Indiana Worker's Compensation Institute

The role and purpose of psychological evaluations in understanding behavioral problems is more clearly understood and accepted for providing clarification in medical and psychological disorders.  In the case of a worker’s compensation claim, any type of complicated medical and psychological disorder is affected by how the diversity of human behavior affects the reactions of the injured worker. The disparity and recovery time required following a work related injury populations it even more difficult to predict who is going to respond positively to the medical and psychological interventions employed to aid recovery.  The psychological and medical literature documents the variable recovery rates for Worker’s Compensation patients compared with those from a noncompensation population.  In addition, psychological evaluations for those being considered for implantable devices and surgical intervention indicate psychological and behavioral factors are critical to the decision making process and success rate of such procedures.

Various types of stressors contribute to the difficulties often experienced by med/psych patients.  The associated problems of physical illness, injury, increased somatic symptoms and sleep disturbance contribute to increased psychological stress and interference with occupational capability and the basic ability to manage the environmental changes.  This causes an increased number of risk factors that contribute to the behavioral and psychological response of medical patients and influence their recovery.  It may even interfere with their ability to overcome some of the difficulties being experienced.  Multiple surgical procedures, repeated experiences in physical therapy and rehabilitation provide both a source of comfort and add to the stress experienced by many medical patients. How a person responds to these various stressors in the course of their treatment can significantly impact their recovery.  For this reason, understanding who was injured is often as important as understanding the injury.

There seems to be great variability, however, in how psychological information is gathered. Clarifying the behavioral aspects of the med/psych case and determining which medical and behavioral interventions are likely to be successful is critical to designing the behaviorally meaningful psychological examination.  More importantly, who conducts the examination based on their expertise and understanding Worker’s Compensation claimants is also critical.  Unfortunately, mental health professionals receive limited training in legal issues, and no training in understanding worker’s compensation.  In addition, external motivating factors in a Worker’s Compensation case often negatively impacts the recovery process.  Thus, the assessment of dissimulation or response bias is needed.   Once again, mental health professionals are rarely trained to assess dissimulation or to question the role of secondary gain.

What is the role of a psychological evaluation in a Worker’s Compensation claim?   First, to establish what psychological factors and psychological disorders, if any, impact the patient’s behavior.  This is determined by conducting a psychological examination and identifying psychological disorders with the assistance of the DSM-IV-TR.  Secondly, are the medical professionals confronting and trying to manage subjective or objective symptoms?  That is, do psychological and behavioral factors impact symptom perception as well as the behavioral presentation of the patient?  A final aspect of the psychological examination is to determine if the legally relevant event caused the psychological disorder.  In addition, some events aggravate underlying psychological disorders.  Thus, psychological evaluations help to clarify those disorders which are pre-existing and existed co-morbidly with the psychological disorder which is causally related to the work event.

The structure of the psychological evaluation is based on conducting a complete diagnostic interview.  The diagnostic interview is an integral aspect of getting to understand the alleged psychological and physical complaints.  The results of the psychological evaluation should not be based solely on self-report.  That is, the determination of causation and other issues critical and appropriate to understanding a Worker’s Compensation claim should not be based simply on a diagnostic interview or limited to the self-report of the claimant.  Psychological testing should be administered which is designed to assess the current complaints.  These tests should be normatively based psychometric measures that provide clarification of the complaints and behaviors reported.  Reviewing medical and psychological records pertinent to the claim aids in understanding the behavioral patterns of the claimant.  Being able to compare data from multiple sources aids in determining the consistency of the symptoms and helping to clarify the credibility of the symptom report.  Without such information it is nearly impossible to determine a cause and effect relationship.  Moreover, concurrent psychological stressors can be identified.   Most importantly, comparing the consistency and inconsistency of the data is achieved.

By utilizing multiple data sources clinical judgment is then based on multiple sources of information and not simply on clinical judgment.   Clinical judgments are often lacking in accuracy when clinicians base their opinions simply on clinical experience or the self-report of the patient.  These clinicians are prone to making significant errors in judgment and overlooking meaningful pieces of clinical information.  Thus, an appropriate psychological examination encompasses an interview, psychological testing, record review, mental status observation, and comparison of data from multiple sources before determining an outcome.

