relieves LBP, and I explained to him that I would only address his leg pain. I also explained to him that once you have had ongoing pain for more than four to six months, the brain lays down pain pathways, which are permanent. (1) Although it was necessary to re-do his operation, my observation has been that the sciatica still will often persist. The pain is usually better, but often it is still severe enough to really destroy the quality of your life.  The back pain and residual sciatica are treated by the tools on this website.

The operation

After my operation, which was a redo of removing the disc at L5-S1, Ron did not do that well. As expected, he had ongoing back and leg pain. I had explained the DOC Project to him, but he had not really engaged. Finally, about three months after the surgery, I was extremely clear with him about where he was headed. Living the rest of your life in chronic pain when you are in your early 20’s is not an inviting prospect.

Worker’s Comp

I did not post this story right away. In the interim, I began to think about my historical view in dealing with patients on Worker’s Comp. I was taught and believed that it was my role as a physician to “set boundaries.”  It was in the patient’s best interests for me to be tough and just “shut the door.” Injured workers, I thought, are focused on gaming the system and remaining off of work. It is often repeated in seminars that injured workers have “secondary gain” issues, and that if the benefits were decreased or cut off that would be the best motivator to get people back on the job.

Thriving??

I realize that a only small percent of people are gaming the system. However, my strong observation is that given the opportunity, people want to thrive. Surviving on a fixed income when you are only in your 30’s or 40’s is not living a full life. Years ago I would have told him to “buck up and just get back to work. That would be the best thing for you to do to help your life and pain.” I would have just closed his case.

Motivation

When you have been physically and emotionally beat up by the pain and the system, you have lost the ability and motivation to become productive. Once you have the tools to reconnect with who you really are and where you want to go, there is no stopping you.

It took about six weeks for Ron to fully engage, but he did it. This whole project is about showing you the tools to heal yourself. My role is to be a coach and cheerleader.  Watching patients like Ron start smiling again as they make strides in becoming pain free is one of the most rewarding aspects of my practice. I am grateful that I have been able to help show him the way.

1. Hashmi, JA, et al. “Shape shifting pain: chronification of back pain shifts brain representation from nociceptive to emotional circuits.” Brain (2013); 136: 2751–2768.

The post Ron Salvages His Own Spine Surgery first appeared on Back in Control.

The post Ron Salvages His Own Spine Surgery appeared first on Back in Control.

Every injured worker should have access to some level of mental health support. I work with a veteran pain psychologist who is wonderful. 90% of her practice is caring for my patients. If she feels it is necessary, she will refer a patient to one of several psychiatrists for medication management.

Chronic Pain and Mental Health

It is unclear, from the psychiatrist’s viewpoint, what constitutes a diagnosable psychiatric disorder. On my intake questionnaire, I have a simple 0 to 10 scale for anxiety, depression, and irritability. Essentially every injured worker that has been out of work for more than six weeks is greater than a 6 out of 10 on at least two of these scales.  What would be my threshold for a formal referral, especially in light of the fact that my state will not pay for an evaluation in a timely manner? What is even more worrisome to me is the patient who puts down a zero for all three. He or she is just a time bomb.

Diagnosis Problems

In the disability literature, there are hundreds of papers linking stress and disability, but there is not a clear-cut definition of anxiety disorder to aid practitioners in diagnosing an injured worker. How bad does a patient’s anxiety have to be in order for it to be diagnosable? What is the definition of a diagnosable mental health disorder in general?  As there is not a concise definition, I am in a continual battle with worker’s comp trying to persuade them to “buy” a psychiatric diagnosis. While the patient is waiting, what are we to do?  Their stress level climbs even higher as they wait for an answer.

A Case

I saw a patient a few months ago who is a young mother. I have known her for years.  She developed quite severe axial back pain. We had a short but direct conversation about stress and pain. She came in a couple weeks later with her back pain feeling moderately improved but seemed upset. I had a little extra time to talk to her. She started out by saying that she had separated from her husband and was having a hard time finding a job and a place to live. I knew that he had not been working and she was home with two young children. It turns out that he had been regularly beating her. It happened enough that her children felt afraid of her if she yelled at them, but the physical abuse that occurred in front of them seemed OK. If you met her, you would be more than upset. She is one of the nicest people you could meet. Under no criteria would she have a diagnosable psychiatric condition. She really did not know what direction to go. Her mother was helping out the best she could. I emailed my pain psychologist and although she had no funds, she was able to be helped out. On top of that, her husband has chronic pain from failed back surgery.

Stress Management

Every person from elementary school on should be taught stress management and mental health skills. I feel the one factor that determines one’s success in life is the ability to process and handle stress. Even basic stress management tools are extremely helpful.

