Monthly Archives: December 2017

Myofascial Pain Syndrome

 

In previous posts, we have discussed the challenges attendant to chronic pain, including how dentists often experience pain due to the unnatural and static positions they must maintain for extended periods of time (which place stress on their musculoskeletal and muscular systems).  This post will delve further into one such chronic pain condition, myofascial pain syndrome (MPS).

Overview

Myofascial pain syndrome is a chronic pain condition that affects the fascia (the connective tissues that spreads throughout the body).  Specifically, myofascial pain syndrome refers to the pain and inflammation of muscles and soft tissue.

With someone suffering from myofascial pain syndrome, pressure on sensitive points in muscles (trigger points) can cause pain in seemingly unrelated parts of their body (called referred pain). A single muscle or a muscle group may be involved. Typically, the pain affects one side of the body only, or one side significantly more than the other.  There may also be tenderness in areas not experiencing chronic pain.

Symptoms

While many people experience muscle pain or tension, those who suffer from myofascial pain syndrome experience persistent and worsening pain.  Additional symptoms include:

  • Deep and aching pain at specific trigger or tender points
  • Spasms
  • Tenderness
  • A knot or clump in a muscle area
  • Insomnia or sleep disturbances
  • Fatigue
  • Depression (which often co-occurs with MPS)

Causes

The pain and strain in a muscle caused by a trigger point associated with MPS can be attributed to numerous sources, including:

  • Injury or prior injury
  • Excessive strain or overuse of a muscle or muscle group
  • Unnatural movements
  • Repetitive motions
  • Poor sleep schedules and sleeping positions
  • Fatigue
  • Certain medical conditions (e.g. heart attack)
  • Lack of activity
  • Stress or anxiety

Diagnosis

Because there are no visual indicators such as redness or swelling associated with MPS, doctors typically will perform a physical exam that includes applying pressure to the painful area.  A doctor will feel for trigger points, which are divided into four types:

  • Active – an area of extreme tenderness associated with local or regional pain.
  • Latent – a dormant area that has the potential to act like a trigger point, and may be associated with numbness or restriction of movement.
  • Secondary – a highly irritable spot in a muscle that may become active due to a trigger point, or if there is overload on another muscle.
  • Satellite Myofascial Point – a highly irritable spot that becomes inactive because the muscle is in the region of another trigger point.

Although not as common, physicians may use Electromyography (EMG) to locate trigger points.  In addition, doctors will usually conduct additional tests and procedures to rule out other causes of the muscle pain (e.g., lab tests to rule out vitamin deficiency).

Treatments:

Myofascial pain is treated using a variety of techniques, often in conjunction, such as:

  • Medication (e.g. pain medications, medication for muscle spasm, antidepressants)
  • Trigger point injections (which typically contain a local anesthetic or saline, sometimes with corticosteroid)
  • Physical Therapy
  • Spray and stretch (a treatment where a cooling agent is sprayed on the sore muscle, followed by gentle stretching)
  • Massage Therapy
  • Acupuncture
  • Heat Therapy
  • Ultrasound
  • Posture and Stretching Training

Exercise, relaxation, and a healthy diet are also recommended techniques to help alleviate MPS pain.

These posts are for informative purposes only and should not be used as a substitute for consultation with and diagnosis by a medical professional. If you are experiencing any of the symptoms described below and have yet to consult with a doctor, do not use this resource to self-diagnose. Please contact your doctor immediately and schedule an appointment to be evaluated for your symptoms.

 

References:

Mayo Clinic, http://www.mayoclinic.org/
WebMD, http://www.webmd.com/
Cleveland Clinic, clevelandclinic.org
MedicineNet, https://www.medicinenet.com/script/main/hp.asp
Chowdhury, Nayeema, OMS IV and Leonard Be. Goldstein, DDS, PhD, Diagnosis and Management Of Myofascial Pain Syndrome, Practical Pain Management, last updated March 19, 2012, https://www.practicalpainmanagement.com/pain/myofascial/diagnosis-management-myofascial-pain-syndrome.

 

 

 

Post-Traumatic Stress Disorder (PTSD)

In prior posts, we’ve examined how the demands of practicing render physicians and dentists uniquely susceptible to anxiety and depression.  In this post, we are going to examine Post-Traumatic Stress Disorder (PTSD), another serious condition that often affects doctors—particularly doctors who work in high stress environments and who are repeatedly exposed to trauma on a daily basis.

What is PTSD?

PTSD is a mental health disorder caused by exposure to a shocking or dangerous event.  Although most people who experience a traumatic event experience an immediate emotional response when they are experiencing the event, those who develop PTSD continue to experience the symptoms of exposure to trauma after the event, and feel stressed or panicked even when there is no danger.  While some of the symptoms are similar to other anxiety disorders, PTSD is categorized as a particular type of anxiety that is caused by a specific external catalyst.  The onset of PTSD can occur within months after a traumatic event; however, in some cases symptoms may not appear until years later.