The ultimate value to claims examiners and physicians in requesting a psychological examination is that it helps those who are involved in treating the patient to better understand the effects of the work-related event and psychological disorder.  The life of the claimant, prognosis for recovery, and treatment needs can also be facilitated.  This helps to determine what is necessary to regain useful function, thus reducing the possibility of permanent impairment.  In the medical context, the information gained from a psychological evaluation helps physicians sort out additional information that will enhance their ability to determine which patients have a better and more reasonable prognosis for benefiting from the medical treatment recommended and provided.  The key is to make the information relevant and useful to the recovery of the injured worker.

Tarsometatarsal (midfoot) injuries are relatively rare injuries.  They make up 0.2% of all fractures.  Despite their infrequent occurrence they can be quite debilitating.  They range from mild, stable sprains to those with severe displacement and a high rate of associated injuries.  The midfoot is normally highly stable secondary to its unique bony arrangement between the tarsal (3 cuneiforms and cuboid) and metatarsal bones and multiple strong ligaments. The midfoot is highly important to the overall stability and function of the lower extremity.  These injuries most commonly occur in motor vehicle accidents, crush injuries, and twisting associated with falls.  These injuries can be from direct blows or loads on a hyperflexed foot.  One must have a high index of suspicion as 20-40% of these injuries are missed on initial exam.  The male to female ratio is 2-4:1 and the average age is mid-30’s.

Pain and swelling in the midfoot are hallmarks of the condition but can vary based on the severity of injury.  Severe injuries will reveal gross deformity.  Instability may or may not be obvious.  The severity of the injury will dictate whether a patient can bear weight on the foot.  1 in 5 will be open (compound) fractures. Associated injuries are found in approximately 80 % of patients.  AP, Lateral, and Internal Oblique X-rays are mandatory and should be weight-bearing if possible.  Some unstable injuries may spontaneously reduce and be missed on nonweight-bearing films.  Stress X-rays or opposite foot X-rays are also occasionally needed to detect subtle instability.  CT scans are frequently used to accurately assess joint damage and to assist with pre-operative planning.  Fractures involving the 2nd metatarsal base are seen in approximately 90% of injuries.

The key to a successful outcome is an anatomic reduction.  Studies suggest a 50-95% good to excellent result with an anatomic reduction versus 17-30% if anatomic alignment is not obtained.  Open reduction and internal fixation (ORIF) is always needed for any unstable, subluxated, or dislocated injuries.  Surgery is usually performed in the first 7-10 days as soft tissue swelling allows.  Screws are placed across the first 3 tarsometatarsal joints to restore and maintain an anatomic reduction.   K-wires are used across the 4th and 5th joints if needed for stability to minimize injury to the joints and maximize later motion.

Post-operatively patients are kept nonweight-bearing for 6-10 weeks.  K-wires are removed after 6 weeks and the screws are removed at about 4 months to try and maximize midfoot motion.  Physical therapy is usually started after the period of nonweight-bearing.  Patients return to sedentary work by 4-6 weeks.  It typically requires 5-6 months to return to jobs requiring prolonged standing, walking, climbing, or lifting. Many patients will return with some long term restrictions.  Maximum medical improvement takes approximately one year.  Patients require shoe modifications and/or orthotics to maximize function.  100% of patients will develop X-ray findings of arthritis which may or may not be symptomatic.  Arthritis that can not be managed with anti-inflammatory medications, shoe modifications/orthotics, and activity modifications require midfoot fusions of the affected joints.

Many patients require permanent work restrictions and/or job changes.  50% of patients will have some permanent impairment.  Post-traumatic arthritis can result in a PPI of 4% whole person, 10% lower extremity, 14% foot up to 8, 20, and 28%.  A midfoot fusion results in a 4% whole person, 10% extremity, and 14% foot impairment.

