Tag Archives: chronic pain

Spine-Related Musculoskeletal Conditions – Part 5 – Disc Bulge, Disc Herniation, and Disc Protrusion

Our posts in this series have been reviewing spine-related musculoskeletal conditions that are frequently seen in dentists and surgeons.  In this post, we will be looking at disc bulge, disc herniation, and disc protrusion.

Disc Bulge, Disc Herniation, and Disc Protrusion

Definitions:

  • Disc Bulge: Protrusion of a spinal disc outside the vertebral body that has not fully ruptured through the disc membrane, known as the annulus.
  • Disc Herniation: Protrusion of a spinal disc outside the vertebral body that has ruptured through the annulus, exposing a portion of the nucleus – the gel-like center of the disc.
  • Disc Protrusion: A general term to describe any type of disc bulge or herniation, in which a portion of the disc protrudes beyond the vertebral body.

Overview: A number of terms are used to describe spinal disc pathology and the associated symptoms.  To complicate matters further, there is not a clear consensus among medical professionals about the precise meaning of each term.

There are thirty-three vertebrae in the vertebral column of the human spine, twenty-four of which articulate and move.  Between each of the vertebrae in the three articulating sections of the spine – the cervical, thoracic, and lumbar spine – there is an intervertebral disc.  Each disc, composed of soft jelly-like center (nucleus) surrounded by a capsule of connective tissue (annulus), provides shock absorption and flexibility within the spine. When the protrusion puts pressure on the spinal cord or a nerve root, it can lead to a wide range of symptoms.

Symptoms: Symptoms will vary based on the location of the disc:

  • Lumbar: Pain radiating down the leg (sciatica) is the most common symptom associated with a lumbar disc herniation. Weakness in the foot and difficulty when raising the big toe (foot drop) and numbness/pain on the top of the foot are also prevalent.
  • Cervical: Pain, weakness, numbness, and tingling in the shoulder, arm, or hand depending on the location of the herniated disc.

Causes: Disc bulges are often the result of the normal process of aging, and by themselves may not cause any recognizable symptoms. Bad posture associated with frequent sitting or standing and occupational hazards such as repetitive bending or standing can accelerate the formation of disc bulges.

Disc herniation is often a progression in severity from a disc bulge.  As discs wear down over time, they may degenerate and lose some of their water content.  This condition, known as Degenerative Disc Disease, is discussed in greater detail below.  As discs degenerate and degrade, they become more flexible and the annulus may be more susceptible to tearing or rupturing.  Disc herniation can also be caused by traumatic, acute injuries such as a hard fall or blow to the back.

Diagnosis:  Diagnosis of a herniated or bulging disc typically begins with a physical exam that tests the patient’s reflexes, muscle strength, walking ability, and sensory perception (light touches, pin pricks, etc.).  If a protrusion is indicated by the physical test, imaging may be ordered in the form of X-rays, MRIs, CT scans, and/or Myelograms.

Treatment:  Non-invasive treatment may include heat therapy, exercise, physical therapy, chiropractic treatment, therapeutic ultrasound, and medication.  Epidural steroid injections may be considered as an intermediate treatment.  For more severe cases, a microdiscectomy may be performed, typically in an outpatient setting.  In this procedure, a small portion of bone and/or disc material is removed to relieve pressure on the affected nerve root.

Our next post will discuss degenerative disc disease.

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:

1. Spine-health, https://www.spine-health.com/.
2. Mayo Clinic, http://www.mayoclinic.org/.
3. The Neurological Institute of New York,
http://columbianeurology.org/about-us/neurological-institute-new-york.
4. John Hopkins Medicine, http://www.hopkinsmedicine.org/.
5. WebMD, http://www.webmd.com/.

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Spine-Related Musculoskeletal Conditions – Part 4 – Spondylolisthesis

In this series of blog posts, we have been reviewing spine-related musculoskeletal conditions.  The next condition we will be looking at is spondylolisthesis.

Spondylolisthesis

Definition: Occurs when a vertebra (typically in the lumbar spine) slides forward over the vertebra beneath it.

Overview:  The vertebrae in the spinal column are linked together by small joints (facets) that permit the spine to bend forward (flexion) and backward (extension) while limiting rotational movement.  Spondylolisthesis occurs when a joint defect in the vertebrae (resulting from either a stress fracture or degeneration) permits one vertebra to slip forward on the one beneath it.

