Monday, June 25, 2001

This Week's Topic: The Unsolvable Dilemma

Question: "As an attorney, I think that there are some valid cases for which there can be no effective resolution. Do you agree?"

Dr. Adams replies: If I understand the question, I assume we are talking about patients that have reached MMI, have residual limitations and for which there is no acceptable (to the patient) ending.  

I feel this is quite true, and it exists in several types of cases:

a. Where the residual limitations far out-shadow the patient’s residual education and skills

b. Where the patient is at MMI, yet subjective complaints are increasing as in the case of valid RSD

c. Where the patient’s residual pain is so great there is no true quality of life, and/or

d. Where the patient cannot financially compensate for the ind ebtedness that has accumulated during the course of care.  

For some patients, their pre-injury income was so low that receiving workers’ compensation is not as significant of a financial loss as it is for someone with an executive’s salary attempting to exist on that same workers’ compensation amount. Debt rapidly mounts, credit is ruined, arguments with spouse over finances ensue, children’s emotional and financial needs are not met, and the problem rapidly escalates.  

The simple fact is that we attempt to manage cases by obtaining medical and administrative closure based upon PPD ratings. In reality, these ratings are almost totally unrelated to the socioeconomic impact of the injury.

What we feel is obstructionistic, when a patient does not wish to settle, may, indeed, be their own sense of futility and fear of their future.

Monday, June 18, 2001.

This Week's Topic: Post-Surgical Concerns  

Question: "As a surgeon, even when I see successful surgeries, I seem to run into problems in which the injured patient appears no to progress. Their complaints are the same as before surgery. Thoughts?"  

Dr. Adams replies: Likely the problems the patient is encountering were set in motion prior to surgery and sometimes prior to injury. We have discussed before the mounting financial concerns, lack of preparedness for the future, marital strife and complicating general medical conditions (diabetes, hypertension, etc) that pre-date the surgery and often the injury itself.  

While surgery can successfully manage the mechanical/physical problem, it may be a successful procedure on a patient with an unsuccessful life. The patient has no impetus for recovery, as we would define it. If you define surgery as ameliorating most of the tissue damage, then surgery has an objective goal.  

If, however, you define recovery as the patient's re-entering the workforce and productivity, then there may be numerous complications that are chiefly psychosocial. For many patients, they simply do not know "what am I to do next with life." They have no contingency/backup plan and often no resources, financial, family or educational.  

Much can be gained by determining that for which the patient hopes to mobilize. Even two years after surgery, in response to the question "if you do not go back to your old job, what will you do?"  The most common reply I receive is "I have no idea."  

To complete our role, we must help them find that direction.

June 11, 2001 

This Week's Topic: Denial & The Goalless Worker 

Question: “You had mentioned in a recent lecture that the two enemies of the injured worker were being goalless and living in denial. I understand the lack of goals, but what did you mean by denial? 

Dr. Adams replies: Denial is our most primitive defense. It permits us to smoke, drink, speed, gamble, etc. All risk behavior is based upon denial of the probable negative outcome. 

For many injured workers, there has been denial of risks inherent in their work. There has been denial of the importance of the education that they terminated too early in life. There is denial of the financial indebtedness in which they have maintained themselves. There is denial of past neglect or transgressions in their marriage, a marriage upon which they may now be dependent. 

There is also denial that they can exist in the workforce without career goals and objectives. In order, to have a full, self-supporting career for one’s family and oneself, there must be vocational direction. Unfortunately, many workers exist from “pay check to pay check.” There is no risk planning. 

Additionally, individuals live in denial of potential physical risk and injury. Then, when injured, they attempt to live in denial of the consequences, hoping one more procedure will resolve their failed back.  

After an injury, the worker is confronted with the consequences of his/her past denial. Most often, the injured worker does not wish to address these consequences. 

June 4, 2001. 

This Week's Topic: Pain and Sleep Architecture 

Question: I am a nurse case manager and some of my cases involve chronic pain that I believe to be actually lack of sleep. Is there a relationship between pain perception and sleep? 