Tarsometatarsal fracture-dislocations are relatively rare injuries that can lead to significant impairment and job limitations.  The key to maximum recovery is a high index of suspicion as 20-40% of injuries are missed on initial exam and an anatomic surgical reduction performed by an orthopaedic foot and ankle specialist.

Many spine procedures needed to treat patients with common spine problems encountered in our working bipedal world required the following:  a 3-5 day stay in the hospital, large painful muscle-stripping incisions, the harvesting of bone graft, with a 30%-40% chance of continued pain up to 2 years after surgery at the graft site, and rehabilitation in the hospital before a patient could be discharged to home.   Mercifully, these same procedures germane to cervical and lumbar surgery have evolved to our advantage.

Innovative advances in the technology of spinal fixation and instrumentation, clinical use of bone morphogenic proteins (BMP) and bone substitutes have allowed spine surgeons to develop minimally invasive spinal (MISS) procedures.  The goal of these procedures is less operative trauma to the normal anatomic soft tissues while correcting spinal pathology.   Patients, therefore, can return to their activities of daily living quickly with minimal pain and discomfort.  This translates into less cost, disability, and time lost from work associated with the treatment of spinal pathology.  A facility that can provide efficient and timely diagnosis, treatment and management of a largely industrial population will contribute directly to a company’s bottom line – prompt return of their employee’s to gainful employment.

Straightforward spine procedures such as single level anterior cervical fusion and microlumbar discectomy are being done frequently in surgery centers on an outpatient basis.  The impetus to do more advanced cases employing the above technology is now available.  Soon single level laminectomy’s, posterior cervical foraminotomies, PLIF’s and ALIF’s will join the list. Thus, with proper patient selection and education, liberal use of pre-emptive and post-operative analgesia many MISS procedures can be done on an outpatient or 23 hour short-stay basis.  And, as more spine surgeons become comfortable doing these types of procedures in this environment, outpatient spinal surgery could rapidly become the standard of care.

The future of spine surgery remains bright and exciting.  The correct use of the above technology will take the field of spine surgery into a new era.  Our patients will have better results, less pain and morbidity with return to a productive life with minimal delay.

What is a Medical Record Search?  How will this search help the adjuster make a decision about questionable claims?

Most adjusters have experienced a claim that made them suspicious.  The claimant is not completely forthright when asked about medical history.  The claimant cannot remember names of past physicians or are evasive when asked direct question about medical history.  Without past medical records there is no way to prove or disprove pre-existing conditions.  Investigation can be expensive especially when all you have to go on is a gut feeling and the existence of Red Flags in regard to the claim.

A Medical Record Search could be the answer.  This investigative service will provide the adjuster with information that could be crucial to settling the claim quickly or directing the adjuster to investigate the claim in more detail. This one service can reveal providers who have seen the claimant in the past.  A list of providers never mentioned by the claimant is now available. These records may reveal medical conditions that affect the claim. It also sheds light on the integrity of the claimant.  Has this person withheld information that is pertinent to the case? This search may also reveal the claimant is being truthful allowing the adjuster to pay the claim in good faith

The adjuster simply provides name, date of birth, social security number, address of the claimant and a signed release if available.  A demographic search of hospitals, family physicians, orthopaedic physicians and chiropractors will reveal if the claimant has been seen.  Other areas of medicine can be researched as they apply to the claim.  The information obtained varies from provider to provider.  Some offices will give dates of service and why the person was seen.  Other providers will only acknowledge the patient has been seen. A report showing all providers contacted with their addresses and telephone numbers will be presented to the adjuster.

The adjusters who have been using this search have expressed the importance of the information provided to them. A Medical Record Search is a simple inexpensive way to reveal the integrity of a claimant.  Most importantly, a Medical Record Search will provide the adjuster with information to make an educated decision in regard to paying a claim or denying a claim.

As the physical therapy profession has advanced, treatment emphasis has gone from passive modality oriented treatment to more active exercise oriented programs.  Spinal stabilization has become the standard treatment for spinal dysfunction or back pain.  What exactly does that mean?  When you send your client for one of these programs, what should you expect to be addressed?