Spondylolisthesis is most common in the lower back, though in rare cases it can occur in the cervical spine.  It most frequently occurs at the L4-L5 and L3-L4 levels of the lumbar spine.

There are two types of spondylolisthesis: isthmic spondylolisthesis (IS) and degenerative spondylolisthesis (DS). IS occurs when a stress fracture of a small bone called the pars interarticularis permits a vertebra to slip forward over the vertebra below it.  IS is rare, and is most common in young children who participate in sports that put repeated stress on the lower back.

DS is far more common and most regularly occurs among people over the age of 50.  DS is a result of the gradual breakdown of the intervertebral discs and the facet joints in the spine.  As the discs lose volume, more stress and pressure is placed on the facet joints.  As the facet joints begin to degrade under the increased wear and pressure, they may allow too much flexion and cause a vertebra to slip forward over the vertebral body below it.

The slippage can place direct pressure on the spinal cord (spinal stenosis) and on the nerve roots exiting the spinal column (foraminal stenosis).

Symptoms: Lower back pain, leg pain (especially “running down” the leg), and sciatic pain are common.  Numbness or weakness often occurs in one or both legs.  Leg/back pain that is worse when bending over or twisting is common, as is pain that is worse standing than sitting.

Causes: Degenerative disc disease is a common cause of spondylolisthesis.  As we discussed above, when the intervertebral discs lose volume the spinal column becomes more compressed.  Without the shock absorption of the discs, more pressure is exerted on the facet joints.  This pressure and wear accelerates the degradation of the facets and allows for the increased flexion in the spine that can lead to vertebral slippage.  As clinical dentistry has moved from a standing profession to a seated one, dentists are at a higher risk for lower back conditions like spondylolisthesis.  Axial loading (the weight of the body compressing the spine vertically) on the lumbar spine is significantly higher in a seated position than it is standing.

Diagnosis: X-rays are used to determine whether or not a vertebra is out of place.  If the displaced vertebra is putting pressure on the spinal cord or nerve roots, a CT scan may be ordered to identify the severity of the problem.

Treatment: As with many other conditions discussed in this series, conservative treatment may include some combination of physical therapy, exercise, strength training, manual manipulation, and medication.  Epidural steroid injections are sometimes prescribed for those in severe pain.  Spinal fusion surgery is sometimes used for severe pain that has not been successfully treated with less invasive treatment.  Typically, a posterior fusion with a pedicle screw implementation is used, but a surgeon may also recommend a spinal fusion done from the font of the spine simultaneously.

Our next post in the series will examine disc bulge, disc herniation, and disc protrusion.

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:

1. Spine-health, https://www.spine-health.com/.
2. Mayo Clinic, http://www.mayoclinic.org/.
3. The Neurological Institute of New York,
http://columbianeurology.org/about-us/neurological-institute-new-york.
4. John Hopkins Medicine, http://www.hopkinsmedicine.org/.
5. WebMD, http://www.webmd.com/.

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Spine-Related Musculoskeletal Conditions – Part 3 – Stenosis

In this series, we have been looking at spine-related musculoskeletal conditions that many dentists and surgeons suffer from.  In this post, we will be looking at spinal and foraminal stenosis.

Cervical Spinal Stenosis:

Definition: The narrowing of the spinal canal in the cervical vertebrae, often due to inflammation of the surrounding cartilage and tissue.

Overview: The spinal canal is formed by the hollow spaces in the middle of the vertebrae, which form a protective tunnel for the spinal cord to pass through the spinal column. Cervical spinal stenosis is a progressive and potentially dangerous condition that occurs when inflammation narrows the cervical spinal canal. The narrowing of this already tight space can result in direct pressure on the spinal cord, leading to a number of neurological complications.  Cervical spinal stenosis can be crippling if the spinal cord becomes damaged.

Symptoms: Symptoms usually develop gradually over time and can include numbness, weakness, tingling in neck, shoulders, arms, hands, or legs, as well as intermittent, sharp pain in the arms and legs, especially when bending forward.  Deterioration of fine motor skills and issues with gait and balance can also occur.  In more severe cases, bladder and bowel issues may develop.