Dr. Adams replies: There is actually a four way relationship:

a.         As you know pain can disrupt sleep onset, duration and architecture (structure of the sleep)

b.         Narcotic pain medication can change sleep architecture such that sleep is not restful/restorative.

c.         One of the cardinal signs of depression is a change in sleep architecture, most commonly early morning awakening and/or periods of seeking excessive sleep.

d.         Deprived of sleep, the experience of pain becomes less bearable and more incapacitating. 

There are, therefore, several things you should do:

a.         Order a psychological evaluation to determine if the patient is depressed and the source(s) of the depression

b.         Be certain that the examining psychologist is aware of the medication regimen, including pharmacy records

c.         Ask the examining psychologist to obtain a sleep history from the patient including day time naps or change in sleep patterns and habits

d.         Determine what assistance the patient needs with sleep (medication changes, relaxation therapies, sleep structure or even sleep studies) 

The pain-medication-sleep-depression relationship may be the key element in why the patient is either not recovering or not adapting to their pain. It often also explain why the pain complaints "seem" disproportionate to the clinical findings. 

May 27, 2001

This Week's Topic: Dubious Sexual Problems 

Question: "Okay, I have one for you. A surgeon started an injured worker on antidepressants and now she complains that she has sexual problems. I think that is unlikely…what is your opinion?"

Dr. Adams replies: All antidepressants are not alike, especially when it comes to sexual side effects.

Problems with sexual desire, interest in sex, and ability to achieve orgasm have been reported frequently since a new crop of antidepressants began hitting the market in recent years. Both men and women have reported sexual side effects from these medications, but some studies have shown the issue may be bigger than anyone realizes because doctors often don't ask about sexual problems.

At the same time, patients are often reluctant and uncomfortable to volunteer such information.

A study was recently reported that examined more than 6,200 men and women in more than 1,000 doctors' offices who were taking Wellbutrin, Effexor, Remeron, Serzone, Celexa, Prozac, Paxil, or Zoloft for depression.

These medications constitute every new antidepressant marketed since 1988. Four of them, including Prozac, belong to the class of antidepressants known as selective serotonin reuptake inhibitors, or SSRIs, which are currently the most popular choice for treating depression.

The antidepressants that caused the least sexual dysfunction were Serzone (28%) the slow-release Wellbutrin SR (24%), and the immediate-release Wellbutrin (22%) -- all of which are non-SSRIs.

Among the SSRIs, all were associated with about a 40% risk of sexual problems. When the researchers included just the patients for whom the only possible cause of sexual dysfunction was the antidepressant, Wellbutrin was associated with a 7% risk of sexual side effects, compared with 23-30% for the other drugs.

The researchers teased out some factors from the study group -- the people with the following characteristics seemed to be at higher risk for sexual dysfunction:

• Those over age 50
• Those that were married
• Those having less than a college education
• Those lacking full-time employment
• Those who smoked 6-20 cigarettes a day
• Those taking high doses of any antidepressant
• Those taking any other medication in addition to an antidepressant
• Those having a history of sexual problems while on an antidepressant in the past
• Those having a history of no or little sexual enjoyment or a belief that sex is not important

Being on an antidepressant for a long time did not increase the risk for sexual problems.

37% had sexual side effects.  

Sexual side effects can be minimized or avoided by lowering the dose of most SSRIs.

Even though Wellbutrin was associated with a low rate of sexual side effects, it isn't the best drug for certain types of depression, specifically when anxiety is also involved. Wellbutrin is for the lethargic depressed patient, not the patient who is having panic attacks or obsessing over things. Saying everybody has to switch to Wellbutrin or Serzone is not a sound opinion. For the anxious depressive, I really think there is nothing yet to top the SSRIs, and that is why lowering the dose, even several times, is the better option.

May 20, 2001

This Week's Topic: This Week's Topic: Depression and Healing

Question: "I read an interesting article recently on how depression slows the healing process. Are you familiar with this?" 

Dr. Adams replies: Depression is a physical condition. Often it is triggered by environmental events (e.g. trauma, loss, etc). There is likely a genetic component since mood disorders can occur among first degree relatives. 

Depression is expressed in the brain by a depletion of specific neurotransmitters and, therefore, compromised communication between brain cells.  

It is true that there are articles in the recent wound literature that indicate that depressed individuals tend to heal more slowly.  

Perhaps more importantly, the psychological components of depression include helplessness and hopelessness.  