Spinal stability is the ability of the spine to distribute the normal stresses that pass through it evenly to all of the segments.  This is accomplished by maintaining proper postural alignment with activities throughout the day.  Treatment to reach this goal should include education on proper positioning, and strengthening or retraining specific muscles that surround the spine.  These muscles include transversus abdominis, the multifidi, gluteus maximus, and gluteus medius.

In years past, treatment has focused on strengthening the superficial abdominal muscles, the rectus abdominis and obliques.  More recent research has shown the importance of the deep horizontal muscle, the transversus abdominis.  It works with the pelvic floor muscles and multifidi to form a protective cylinder around the spine to insure that any stresses through the spine are distributed evenly amongst all the vertebrae versus being translated to just a few vertebrae.  As with any machine, the weakest link is the one that gives first, transferring stress to the already unhealthy spinal segment.  Evening the load is of utmost importance.

The above stabilization muscles can become weak like any other muscle, and can be affected by reflex inhibition through repetitive or traumatic injury, or the normal trauma associated with surgery surrounding them.  The multifidi can be observed to have noticeable atrophy in individuals with spine dysfunction.  It is important to insure that these muscles resume their normal function after any of the above occurrences.

In addition to the muscle groups above, the gluteal muscles play an important role in spinal stabilization.  The gluteus medius originates as a fan shaped muscle on the outside of the ilium or pelvic bone.  It fans over to attach to the trochanter of the femur.  It serves to help stabilize and compress the SI joint.  When it is not functioning correctly, the hip flexors, IT band, or quadratus lumborum can be forced to compensate leading to further dysfunction in these muscles.  The extra forces or trauma on the SI joint can also lead to SI instability and pain.

The gluteus maximus works to extend the hip.  With proper spinal stability it will function independently.  With weakness or poor neuromuscular function of glut max, the lumbar paraspinals will be forced to help with hip extension.  This can lead to unnecessary stress at the individual spinal segments, further degeneration or damage to the vertebrae and surrounding structures, and eventually pain.

The role of physical therapists is to identify muscles that are working too hard and muscles that are not working hard enough.  Treatment should focus on reeducation of the muscles to play their primary role.  There are many popular exercise programs that address spinal stabilization such as those developed by Shirley Sahrmann, the San Francisco Spine Institute, Vladimir Janda, or the Watkins Protocol.  Proper function of these muscles along with education on proper biomechanics should be introduced before a strenuous work hardening or work conditioning program, or further abnormal stresses to the affected joints can continue to occur, resulting in increased pain and dysfunction. The sooner these imbalances are addressed, the quicker the recovery process can begin to occur.a

A Life Care Plan (LCP) is a tool used for the purpose of projecting and estimating medical and non-medical needs of the person with a catastrophic injury utilizing a consistent and scientific approach.  The Life Care Plan addresses and projects the costs and frequency of needed goods and services over the estimated lifespan.[i] It is a guide for the patient, family, caregivers, and payor source to follow to ensure that funds will be available over the patient’s lifetime.

The Certified Nurse Life Care Planner (CNLCP) is uniquely qualified to develop the Life Care Plan due to his/her extended experience, knowledge, and education of the nursing process, which forms the foundation of the Life Care Plan. To become certified, a professional nurse must complete advanced course work as well as pass the national certification examination with 78% or higher raw score. The Certified Nurse Life Care Planner collaborates with other members of the healthcare team to formulate an individualized plan to meet the needs of the patient.

Life Care Plans are utilized by a variety of referral sources for several reasons. Insurance carriers or third party administrators may utilize the Life Care Plan for accurate reserve setting on catastrophic claims and as a guide for the authorization of appropriate and medically necessary treatment. Personal injury, medical malpractice, divorce and family law attorneys use the Life Care Plan to assess damages for settlement.  Defense attorneys often request that the Certified Nurse Life Care Planner review and critique the plaintiff’s Life Care Plan for accuracy prior to settlement. Advocacy groups and rehabilitation centers are among other groups that utilize the Life Care Plan as a roadmap to ensure the adequacy and availability of services for a patient.