Support

Every injured worker needs to have access to at a group or organization that teaches these type of skills and offers other support. Individual referrals to psychologists can be figured out more easily in this setting. Losing a job in a capitalistic society is a disaster.  It is bad enough if you are single; it is much worse if you are the breadwinner of a family. Even the thought of being in this situation is mentally crippling.

Labels

A major concern and obstacle to accessing mental health support is our tendency to label people. Injured workers quickly become labeled. This is particularly true if they make the mistake of complaining too loudly or expressing their frustration. They become “difficult” and “manipulative.”  If their stress becomes higher, they may have more pain and ask for more meds. This gets them labeled “drug seekers.”  The list of labels goes on. If a patient is labeled as “anxious” or “depressed,” they are often put on antidepressants and their anxiety is considered “addressed.”  If after a few months they are still depressed, then they might be referred to a psychiatrist or psychologist. By this time, months have passed and often the lives of patients have unraveled.

The Patient is a Person

The patient’s whole life, including her mental life, must be acknowledged from the minute she is injured. Every person that comes in contact with her makes a difference. Even the acknowledgment of her suffering is important.

I made a comment a few weeks ago to David Tauben, who is the head of the University of Washington pain center, and David Elaimy, my surgical performance coach, that they should put on a mini-seminar, “Enjoying the Management of Your Chronic Pain Patients.”  A major part of the enjoyment of being a physician is addressing the whole patient and making the correct diagnosis. If I had just sent the young mother I mentioned above to physical therapy for neck pain, it would not have been helpful. Thanks to the DOCC Project methods, she will be able to get her life back on track and have the tools to live a much more fulfulling life.

BF

The post Everyone Needs Support first appeared on Back in Control.

The post Everyone Needs Support appeared first on Back in Control.

I have argued for 25 years that a claims examiner should not be in charge of a given case.  The caseload for a given examiner used to be 400-600 workers.  Even if you had an occupational medicine physician in each claims examiner’s chair, she could not manage the claim.  I would hope the ratios were better, but even if it were 200-300 claims per examiner, the responsiveness would not be even close to the workers’ needs.  Each worker’s ENTIRE LIFE depends on an overloaded examiner.

Many claims examiners seem to have the mandate to “be tough” and move the claim through as quickly as possible.  I assume that the vast majority of examiners are initially motivated to provide the best service possible to the patient.  However, after dealing with angry workers on a regular basis, it is difficult not to develop a “thick skin.”  What that attitude does is make the claimant angry, and everything grinds to a halt.  I have to spend a lot of time just calming down my patient (and myself).  In the end, the “labeling” of workers as anything less than a “human being caught in the quagmire of a huge system” is counter-productive.  There has always been an obvious dividing line between workers with a benevolent claims examiner and those with a hard-liner.

I understand from the claims examiner’s perspective that it is important to move a claim through quickly.  However, claims tend to be dealt with more quickly when the relationship of the examiner to the worker is one of an ally helping navigate the worker through the maze of worker’s comp.

Additionally, there is a high turnover rate amongst claims examiners.   It takes several weeks for the new examiner just to get through his or her stack of claims, during which time patient anxiety goes through the roof.  How would any of us feel to have our middle school teacher changed halfway through the year and then find that her replacement has no idea who any of us are or what are needs are?

The level of medical training a claims examiner has is minimal. The claims examiners do not have enough medical training to make thoughtful medical decisions.  Currently, even if your surgical approval company approves a given surgery, I often have to still argue with the examiner about getting the surgery performed.  An insane phrase I here all too often: “The final word rests with the claims examiner.”

Many examiners do develop a valuable perspective in recognizing outliers and dangerous medical care.  However, that perspective is not uniform, and I cannot quantify what percent have that kind of experience.  I do know that many examiners are new and do not have that perspective.  There is too much variability to put so much responsibility into this position. Even if I could clone myself and sit in every claims examiner’s chair, I could not competently make the best medical decisions for that given patient.  Medical care cannot be delivered at that distance.  The examiners are in a “no win” situation.

I am also well aware of the “rumor mill” amongst the claims examiners.  Certain physicians are labeled and care is delayed.  Different treatment philosophies get picked up within the system.  Their own concepts of the human body and medical care enter the medical decisions.  When confronted, they will ask for an IME, which delays all care for at least 4-6 weeks.  They then use the IME recommendations as a template for the care of the patient.  The IME physician spends just a few minutes with the patient and their attitude is not one of providing the optimum care for the patient.  I understand that there is a need for IME’s, but that need is not to influence ongoing medical care.  With that “authority,” the claims examiner often makes everything even more difficult for the physician and the patient.