Depressed patients are less likely to extend full effort in physical therapy. They are less likely to attempt weight control. They are less likely to take their medications as prescribed. 

And they are quite often unaware of, or unwilling to admit, their depression.  

Thus, when healing is impeded by depression, it will be you who detects its existence and makes the appropriate decisions for intervention.  

Always remember that depression impacts perceptions of pain, ability to sleep, regulation of appetite, sexual drive, memory, concentration, decision-making and enthusiasm. Determining its existence among patients with physical complaints can be crucial to implementing a course of intervention.

May 13, 2001

This Week's Topic: The Injured Worker Community

Question: "I am a nurse case manager, and I have visited rural Georgia communities where injured workers congregate at local restaurants and share, if not boast, about their role in workers’ compensation. What do you make of this? Is this not irrational?"

Dr. Adams replies: The phenomenon is not unusual and not unexpected.  

In rural areas, there is a higher proportion of seasonal labor workers. These individuals share vocations, lifestyles, and values in common. They are also often of similar socio-economic status. When one purchases a new vehicle or improves his/her residence, everyone else is aware. 

In such a setting, when one person receiving medication, disability income or a cash settlement, it is often known by most of the community. It can become a “prestigious” role since it obviates the need for daily employment, provides consistent income, and may result in a lump sum financial conclusion enabling an elevation within that small community. 

It then becomes part of the daily lives of all as it is discussed and becomes valued. 

This is extremely important to have evaluated since it may alter the goals and expectancies you have of the patient. It is often referred to as the “psychological milieu of recovery.”  

This Week's Topic: Depression and Heart Disease

Question: "I have an injured worker who has now had a heart attack. He says that he had the heard attack because he was depressed after his injury. He blames us for not having provided him with psychological care for his depression. I believe there is nothing to support this contention, and it is absurd. Your opinion?"

Dr. Adams replies: The relationship between depression and heart disease (and stroke) is a reciprocal one. Those who are depressed are more likely to have a stroke or myocardial infarction, and in turn, depression is a common outcome to both of these physical events. Anti-depressant medication and psychotherapy can serve as a form of prevention, but choice in the incorrect medication may actually potentiate both heart disease and stroke.

Although routine screening for depression is controversial, the incidence and effects of depression among heart patients and stroke survivors are persuasive arguments for screening among these subgroups. 

^{However, depression appears to be the more enduring predictor of mortality. Only recently has the magnitude of the interaction between heart disease and depression been appreciated. The relationship between depression and heart disease is reciprocal, with each condition contributing excess, potentially avoidable, morbidity and mortality to the other.} 

^{The majority of studies in patient populations with cardiovascular disease. showed a significant relationship between depression and mortality, but inferences were confounded by treatment and the effects of associated behaviors. More recent epidemiologic studies demonstrate that even when the effects of smoking are controlled, depression remains a significant independent predictor of mortality among heart patients and stroke survivors.}

^{The acute disability following myocardial infarction is associated with a substantial incidence of major depression. And the loss of social roles and independence due to cardiomyopathy and arrhythmia may also cause depression.} 

^{Similarly, apathy, lack of physical activity, inability to stop smoking, alcohol abuse, and hypercortisolemia associated with depression also predispose the individual to heart disease. Depression following heart attack or stroke interferes with physical rehabilitation, return to sexual function, and adherence to the therapeutic regimen (eg, antiarrhythmia medications and anticoagulants).} 

It is recommended that antidepressants that do not promote arrhythmias, lower blood pressure, or interfere with anticoagulant therapy be used for treatment. 

The effects of new antidepressants ("SSRI's" such as Prozac, Paxil, etc) on cortisol, catecholamines, heart rate variability, platelet aggregation, and arteriosclerosing lipids are only now being appreciated. The choice of antidepressants was formerly determined by avoidance of cardiovascular side effects. In contrast, newer generations of antidepressants may also offer protective effects for both the heart and brain. 

For optimum effects, antidepressant medication should be combined with lifestyle counseling and psychotherapy for both the depressed patient and his or her spouse or partner. Both behavioral and mental health interventions will be required to fully reduce the excess morbidity and mortality of heart disease and stroke complicated by depression.