The most common conditions requiring a Life Care Plan include but are not limited to, catastrophic injuries, spinal cord injuries, traumatic brain injuries, amputations, burns, chronic pain conditions, neonatal and pediatric conditions such as cerebral palsy, and conditions affecting the geriatric populations.

The Life Care Plan is developed by a trained Certified Nurse Life Care Planner, utilizing the nursing process as well as employing research and case management skills. A patient assessment is performed via review of the medical record, thorough medical research, and an inperson interview with the patient. Additional interviews with the family, caregiver, employer, or teachers, are conducted if necessary to obtain a complete patient assessment. The collected data is then analyzed to identify health issues and formulate nursing diagnoses.  The Certified Nurse Life Care Planner may recommend that the patient be evaluated by additional provider specialties to more accurately assess the patient’s needs. An individualized, comprehensive plan of action is developed and associated costs of care, services, and goods are calculated. Following completion of the Life Care Plan, the life care planner will evaluate the effectiveness of the plan for optimal outcomes.  In-person evaluation however, is not always possible if the plan is used solely for the purposes of reserve setting or settlement. The plan should be reviewed and updated every six months.

The average time required to complete a thorough Life Care Plan varies depending on the complexity and number of medical issues and the expedience of data collection. From the time of referral to its completion, the Life Care Plan may require anywhere from 2 to 4 months and involve 30 to 50+ hours of intensive development. Due to the time intensity of the plan development, it is therefore crucial that the referral be made as soon as possible to the Certified Nurse Life Care Planner.

The Life Care Plan is more than a “snapshot” of medical care and associated costs.  It is more than a mere cost-projection of care.  Rather, the Life Care Plan is an individualized, comprehensive, and thorough analysis of the patient’s needs over his/her remaining lifespan, specific to the medical condition.  The Life Care Plan is an invaluable tool for claims professionals, attorneys, patients, families, and providers to ensure that the patient obtains and maintains the highest level of functionality and quality of life all the while utilizing the allocated resources identified and outlined in the individualized plan.

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Ms Karfomenos and Mr. Hess are the principle partners of Hess, Karfomenos and Associates LLC, a firm whose business focus is Medical Case Management, Life Care Planning and Legal Nurse Consulting. Both Ms. Karfomenos and Mr. Hess sit on the Certification Board of the American Association of Nurse Life Care Planners and are nationally certified as Nurse Life Care Planners as well as Case Managers. The firm has extensive Worker’s Compensation experience in multiple state jurisdictions. Their offices are located physically in North Central Indiana. They may be contacted by visiting their website; www.hkamedlegal.com

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1American Association of Nurse Life Care Planners. (2000).  Setting the Standards In Life Care Planning.

Kopishke, L. (2002). Damages: An expert role for the life care planner. Journal of Legal Nurse Consulting, 13(3), 11-21.

Shoulder instability has been, until recently, an under-recognized source of shoulder pain in individuals involved in repetitive or prolonged overhead activities in the workplace.  Once thought to be unique to young (< 30 years of age) athletes involved in throwing, swimming, and racquet sports, shoulder instability is becoming a more frequently recognized factor in shoulder pain in industry.  Despite the increased incidence of individuals having shoulder pain as a result of instability, many of these patients continue to be inappropriately diagnosed and treated for injuries associated with instability rather than for the primary problem.

Accurate diagnosis of individuals with shoulder instability begins with recognition of laxity of the glenohumeral joint.  In the absence of a defined injury, the examiner must invoke clinical tests to detect the presence of laxity.  These techniques provoke the glenohumeral joint in anterior, posterior, and inferior directions.  The load and shift test, apprehension test, relocation test, and sulcus sign are often used for this purpose.  Atraumatic laxity is often present in more than one direction, and occasionally in both shoulders.  In this case, the instability is more specifically referred to as multi-directional instability (MDI).  Instability in one direction most often occurs in the anterior or posterior direction.