Meanwhile, I try to help “calm down” the patient, as the circumstances are extremely adverse from our perspective, and the patient’s pain and tolerance to the pain is completely out of whack.  As the final nail in the coffin, I usually cannot persuade worker’s comp, which has wreaked havoc on my patient’s life, to approve any mental health services.

I disagree with comments about the ideal system not being able to respond to the needs of a given patient.  Payments of modest financial incentives can and will change physician behavior.  But no system can respond to the complexity of an injured worker’s life and specific needs.  Each one of us becomes incredibly frustrated just dealing with airlines trying to make changes to a travel itinerary. Imagine having you’re medical treatment plan being altered against your wishes. These claims examiners are dealing with these workers entire life, including their ability to put food on the table.  My point is that any system cannot respond to the specific complexity of a given claim.  The better solution is to give the workers the tools to navigate their own way through the morass.

I am suggesting the following regarding the role of the claims examiners:

• Respect the injured worker and treat them accordingly.
  • It should be a major part of their orientation and ongoing in-service training.
• They should not be involved in medical decision making.
  • They should be able to approve reasonable care quickly and then ask for RN or physician input if they have questions.
  • This process should be expedited as quickly as possible.
  • How does delaying the ordering of tests save any money?  It would be different if there were no time loss.  The delay costs much more than the test.
• Their main role should be to make sure that the claim is run as seamlessly as possible.  Improving communication between all parties should be emphasized.
• They need to understand how trapped their claimants feel and not react when the worker is upset.  What would they do in a similar circumstance?  I don’t think any of us on the roundtable would react much differently.

There are many physicians who will not see worker’s comp patients due to the hassle factor.  Often, if a surgeon deals with worker’s comp, it is just to do a consultation and perform surgery.  By isolating out the worker’s comp variables, the decision making process regarding major surgery can become flawed.

I spend most of my time talking patients out of any type of spine surgery.  I specifically work just on discrete structural problems with matching clinical symptoms. I am diligent in trying to deal with all of the variables affecting the outcome of surgery, especially with a worker’s comp situation.  I will meet with nurse case managers as well as talk and meet with vocational counselors.  I will not close a claim until all parties have a plan in place.  I have one patient who had eight people involved in getting him back to work.  It took me ten months and at least five hours of phone calls and meetings.  After four years of chronic pain and disability, he is now working full time again.

I am one of the most interactive surgeons I know in getting a claim resolved.  I have learned how broken this system is.  I am not blaming the claims examiners.  It is a system that sets them up to fail.  Although I think the ultimate answer is to give the patients the tools to navigate their own way back to full health, there are many system changes that must be made.

I realize that there are several claims examiners on the roundtable.  I will be looking for their input with interest.  Right now, life in the trenches with my injured workers is intolerable.

BF

The post Examiners from the Worker’s Perspective first appeared on Back in Control.

The post Examiners from the Worker’s Perspective appeared first on Back in Control.

The problem is that even an ideal system will never be able to respond to the needs of a given patient quickly enough to really make a large-scale difference.  Not only are there problems navigating through all of the various parts of the worker’s comp system, these patients’ personal lives are often a disaster.  I don’t know if many of them are still even on their feet.

The more effective strategy is to give patients the tools to deal with stress.  They can often navigate their way relatively quickly through the process.  The tools also make a difference in their personal life and their families will become their support system instead of targets for their frustrations.  Conversely, without any personal support, their anger will cause them to disengage from reason and the opposite effect occurs.

It’s true that, where I practice, 80% of injured workers do well with minimal intervention.  But we don’t know which injured workers will become one of the 5% that consumes 84% of the medical resources in the state of Washington. Even the simplest injury creates additional stress on a given worker.  It is the luck of the draw whether they end up with a physician and employer that can create a smooth process.  It is unpredictable what provider or circumstance will set off the cascade of extreme disability. The idea of being pro-active in a claim is 20 years ahead of its time. It has been incredibly frustrating watching employers, in the face of overwhelming data, still not want to engage in any type of innovative process.

The category of mental health strategies described are the one’s we have been routinely using.  My concept is to “calm down” the nervous system, which has consistently decreased my patient’s perception of pain.  However, I always start with sleep.  None of the tools are effective without sleep.

I think the roundtable could develop a laundry list of strategies that could be ferreted out and implemented.  This is a group that has the power to change some things and I would challenge us to get focused.

I did become incredibly discouraged last night thinking about national politics.  Regardless of your political leanings, jobs are disappearing.  No matter how skilled you are with these stress management tools, none of them are going to negate not being able to put food on the table for yourself or your family.

BF

The post Arm the Worker first appeared on Back in Control.