Causes: Though in rare cases cervical spinal stenosis is a congenital condition, it often results from inflammation due to other spinal conditions, such as spinal osteoarthritis, degenerative disc disease, and disc bulging.

Diagnosis: A combination of X-ray, MRI, and computed tomography (CT) scans may be used to diagnose spinal stenosis.  Blood tests may be used to eliminate other diseases such as multiple sclerosis and vitamin B12 deficiency.

Treatment: Conservative, non-invasive treatments may include exercise, physical therapy, and activity modification.  Medications may include anti-inflammatory drugs, narcotic pain medication, muscle relaxers, and epidural steroid injections.  In more severe cases, several surgical options exist, dependent upon the particular characteristics of the patient’s condition:

  1. Anterior cervical discectomy/corpectomy with fusion (ADCF): The spine is accessed through the front of the patient’s neck, the disc is removed from between the two vertebrae, and the vertebrae are then fused together to stabilize the spine.
  2. Laminectomy: This is a “decompression” surgical procedure performed to relieve pressure on the spinal cord. In this surgery, the lamina (the rear portion of the vertebra covering the spinal canal) is removed from the affected vertebra to enlarge the spinal canal and decrease pressure on the spinal cord.
  3. Interspinous Process Spacers: In this procedure, small metal spacers are surgically placed between the vertebrae to restore the spacing typically created by a healthy disc. This procedure is typically reserved for individuals with foraminal stenosis, however, and has only had limited effectiveness with patients suffering from spinal stenosis.

Foraminal Stenosis

Definition: Compression of the nerve roots connected to the spinal cord, caused by the narrowing of the passageway through which the nerves exit the spinal column.

Overview: The nerve roots branching off the spinal cord to other parts of the body exit the spinal column through small openings on the sides of the vertebrae called a foramen. This space can become clogged or narrowed due to a number of spine-related conditions. The narrowing or partial obstruction of the foraminal canal caused by one of these conditions can put pressure on the nerve roots emerging from the spinal column, and may lead to an array of neurological symptoms that get progressively worse over time.

Symptoms: Tingling, numbness, or weakness in the feet or hands.  Local pain in the extremities.  “Pins and needles” or burning sensation. Intermittent neck or back pain.

Causes: Bulging or herniated discs may obstruct the foraminal canal, putting pressure on the nerve roots.  It can also be caused by spinal osteoarthritis, osteophytes, and spondylolisthesis.  Dentists are susceptible to foraminal stenosis, as they often hold their necks in extended positions.

Diagnosis: A CT scan and a Myelogram are used to diagnose foraminal stenosis. A Myelogram is an X-ray in which an opaque dye (which shows up on the X-ray) is injected into the sac around the nerve roots. The dye moves through the foramina, allowing the doctor to see the degree to which the foramen is narrowed or obstructed.

Treatments: Conservative treatments may include physical therapy, stretching and strength training, and oral pain-relieving medication. Corticosteroid injections are an option for more severe cases to reduce inflammation and pain.  In extreme cases, a surgical procedure known as a foraminotomy may be used to remove the bone spur or disc material that is putting pressure on the nerve root as it exits the spinal column through the foramen.

Our next post in this series will discuss spondylolisthesis.

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:

1. Spine-health, https://www.spine-health.com/.
2. Mayo Clinic, http://www.mayoclinic.org/.
3. The Neurological Institute of New York,
http://columbianeurology.org/about-us/neurological-institute-new-york.
4. John Hopkins Medicine, http://www.hopkinsmedicine.org/.
5. WebMD, http://www.webmd.com/.

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Spine-Related Musculoskeletal Conditions – Part 2 – Spinal Osteoarthritis

In the first part of this series, we discussed the fact that dentists and surgeons often suffer from musculoskeletal conditions.  In the remaining posts in this series, we will be looking at particular musculoskeletal conditions, starting with spinal osteoarthritis.

Spinal Osteoarthritis

Definition: Spinal osteoarthritis is also known as degenerative joint disease. It is a breakdown of the cartilage in the facet joints, which link together the spine’s vertebrae.

Overview: At the top and bottom of each vertebra is a small pair of joints called facets. Facets connect the vertebrae in order to restrict movement in certain directions and to allow the spine to move as one fluid unit.  The surfaces of the facets, like any other joint in the human body, are covered by a lubricating cartilage which allows them to operate smoothly and with little friction.