If these individuals have inherent laxity in their shoulders, why do they become symptomatic without a defined injury?  In the presence of prolonged or repeated movement of the arm that may also include lifting and holding of tools and other objects, the rotator cuff is required to make up for the lack of capsular stability.  The result is overuse of the rotator cuff, manifested in symptoms of increasing pain and inflammation of the rotator cuff and capsule.  It becomes evident when examining the individual with symptomatic instability that strength and coordination of movement of the shoulder is diminished.  The rotator cuff and biceps tendon are often inflamed and tender to palpation.

Patients identified with atraumatic instability have historically responded favorably to conservative care.  Interventions including anti-inflammatory medications, modalities for pain relief and anti-inflammatory purposes, activity modification, pain-free strengthening of the rotator cuff and scapular stabilizers, and functional integration activities are often cited mainstays of treatment.

Additionally, taping the involved shoulder to provide stability during the acute and sub-acute phases of rehabilitation will accelerate movement to the more aggressive strengthening that precedes returning to pain-free occupational demands.  Application of tape is performed every 48 to 72 hours during the acute and sub-acute phases, and the frequency of application is decreased as strength increase and functional stability increases over time.

Several interventions that continue to be widely used have questionable roles in the treatment of patients with atraumatic instability.  Strengthening with elastic bands, while convenient for their mobility and versatility, often serve to inflame tissues that are already irritable.  Second, stretching of the shoulder joint beyond comfortable physiological limits has no place in the treatment of patients with shoulder instability.  Finally, the use of non-specific strengthening modalities such as the UBE in the acute or sub-acute phases of rehab is inappropriate and possibly injurious.

Individuals with a traumatic onset of instability are less likely to have a favorable outcome with conservative intervention because of the increased prevalence of co-morbid conditions after injury.  Bony pathology to the glenoid (Bankart lesion) or humeral head (Hill-Sach’s lesion), tears to the glenoid labrum (ie SLAP lesions), or injuries to the capsule present changes to normal anatomy that may prevent the restoration of full function.  Surgical intervention to repair the abnormal anatomy and prevent subsequent episodes of instability may be the best intervention for these patients.  However, in the presence of normal anatomy and a well conceived rehabilitation program, many patients are still able to achieve full function after subluxation or dislocation.

In conclusion, accurate diagnosis of individuals with shoulder pain and functional limitations due to glenohumeral instability is an important first step to successful rehabilitation and return to work.  Patients with normal anatomy should be able to return to full function within a short period of time if appropriate intervention is offered.  Conservative management including protection from re-injury, taping, pain-free strengthening, and anti-inflammatory care are all associated with successful outcomes.  Early use of elastic bands, non-specific strengthening, or aggressive stretching have been noted to delay or prevent successful recovery.

Psychological and behavioral factors have long been understood to be important in assessing the suitability of patients for implantable devices.  In the management of chronic pain patients, spinal cord stimulators, morphine pumps and other devices have been used to alleviate unremitting pain, to increase functional ability, and to allow patients to discontinue or limit the chronic use of narcotic medication.  However, selecting appropriate patients for the use of such devices is an important process and needs to be better understood.

Behavioral and psychological factors clearly have been found relevant in excluding individuals. Although high success rates, often 60 to 80 percent, are reported in utilizing spinal cord stimulators for the relief of chronic back pain, these numbers usually represent the population of psychologically screened patients.  That is, this group represents the absolute best candidates for further medical intervention.  Thus, even among the candidates who have already been determined to be most suitable, only 60 to 80 percent benefit.  Thus, psychological evaluations for determining suitability of an implantable device such as spinal cord stimulator provide physicians assistance in determining and understanding the possible outcome prior to implanting the device itself.

The December 1996 issue of  Pain Forum focused on the issue of determining the psychological suitability of implantable devices.  Multiple factors have been found to be relevant in determining which individuals should be considered and which should not.  The exclusionary screening criteria identified by Nelson, et al, (1996) identifies the psychological-behavioral features that should be evaluated to assess a patient’s qualification.  While the screening criteria do not represent a perfect algorithm for determining psychological suitability for implantable devices, it represents the best model to identify those factors which are most relevant in determining which patients will benefit from this type of treatment.