^{Research indicates that cardiovascular mortality has been linked to a variety of mental disorders and behavioral and psychological attributes, including sedentary lifestyle, hostility, cynicism, personality type (time urgency), smoking, alcohol abuse, and bereavement.} 

If you would like to know how this occurs:

^{Several articles describe diverse mechanisms by which depression's physiologic effects promote stroke and heart attack. Depression increases the cardiotoxic neurohumoral effects of emotional stress. Elevated cortisol described in major depression amplifies the cardiotoxic effects of catecholamines and accelerates arteriosclerosis. Depression and cardiac arrhythmias are linked through the autonomic nervous system seen in the measurement of heart rate variability. Some depressed persons exhibit decreased heart rate variability that has been related to arrhythmia vulnerability.} 

^{(In a comparison of indices of platelet activation (platelet factor 4 and beta-thromboglobulin) between depressed and nondepressed elderly subjects, the serotonin transporter protein and the serotonin transporter-linked promoter region are shared by platelets and brain neurons so that both central and peripheral effects would be expected. Platelet activation was significantly elevated among the depressed group both in the presence and absence of ischemic heart disease. These results suggest a common pathway to ischemic events both in the brain and the heart though which depression, via physiologic rather than behavioral effects, increases mortality.)}

April 30, 2001 

This Week's Topic: "Explosive Patients" 

Question: “In my surgical practice, I see many workers’ comp patients. Some of them are extremely inappreciative if not threatening. Almost anything seems to provoke them. It is very unpleasant and wondered if there is a common cause and realistic approach?" 

Dr. Adams Replies: "Yes, there is both a common cause and an effective approach. On my website (psychological.com) this week, I discuss Dialectical Behavior Therapy (DBT) which has been shown effective with patients with borderline personality disorder, patients with bulimia, and patients with widely swinging and often highly inappropriate moods. 

In brief, whether genetic or learned, many injured workers lack the capacity for self-soothing (e.g. “calming down”) when confused, upset or disappointed. 

Unable to calm, they either attempt to curb the feelings with drugs or alcohol, verbally or physically attack a convenient target, and/or in some cases harm themselves. 

Since office visits are brief, and certainly not a place for psychotherapy, there are still approaches used in psychotherapy that you can implement:

a.    “Let’s step back and look at this situation we are in with your back (neck, shoulder, knee, etc)” allowing them a perceived distance from the immediacy of the threat.

b.    Distract them by bringing up important, but not necessarily provocative topics such as “which of your medications (therapies, doctors, etc) are most effective for you?

c.    Asking them “what would be of assistance to you this moment…what would help you relax”, reminding them, thereby that they need (can learn) to self-soothe (something they inherent lack without assistance)

d.    Assisting them to not dichotomize things into good/evil…”this is very unpleasant, but it is manageable if you will work with me.” 

Globally, the problem is that anything that they emotionally experience triggers their need for immediacy of relief. Aggression towards others or even themselves provides (learned) immediate relief and then drastic consequences.  

April 23, 2001

This Week's Topic: "Interfering with Recovery" 

Question: "(paraphrased) As a nurse case manager, when I encourage an injured worker to be more active, the insurer will sometimes video tape the patient, show the tape to the primary doctor, and then have the doctor release the patient and suspend benefits. So how can you say that we should encourage the patient to be more active?" 

Dr. Adams Replies: “Two things:

a.    It is imperative that all injured workers be as active as their physical condition permits. As you know most do a great deal less than that of which they are capable. Many can walk, garden, clean the house, and engage in numerous other activities within their objective limitations. They fall into a pattern, however, of doing little more than watching TV, gaining weight, looking forward to their next pill and/or drinking. They become sedentary, obese, irritable and acclimated to living a life of restriction and self-imposed disability. The need for them to be active is unquestionable.

b.    However, as you accurately point out, if you are able to mobilize them, then other forces may use this healthy behavior in an unhealthy fashion and punish the patient…and you…for having mobilized. 

This can be readily resolved. 

1.    You need a written treatment plan that describes the activities that you are encouraging. You need a copy sent to each treating doctor that assures that the doctor is aware of the plan, that the plan falls within objective limitations, and that the plan is endorsed by the doctor as part of rehabilitation.