When the cartilage protecting the facets degrades or wears down, the bony surfaces of the facets rub against each other.  This can cause inflammation, severe pain, and the formation of osteophytes (bone spurs) on or around the joint surfaces.  It may also cause numbness and/or weakness in the legs and arms as a result of contact between the vertebrae and the nerves leaving the spinal cord.

Symptoms: Neck pain and stiffness. Severe pain may radiate down into shoulders and up the neck.  Weakness, numbness, or tingling in the fingers, hands, and/or arms are also often present.  Usually back discomfort is relieved when a person is lying down.  Studies have also linked anxiety and depression to osteoarthritis.[1]

Causes: Spinal osteoarthritis frequently occurs in conjunction with degenerative disc disease.  As the discs between the vertebrae in the spinal column degrade and decrease in volume, the increased pressure and contact between the facet joints can cause an accelerated degradation of the joint cartilage.

Repetitive strain or stress on the spine, often due to poor posture, to is a common cause of spinal osteoarthritis.  People with jobs requiring repetitive movements and strained positions are considered to be at greater risk for conditions like spinal osteoarthritis; however, injury or trauma to a joint or a genetic defect involving cartilage are also causes.  Dentists are at a higher risk than many other professions to develop this condition due to the awkward, static postures they must maintain.

Diagnosis: X-rays may be used to identify loss of cartilage, bone spurs, and bone damage. Magnetic resonance imaging (MRI) may be used to analyze the intervertebral discs and the nerves exiting the spinal column.

Treatment: Conservative, non-invasive treatment plans may include some combination of heat/cold therapy, medication, physical therapy, strength training, and stretching. In more severe cases, a surgical treatment such as spinal fusion is utilized.

Our next post in this series will examine spinal stenosis, another common cause of neck and back 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.

[1] Sharma, A., et. al, Anxiety and depression in patients with osteoarthritis: impact and management challenges, Open Access Rheumatology: Research and Reviews 2016:8 (2016).

References:

1. Spine-health, https://www.spine-health.com/.
2. Mayo Clinic, http://www.mayoclinic.org/.
3. The Neurological Institute of New York,
http://columbianeurology.org/about-us/neurological-institute-new-york.
4. John Hopkins Medicine, http://www.hopkinsmedicine.org/.
5. WebMD, http://www.webmd.com/.

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What is a Neuropsychological Evaluation? – Part 1

We’ve talked before about how your insurance company may require you to undergo an independent medical examination (IME) by a physician of their choosing and how they may also ask for a Functional Capacity Evaluation (FCE).

Neuropsychological evaluations are another tool insurers utilize when investigating disability claims.  A neuropsychological evaluation is also something that a claimant filing a disability claim may choose to undergo independently, to provide additional proof of his or her disability.  In this series of posts, we will be talking about what a neuropsychological evaluation is, what to expect during an examination, and how an exam could affect your claim.

What is a Neuropsychological Evaluation?

Neuropsychology is the study of the relationship between the brain and behavior.  A neuropsychological evaluation is a method of testing where a neuropsychologist seeks to obtain data about a subject’s cognitive, behavioral, linguistic, motor, and executive functioning in order to identify changes that are, often, the result of a disease or injury.  The evaluation can lead to the diagnosis of a cognitive deficit or the confirmation of a diagnosis, as well as provide differential diagnoses.

Neuropsychological evaluations are most often associated with conditions that exhibit cognitive dysfunctions, such as

Conditions such as those enumerated above often have symptoms that vary person by person, and the amount of cognitive impairment can often not be fully assessed by other diagnostic tools such as an MRI, or a traditional psychological evaluation.

Neuropsychological tests are standardized tests that are given and scored in a similar manner each time they are used.  The tests are designed to evaluate the following:

  • Intellectual Functioning
  • Academic Achievement
  • Language Processing
  • Visuospatial Processing
  • Attention/Concentration
  • Verbal Learning and Memory
  • Executive Functions
  • Speed of Processing
  • Sensory-Perceptual Functions
  • Motor Speed and Strength
  • Motivation
  • Personality

There are many different accepted tests for each domain listed above.  Accordingly, an examiner will likely not perform every test, but rather select tests from each category that will best evaluate the particular question posed by the referrer.