The factors utilized to assess spinal cord stimulator patients include psychological and behavioral features. Often psychological testing and a review of medical records are necessary to fully understand factors related to a person’s response to pain.  Moreover, some patients make an attempt to present as highly desirable in an effort to influence the physician about the need for such an intervention. In addition, the presence of litigation either in the form of Worker’s Compensation or personal injury claims can also influence an individual’s desire for such devices.

An appropriate psychological examination will consider several factors. First, the psychological stability of the patient, or the role of psychosis or other serious mental illness, needs to be assessed.  A psychologically troubled individual can have a pain condition as real as that of anyone else. However, if a psychological illness, particularly a psychotic condition, is significant, it will increase the likelihood of highly focused somatic preoccupations. Consequently, success of a spinal cord stimulator in such a case is extremely remote. Moreover, actively suicidal or homicidal patients are poor candidates as their impulsiveness and emotional disturbance will obviously affect their thinking and ability to be stabilized by such an intervention.  In addition, patients with poorly treated major depression or other mood disturbances are also contraindicated. Often providing treatment to stabilize the mood disorder is necessary prior to proceeding with invasive medical care.  That is, moderate to severe depression should first be treated with medication and psychotherapy.

The presence of a somatization disorder or other somatoform pain disorder involving vague physical complaints that do not seem to correlate with organic findings is also considered one of the exclusionary criteria, especially with chronic pain patients.  This particular feature needs to be carefully examined as some amount of somatization is common and should be expected with the chronic pain population. Nevertheless, a propensity for extreme somatization in conjunction with other factors clearly will impact the response to spinal cord stimulator implantation. Even when pain complaints can be documented and correlated with obvious physical findings, an exaggerated pain response can be found and ultimately will influence the individual’s symptom perception. Obviously alcohol or drug dependency of either illegal or prescription drugs should be carefully monitored.  Excessive drug seeking behavior should first be controlled prior to further consideration. Compensation or litigation should generally be resolved or at least excluded as a possible motivating factor, particularly if a decision regarding the implantation of the spinal cord stimulator is dependent on this litigation.  In some cases, long term disability status or compensation issues are dependent on continued medical treatment.

Thus, a decision to proceed with spinal cord stimulator may be motivated not by a desire to manage pain more effectively but rather to maintain disability or compensation status.

A lack of appropriate social support has historically always been a critical variable in the success of chronic pain patients to better manage their condition.  It is advisable to have family members or close friends be committed to the process of evaluation and treatment with the spinal cord stimulator.  This aids not only in supporting the individual as he goes through the process but also in assisting with basic self-care activities that may be necessary. Finally, behavioral and cognitive deficits that compromise reasoning, judgment and memory also will interfere with the ability of the patient to adequately participate in the treatment process.  The individual whose cognitive functioning has either deteriorated or is compromised by various factors will be unable to provide sufficient information to accurately assess the degree to which the procedure is suitable and helpful. Thus, valid reporting of information, particularly levels of pain or position, cannot be expected from the patient who is cognitively compromised or emotionally overwhelmed.

Understanding the role of these factors and considering each of these factors as part of exclusionary criteria aids the physician, the patient and those providing assistance to the pain patient. Moreover, decisions related to further invasive treatment are not simply based on an effort to resolve pain but rather on behavioral factors that take into account the full context of the individual’s life and his response to medical treatment.

For some patients, an imaging exam can be challenging to complete because of claustrophobia, difficulty lying still or the need to be in a position that is painful due to injury. CDI offers sedation, monitored by professionally trained staff, to assist them through their exam and to make it as comfortable an experience as possible.