2.    You need a copy of this plan in the insurer/employer’s file on the patient and direct dialogue with the claims adjuster (or manager) that this is the plan upon which all have agreed (patient, doctors, and you) and that if the patient is observed in these and related activities, it is no different than physical therapies. The activities are part of the recovery process. 

April 16, 2001

This Week's Topic: "A Night in the Life"

Question: "It seems to me that after injury, these once productive people do little for themselves except sit around, get fat, watch TV and complain. That may be overly harsh, but I see this all the time and then am expected to fix their back." 

Dr. Adams Replies: “It is contrast to see once productive individuals suddenly spend days in nonproductive pursuits, becoming increasingly deconditioned, and doing little to mobilize. 

However, there are factors you are not considering, perhaps one of the most significant of which is lack of sleep. You would think with all the “available” time that they would get too much sleep.  

In reality, most sleep very poorly. While some of this may be attributable to being unable to find a comfortable position and/or moving during sleep, triggering pain and sudden awakening, much of their sleep problem arises from their sleep hygiene. 

They lay in bed watching TV, often day and night, but even more problematic is that when they turn off the light, they are “tired of all this pain” but they are not truly physically fatigued. 

Further, when the lights go out, the thoughts begin…what is going to become of them…how can they financially survive…how do they meet the needs of family…what skills do they have enabling future productivity. This is further complicated by any alcohol or caffeine consumed. 

You may find that accurately diagnosing their sleep problem and its impact will go a long way to a patient who has the energy to assume more responsibility for their daylight hours. 

Once the sleep disorder is accurately diagnosed, there are numerous medications that may be of assistance, but recent studies suggest that these fail to address the core issue, the negative thoughts and behaviors. For those, it may be most effective for the patient to enter a short treatment regimen of cognitive-behavioral psychotherapy."

April 9, 2001. 

“Social Isolation and Obsessive Preoccupation"

Question: "Obviously, I can see an economic benefit for an injured worker returning to full or alternate duty, but is there truly a rehabilitation benefit to them doing so?"

Dr. Adams Replies: "Unquestionably. When someone is out of work, has a physical complaint for which recovery is slow and/or for which recovery will never be complete, there is excessive time for “obsessive rumination and bodily checking.”

Checking behavior is an obsessive-compulsive trend that many, who are injured, develop rapidly. They begin to examine their daily and varying somatic (bodily) complaints, trying to determine how they are today versus how they were the day before…and how they will be tomorrow. They ruminate regarding that of which they were once capable. They process their, sometimes rapid, economic decline. They become irritable with their family. They are relegated to household chores which are either demeaning and/or which hold little interest for them.

Whether returning to full or alternate/light duty, the individual has a daily agenda that differs from that of a continual focus upon their bodily complaints.

Additionally, while at home, and their only social contact being other patients they meet in doctors’ offices, their social capacity decreases. They feel estranged seeing others departing to, and returning from, work. Weekends, holidays and vacations take on a vacuous quality.

Within the limits of the objective limitations, the patient’s best interests are always served by having social contact and some sense of occupational productivity.

Do not forget that we punish prisoners by isolating them. Perhaps nothing is more punitive to the injured worker than their being isolated as a result of an injury."

April 2, 2001

This Week's Topic: "...and Ghosts"

Question: "You perform a large number of pre-surgical examinations. We were wondering what exactly are you looking for when you see these patients." 

Dr. Adams Replies: "Four things:
a.    Understanding
b.    Preparedness
c.    Expectancy and
d.    Ghosts 

A large number of pre-surgical (especially fusion candidates) very poorly understand what the procedure involves, and they need to discuss this with their surgeon but for a variety of reasons, they have not done so. Surgery is looming, and they have not retained what they were told about the surgery. 

In a related fashion, they are unprepared for the discomfort and limitations, of the timeframe for physical therapy and what they can do to increase their maximally benefiting (from diskectomy or laminectomy). They often believe that “old discs will be replaced by new ones” (sic). 

Even in the case of morphine pumps or stimulators, there can be the expectancy that this procedure will restore them to pre-injury health and that all of their orthopedic and neurologic problems will cease to exist. 

But the Ghosts are the greatest concern. They do not tell their surgeon of their addictive history, of their having been abused, of their arrest record, or their educational lackings, or their skill limitations and of their mounting debt, dysfunctional family and even their unrelated but perhaps substantial health problems.