Prevalence

PTSD is associated with those who have been exposed to a traumatic event, such as combat, violence, serious accidents, or natural disasters.   Approximately seven to eight percent of the U.S. population will have PTSD at some point in their lives, with about eight million adults suffering from PTSD in any given year.[1]

PTSD can be caused by one event, or by prolonged exposure to trauma over time.  This exposure can be experienced directly, and through indirect exposure (i.e. witnessing the event).[2]

Many physicians, depending on their specialty, interact on a daily basis with traumatic situations from early on in their careers, and sometimes encounter events where patients die or are seriously harmed in a way that is very distressing to a practitioner.  Significantly, research has shown that 13 percent of medical residents meet the diagnostic criteria for PTSD.[3]  Emergency physicians, physicians practicing in remote or under-served areas, and physicians in training (i.e. residents) are particularly prone to developing PTSD.[4]

The prevalence of PTSD is also substantially elevated in individuals who are also suffering from chronic pain.  While only 3.5 % of the general population has a current PTSD diagnosis, one study found that 35% of a sample of chronic pain patients had PTSD.  Another study of patients with chronic back pain showed that 51% experienced significant PTSD symptoms.  In instances where the chronic pain is caused by the traumatic event (e.g. someone involved in a motorcycle accident or someone injured during the course of a violent crime), the pain can serve as a reminder of the event and worsen the PTSD.[5]

Symptoms

Physicians who suffer from PTSD may lose this ability to confidently react, which can impair their ability to safely practice.  Untreated, PTSD can also lead to a marked decline in quality of life, and potentially other mental health disorders or medical issues.  Some common symptoms of PTSD include:

Re-experiencing symptoms:

  • Flashbacks
  • Nightmares
  • Frightening thoughts
  • Physical reactions or emotional distress after exposure to reminders
  • Intrusive thoughts

Avoidance symptoms:

  • Staying away from places, events, or objects that are reminders to the traumatic experience
  • Avoiding thoughts or feelings related to the traumatic event

Arousal and reactivity symptoms:

  • Being easily startled
  • Feeling tense and “on edge”
  • Having difficulty sleeping
  • Being irritable or aggressive
  • Heightened startle reaction

Cognition and mood symptoms:

  • Trouble remembering key events of the traumatic event
  • Negative thoughts about the world, and oneself
  • Distorted feelings of guilt or blame
  • Loss of interest in previously enjoyed activities
  • Negative affect

Diagnosis

PTSD is typically diagnosed by a clinical psychiatrist or psychologist.  A diagnosis is made when an individual meets the criteria for exposure, and has at least one re-experiencing symptom, one avoidance symptom, two arousal and reactivity symptoms, and two cognition and mood symptoms.

Treatments

Some of treatments that are used, either alone or in conjunction, to treat PTSD include;

  • Cognitive Behavioral Therapy
  • Eye Movement Desensitization and Reprocessing (EMDR)
  • Prolonged Exposure Therapy
  • Antidepressants
  • Anti-anxiety medication
  • Medication for insomnia

The intensity and duration of PTSD symptoms varies.  Individuals who recognize any of the above-referenced symptoms in themselves should talk to a treatment provider right away.

These posts are for informative purposes only and should not be used as a substitute for consultation with and diagnosis by a medical professional. If you are experiencing any of the symptoms described above and have yet to consult with a doctor, do not use this resource to self-diagnose. Please contact your doctor immediately and schedule an appointment to be evaluated for your symptoms.

 

References:

Medscape, http://emedicine.medscape.com

National Institute of Mental Health, https://www.nimh.nih.gov

WebMD, http://www/webmd.com/

[1] U.S. Department of Veterans Affairs, PTSD: National Center for PTSD, How Common Is PTSD?, https://www.ptsd.va.gov/public/ptsd-overview/basics/how-common-is-ptsd.asp

[2] U.S. Department of Veterans Affairs, PTSD: National Center for PTSD, PTSD and DSM-5, https://www.ptsd.va.gov/professional/PTSD-overview/dsm5_criteria_ptsd.asp

[3] Myers, Michael, MD, PTSD in Physicians, Psych Congress Network, Sept. 16, 2015, https://www.psychcongress.com/blog/ptsd-physicians

[4] Lazarus, A., Traumatized by practice: PTSD in physicians, J Med. Pract. Manage., 2014 Sept-Oct; 30(2): 131-4.

[5] DeCarvalho, Lorie T., PhD, U.S. Department of Veterans Affairs, PTSD: National Center for PTSD, The Experience of Chronic Pain and PTSD: A Guide for Health Care Providers,  https://www.ptsd.va.gov/professional/co-occurring/chronic-pain-ptsd-providers.asp

How Long Does It Take to Get Benefits? – Part 2

In an ideal world, you’d receive a favorable decision and your first benefit check shortly after your policy’s elimination period is satisfied.  Unfortunately, even wholly legitimate claims get scrutinized, questioned, delayed, and in some cases, denied.  Below are a few common reasons benefit payments are delayed, particularly at the outset of a claim.