CDI believes in the practice of using sedation only when necessary for the good of the patient and when it is the one way to acquire the necessary images for their physician. In most cases, we are able to talk patients through their exam successfully without sedation, as a technologist remains in contact with the patient throughout the entire exam. Sometimes, our patients use music, mirrored glasses or eye masks provided to them for comfort. Our high-field short bore MRI also helps patients with claustrophobia, as the scanner is about one half the length of a traditional MRI, and most patients can see out outside of the scanner during their exam.

The need for sedation should be indicated to CDI when scheduling. Adult patients and children over the age of five need a note from their referring physician’s office ahead of time indicating there are concerns and that sedation may be needed. For children under the age of five, CDI will prescreen them to determine if sedation may be necessary. Sometimes, patients are not aware that the exam may be uncomfortable for them until they arrive. We can still offer them sedation as an option, however depending on timing we may need to reschedule the exam. Patients with special needs are evaluated by a CDI professional as to whether sedation will be appropriate.

CDI uses different methods of administering sedation to patients. For adults and children over the age of five, we use oral or IV sedation. The potency is the same and puts the patient into a state of sleepiness, however an IV sedation will take effect much faster and for some patients this is necessary. For children under the age of five, we use deep sedation that puts them into a deep sleep for the amount of time necessary to complete the imaging exam. Children under 18 months are given sedation in a liquid form. Children over 18 months and younger than five years, will receive deep sedation via IV or IM (intervascular or intermuscular).

Minimal preparation is required on the part of a patient for the use of sedation. Adults and children older than the age of two cannot eat or drink four hours prior to the exam, and children under the age of two – cannot eat or drink for three hours prior. CDI will administer sedation when the patient arrives for their exam, unless your office prefers to provide them with it directly. In these cases, we ask that the patient take the sedation one hour prior to their appointment. (Note: if a referring office provides the sedation, they are legally responsible for the patient’s reaction). Patients will need a driver in all cases.

After an exam, written instructions are provided. A light diet is recommended and they should be monitored four to six hours after the exam to make sure they do not fall asleep. Sedation does not have any major side effects.

For more information about sedation, please call CDI at 317-846-0717.

What do they need? 
Return-to-work (RTW) programs have increased significantly over the years (dating back almost 3 generations) as a means to bring ill or injured workers back to work – and keep them working.  To design, implement, and manage these programs two components are vital: Communication and Cooperation.

These programs allow workers to ease back into the workplace after an illness or injury, with reduced tasks, physical demands, or temporary assignment elsewhere in the company.  These assignments often last no more than three months and may have a flexible work schedule to allow for medical or rehabilitative treatments.

Companies are embracing RTW programs as a means to reduce absenteeism and to improve productivity.  As for the employees, these programs enable them to remain productive and earn a salary that is in excess of the disability payments they would receive, and importantly to help maintain the relationship between employer and employee, which can become disconnected or even strained while a worker is off the job due to disability.

There are challenges, however, to implementing a RTW program, which cannot be overlooked.  For instance, an experienced production worker who is filing documents is paid far more than this temporary assignment demands.  In a unionized workplace, temporary assignments have to be found for workers that do not cross union jurisdictions or interfere with work rules.  Union representatives need to be involved once a program is implemented.  For these reasons, communication and cooperation are vital to the success of RTW programs.  Because of the various departments involved, the job of managing the RTW programs often falls to a disability manager who can act as liaison between the company and the employee and be in contact with human resources, union representatives, and medical professionals.

Under RTW programs, assignments must be made on a case-by-case basis, depending upon the jobs available, an employee’s skills, and the nature of the illness or injury.  These programs have expanded with time with a focus that includes personal medical leaves as well as worker’s compensation related injuries.

The first step in devising a RTW program is to have support from top management.  One common question asked is, what are the benefits to RTW programs.  The answer lies in productivity analysis.  When a worker is off the job, there are costs incurred such as hiring and training a replacement or paying overtime to those who must do extra.  There is also a risk of a slipped production schedule if a replacement is not hired.  The second part of the answer is the salary issue.  Even if workers receive a reduced salary, they are usually paid more than the temporary tasks demand.  One solution is to create separate funding for all RTW assignments.