Saying No to DrugsGabriel Williams MD

Outline

Address key concepts in interaction, decision making and documentation:

HistoryPhysicalWays to document this informationDocumenting decision making

History

Basics of Pain history: ◦where, when, how

Equipment: current and prior use, do they have it and is it functional?

Chronos

Red Flags

Weakness, numbness, changes in bowel/bladder, unintentional weight loss, history of cancer, progress decrease in function, fever, systemic symptoms.

Functional History

Work history: ask about how many years, what and workman’s comp.

Task specific: anything they cannot do?Home exercise program: If you suspect

they are misrepresenting functional status, ask when was last time they did push ups, dips, back arms, burpies, lunges, water bags…

Sports: last did…ActivitiesFall HistoryReports prepared by custodyAsking custody officers of patient

activities.

Functional History

Other Important History

Sleep History◦Insomnia◦Daytime Somnulence

Substance Abuse History◦Prescription, ivdu, alcohol◦Duration

Family History of alcohol, drug or sexual abuse.Psychiatric Disorders

◦Severity◦Date last treated

Treatment Historyand Compliance

PTHEP: provided written, verbal

HEPProcedures / Operations

Pertinent ROS

OSA not on CPAPCOPDIntolerance to OpioidsMedical noncompliance

Examination

Observation – starts from the moment you can see patient

CaneGlassesAttire - cervical collar,

additional bracing/wraps/built up

Muscle Bulk. Ask for them to remove their shirts.

Behavioral Cues, Evasive History

When patients ask you to repeat questions the increased time allow them to think of an answer.

If patient is not answering your question: Rephrase the question to a simple yes or no or body part answer and ask it again. Repeat asking the same question until answered. Remark how many times you needed to ask the question to get a simple answer. Request they are more forthcoming next time.

Behavioral cues, Evasive History

Long pause together with left gaze often imply a creative answer, and an intense adversarial gaze can stand for a premeditated nonfactual answer.

Disclaimers of “to tell you the truth,” or “honestly” should either negate the sentence or consider adding in a negative to make it factually correct.

Count how many times they mention/ask for a specific medication or pain medications.

Waddell‘s Superficial TendernessNot related to a particular skeletal or neuromuscular structure; may be either superficial or nonanatomic:Superficial - The skin in the lumbar region is tender to light pinch over a wide area not associated with the distribution of a posterior primary ramus.Nonanatornic - Deep tenderness, which is not localized to one structure, is felt over a wide area and often extends to the thoracic spine, sacrum, or pelvis.

Waddell’s Simulation

Simulation tests – These tests give the patient the impression that a particular examination is being carried out when in fact it is not.Axial loading - Low back pain is reported when the examiner presses down on the top of the patient‘s head; neck pain is common and should not be considered indicative of a nonorganic sign.Rotation - Back pain is reported when the shoulders and pelvis are passively rotated in the same plane as the patient stands relaxed with the feet together; in the presence of root irritation, leg pain may be produced and should not be considered indicative of a nonorganic sign.

Waddell’s DistractionDistraction tests A positive physical finding is demonstrated in the routine manner, and this finding is then checked while the patient's attention is distracted; a nonorganic component may be present if the finding disappears when the patient is distracted.Straight leg raising The examiner lifts the patient's foot as when testing the plantar reflex in the sitting position; a nonorganic component may be present if the leg is lifted higher than when tested in the supine position.

Waddell’s RegionalizationDysfunction involving a widespread region of

body parts in a manner that cannot be explained based on anatomy; care must be taken to distinguish from multiple nerve root involvement.

Motor - Demonstrated on testing by a partial cogwheel "giving way" of many muscle groups that cannot be explained on a localized neurologic basis.

Sensory - Include diminished sensation to light touch, pinprick or other neurologic tests fitting a “stocking" rather than a dermatomal pattern.

Waddell’s Overreaction

May take the form of disproportionate verbalization, facial expression, muscle tension and tremor, collapsing, or sweating; judgments should be made with caution, minimizing the examiner's own emotional reaction.

Waddell’s Signs

3 or more positive tests count, 2 or less do not.

Article relates to use of “up-to-date roentgenograms” for diagnosis

Predicted correlation results of chemonucleolysis for prolapsed intervertebral disc: less than 3 signs 74% success, equal or more than 3 signs with 11% success

Waddell’s Signs

Overreaction has been most contested in the literature since “there are considerable cultural variations, and it is very easy to introduce observer bias.”

False positive nonorganic signs do exist, population identified most at risk is elderly who cannot stand.

Waddell’s Signs

Reliability 86% for two examiners.Age, gender, occupation or compensation

did not influence results of nonorganic signs.Correlations with hypochondriasis,

depression, and hysteria.Conflicting evidence regarding nonorganic

signs and return to work.Presence of Waddell’s signs should not

preclude work up.

Exam

Direct versus indirect examinationSpecific ones that I look at: ADF direct

versus staying on heels versus gaitSeated Hip Flexion versus Supine assisted

hip flexionSpine ROM during direct and indirect

examMMT: with suboptimal effort, always ask:

“are you doing the best you can?”

The inverted ankles sign:

Should I make a diagnosis?

Not as simple as naming the painful area...

May want to defer a diagnosis because it does not make sense - discrepancies

misrepresentation of functional status - history, noted during exam

Case

Patient with history of insomnia, claims can only sleep 20 minutes at a time, for a maximum of 2 hours total per 24 hours. Has had this sleep problem for 14 months since morphine was discontinued.

On exam, is alert, talking in complete sentences. Thought process goal oriented.

What do we want to ask next? What should we review?

Review medications, ask about recent drug abuse, manic episodes, bipolar disorder, psychiatric history. If all ROS is negative, what next?

Case

Case

Since it is impossible to have such a profound sleep disorder and objective findings on exam lacking drowsiness and/or delirium, documentation should include noncredible historian and misrepresentation of functional status.

Documentation of Decision Making

Documentation of Decision Making

The risks of constipation, dizziness, nausea, somnulence, respiratory depression, sweating, vomiting, pruritis, urinary retention, overdose, headache, dry mouth, hyperalgesia, fatigue, decreased neuroendocrine axis, triggering addictive behavior outweigh possible benefits of starting/continuing/increasing … given that

there are no functional goalsthere is limited evidence of significant

impairmentpatient has history of abuse or significant

risk factors for drug abuseHistory of opioid intoleranceHistory of noncomplianceHistory of poor relief with opioids

Current treatment for pain is … and plans for pain management include …

Diagnostic studies,Health care applianceAccommodationActivity modification / work restrictionProcedure

Physical therapyModalitiesStress managementHEP management including

revision/restriction or advancementPatient Education

Other Difficult Encounters

Psychiatric Patient◦Axis I◦Axis II

Overtly Manipulative Patient – “In order to be my doctor, you have to prove yourself.”

Angry patient – ◦Acknowledge frustration and redirect ◦Rephrase, Repeat, Remark and Request◦May have to end encounter

Any Questions?

References:

Waddell G, McCulloch JA, Kummel E, Venner RM. Nonorganic physical signs in low-back pain. Spine. 1980;5:117-125.

Scalzitti DA. Screening for psychological factors in patients with low back problems: Waddell’s nonorganic signs. Physical Therapy. 1997;77:306-312.