1. Improperly Completed/Partially Completed Forms

If your initial claim forms are missing information, unreadable, or incomplete, your insurer will likely issue additional forms for completion or use the missing information as an excuse to delay processing the claim.  This applies to both the forms that you are required to complete and sign and the forms the insurer gives you to give to your doctor to fill out, so it is important to follow up with your doctor and make sure that all of the necessary forms are completed and returned in a timely fashion.  If you do not carefully document your claim, and you do not promptly respond to requests for follow-up information, most insurers will delay making a claim decision until you provide them with the requested information.

2. Pending Requests for Information

At the outset of your claim, your insurer will require you to sign an authorization that allows them to request a wide range of information from a wide range of sources, including your doctors and employer.  Oftentimes, the insurer will request information from these other sources (without telling you) and then will delay making a decision on your claim if any of these requests remain pending.

This means that even if you provide the insurance company with everything they requested from you, there may be other information that the company is waiting that is holding up the claims decision.  Consequently, it’s important to ask the insurance company to find out if there are any pending requests, adn then follow up with your doctors, employers, etc. as needed to ensure that the information is provided.

It’s also important to keep tabs on the pending requests, to determine whether the scope of the insurer’s investigation is appropriate.  An experienced disability attorney can advise you on whether a particular request for information is warranted under the circumstances of your particular claim.

3. Failure to Schedule Medical Examinations/Interviews

When you file a disability claim, insurers will almost always require that you participate in a detailed interview and/or undergo an independent medical examination (IME).  While the stated point of these requests is to confirm or verify your disability, they can often be an attempt by your insurer to discredit your own doctor or medical records and generate fodder to deny your claim.  Depending on the nature of your condition, your insurer might also request other types of interviews or exams—such as a functional capacity evaluation (FCE) or neuropsychological evaluation.

Some claimants (mistakenly) believe that if they keep putting off these exams, then they’ll be able to avoid the exams.  However, most disability policies contain a provision that expressly requires the policyholder to submit to exams, and states that failure to do so is grounds for denying a claim or terminating benefits.  So if you put off these exams, it’s only going to delay the company’s claim decision, and possibly result in a claim denial.  However, keep in mind that going into a medical examination, IME, or interview unprepared can be just as bad for your claim, so it’s very important to prepare beforehand.  Once again, an experienced disability attorney can advise you regarding the proper scope of an interview or IME, and can also be present for the interview or IME, if desired.

 

How Long Does It Take to Get Benefits? – Part 1

You’ve made the difficult decision to give up practicing and file a claim.  You’re not working and you need to collect the disability benefits you’ve likely paid years of high premiums for.  So how long will you have to wait until your first benefit check arrives?

Unfortunately, the answer is not clear cut—it depends on the terms of your policy, your insurance company, the assigned benefits analyst, and the complexity of your claim, among other things.

Filing a Claim

Your policy should outline the requirements for filing a claim.  Typically, you must give notice of your claim to your insurer within a certain time frame.  If you miss this important deadline, the insurance company will typically claim that you have prejudiced its ability to investigate your claim, and use this as an excuse to delay making a decision on your claim.  Significantly, if you don’t provide timely notice, it can also foreclose your ability to collect benefits (depending on the circumstances, and the reason for the delay).

Once you file your claim with your insurer, they will then send claim forms to be completed by you and your physician.  Your policy should include a deadline for when your insurer must provide you with these forms (e.g. 15 days).  If they don’t provide you with forms within this time frame, most policies allow you to submit a written statement documenting your proof of loss, in lieu of the forms.   Again, there is a deadline to return these forms and failing to do so gives your insurer an excuse to prolong the decision-making process.

Elimination and Accumulation Periods

Your policy will also contain details about your elimination period.  This is the period of time that must pass between your disability date and eligibility for payment on a claim.  Generally, you must be disabled (as defined in your policy) and not working in your occupation during this time period.

Depending on the terms of your policy, this period does not necessarily have to be consecutive, but it does need to occur within the accumulation period also set out in your policy (for example, your policy might require a 90 day elimination period that must be met within a 7 month accumulation period).  You will not be eligible for payment until the elimination period has been fulfilled.  Typically, insurers won’t provide you with a claim decision until after this date has passed.

It is important to be aware of your elimination period, so that you can plan accordingly (and are not expecting a benefit payment to arrive right way when you are budgeting to meet living expenses, or debts like student loans).   Also, it’s important to keep in mind that receiving a benefit payment immediately following the elimination period is the ideal scenario.  In many claims, it takes much longer for a benefit to be issued.  In our next post, we will address some of the most common reasons benefit payments are delayed.