The post Arm the Worker appeared first on Back in Control.

His tests and treatment were as follows:

• His lumbar MRI showed disc degeneration at every level but no instability.
• He had crippling anxiety including fairly frequent panic attacks.
• He was open to psychological care.
• I engaged him a structured rehab program, but essentially every request we made for biofeedback, psychological intervention, mindfulness/meditation, and back school was denied by Worker’s Comp—over and over again.
• I somewhat kept him on his feet by seeing him back every couple of weeks for about six months. We kept requesting care.  Even personal phone calls to his claims examiner were of no avail.

I referred him to a pain specialist that I have teamed up with, and he continued with a similar program but again with no support from Workers’ Comp.

• The patient still complained of severe crippling anxiety and was somewhat desperate for mental health care.
• I am not currently his treating physician but last week my colleague emailed me and asked me to re-evaluate him.
• It has been recommended to him that he have a two-level lumbar fusion for his degenerated discs.  My friend begged him not to pursue it.
• The patient is anxious, frustrated, and does not want to talk to me or anyone else.  He is now intent on pursuing surgery.

So look at this situation.

• We know that chronic pain increases anxiety and frustration, which exacerbates pain.
• Psychosocial stress is a better predictor of outcome than the surgical pathology.
• The return-to-work rate at one year from a lumbar fusion for low back pain in the State of WA is 15%.
• The patient has documented severe untreated anxiety.
• In addition to his baseline anxiety, interacting with the Worker’s Comp system has pushed him almost into a rage.
• The state still will not pay for any mental health resources
• They will pay for an operation that will cost them between 50-75 thousand dollars and has a re-operation rate between 15-20% within the first twelve months of the index operation.
• If he does not undergo surgery, his claim will be closed and he does not have the emotional capacity to compete in the work force.

I have no ability to intervene, as I am no longer his treating physician.  I realize that “this is not my problem.”  That is correct.  It is not my problem; it belongs to all of us.

Does anyone have any suggestions?

BF

The post It Really is Upside Down first appeared on Back in Control.

The post It Really is Upside Down appeared first on Back in Control.

Not only did I believe you had pain, I know you had it. There is simply not an identifiable source. Patients become understandably obsessive about the possibility that something serious may be missed. Surgeons think mechanically and their language revolves around the idea that there must always be an structural source of pain.

Consequently, patients in chronic pain feel the need to be validated–all of us do. Even if the chances of success with surgery are slim, they will often push hard for the surgery as part of this need. It is much easier to be believed with a scar on your back.

Advantages

Being a victim is an extraordinarily powerful role and works well. There are major advantages of remaining in this angry mode. Some of them are:

• Others expect less of you
• You expect less of yourself
• You have a feeling of power, which masks the feeling of anxiety
• It gives you a sense of entitlement
• You can manipulate those around you who are attached to pulling you out of the victim role. The term used in the addiction world is enabling.
  • This is a huge issue in the world of eating disorders. Every parent wishes to have his or her children to be happy and healthy. When a son or daughter is using control or lack thereof to slowly destroy him or herself, the parents understandably become very concerned. A huge amount of family energy is consumed in trying to deal with this irrational body imagery. The child has complete control of the situation. Until the parents can truly let go of the outcome and just provide resources, the problem is not solvable. It is much too powerful a role for the child to give up.

Workers Comp

All of this is especially relevant in the workers compensation system. You are being treated terribly and being labeled. Almost every aspect of your suffering is continually challenged. If you are not angry, then you are incredibly skillful in suppressing it. I personally cannot talk to most claims examiners for more than five minutes without losing my mind. I do realize that they are controlling your ENTIRE life. You have little, if any, control of the circumstances. That’s frustrating.

The only control you have is remaining in the victim role. If you are angry with your employer, you can really stick it to them with the cost of your care. You can keep aggressively seeking medical care. Why get better? No one really seems to care, even though they say they do. The victim role is somewhat akin to being a suicide bomber. Your employer will survive. Your claims examiner will go to work tomorrow. There is not one person you are going to permanently harm. Yet you have allowed chronic, completely justified, anger to erode your quality of life. Destroyed by bullies

Can you move on?

How attached are you to your victim role? Are you willing to look at how it might be running your life? How victimized do you feel in regards to your pain and the circumstances surrounding it? How angry are you that no one seems to want to listen, believe, or care about your pain? How frustrating is it to feel that you might have to live the rest of your life with this pain?

Do you need validation from others or can you trust yourself.

The victim role is universal. The willingness to take an honest look at it is not.

The post Advantages of Victimhood–No one Believes You first appeared on Back in Control.

The post Advantages of Victimhood–No one Believes You appeared first on Back in Control.