The goal of these neuropsychological tests is to produce raw data.  The results are then evaluated by comparing test scores to healthy individuals of a similar background (age, education, gender, ethnic background, etc.) and to expected levels of cognitive functioning.  The data is then interpreted by the neuropsychologist, and perhaps other providers, to determine the strengths and weaknesses of the subject’s brain, provide suggestions for potential treatment options, set a standard for any future testing, evaluate a course of treatment, make recommendations on steps and modifications that can improve daily living, and evaluate whether a subject can return to work with or without modifications.

In our next post we will go look at what you can expect during a neurospychological evaluation.

Sources:

Atif B. Malike, MD; Chief Editor, et al., Neuropsychological Evaluation, Medscape, http://emedicine.medscape.com/article/317596-overview, updated May 18, 2017.

Neuropsychological Evaluation FAQ, University of North Carolina School of Medicine Department of Neurology, https://www.med.unc.edu/neurology/divisions/movement-disorders/npsycheval

Kathryn Wilder Schaaf, PhD, et al, Frequently Asked Questions About Neuropsychological Evaluation, Virginia Commonwealth University Department of Physical Medicine and Rehabilitation, https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0ahUKEwir3pKk__fUAhUBEmMKHenkDzsQFggoMAA&url=http%3A%2F%2Fwww.tbinrc.com%2FWebsites%2Ftbinrcnew%2Fimages%2FNeuropsych_FAQ.pdf&usg=AFQjCNG0Mv3o17ZrNmXuDN5ITUIh4fWYtA&cad=rja

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Spine-Related Musculoskeletal Conditions – Part 1 – Spondylosis

Living with a spine-related condition can be scary and overwhelming. Unfortunately, the complex nature of the spine and the nervous system can often make the search for answers a frustrating and demoralizing endeavor.  In this series of posts we are going to talk about several spine-related musculoskeletal conditions, many of which are frequently diagnosed in dentists, surgeons, and other physicians.

If you are suffering from a spine-related condition, you have likely visited not only your primary care physician, but also a physical therapist, a chiropractor, a neurologist, an orthopedic surgeon, and/or a pain management doctor.  It’s common for those suffering from a musculoskeletal condition to hear several different terms to describe a set of symptoms, be given multiple explanations for what is causing their pain, and be given a variety of (often conflicting) treatment recommendations.

Dentists and physicians in certain surgical specialties are particularly susceptible to spine-related musculoskeletal conditions, which are among the top reasons insureds file disability claims.  The forward-flexed, static posture that dentists and surgeons must maintain to perform procedures can lead to the overuse and repetitive strain of the neck and back, and contribute to the development of a litany of musculoskeletal conditions.  One study showed that 62% of the general population present musculoskeletal work-related pain, and this increased to 93% when the sample population was made up entirely of dentists.[1]  Unfortunately, although one often thinks of spinal and back injuries occurring later in life after years of strain, chronic musculoskeletal pain is experienced by many dentists by their third year of dental school.[2]

We’ve created this series of blog posts as a resource to help clear up some of the confusion surrounding the common terms used to refer to spine-related musculoskeletal conditions.  For each term we’ll provide a definition, overview, list of common symptoms, causes, methods of diagnosis, and common treatments. In this post, we’re going to briefly look at spondylosis, and then in later posts we will take a more in depth look at some other spine-related conditions.

Spondylosis

Definition: This is an umbrella term used to broadly describe degeneration in the spine.  Some doctors may use it interchangeably with spinal osteoarthritis.  Spondylosis is a descriptive term rather than a clinical diagnosis – it is used to describe anyone suffering from both pain and spinal degeneration.  If your doctor uses this term to describe your condition, you may want to your physician for a more specific diagnosis.

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.

[1] Dias, Ana Giselle Aguiar, et. al, Prevalence of repetitive strain injuries/work related musculoskeletal disorders in different specialties of dentists, RGO, Rev. Gauch. Odontol. Vol. 62 no. 2, Campinas Apr./June 2014,  http://dx.doi.org/10.1590/1981-8637201400020000042714  (citing Regis Filho GI, Michels G, Sell I. Lesões por esforços repetitivos/distúrbios osteomusculares relacionados ao trabalho em cirurgiões-dentistas. Rev Bras Epidemiol. 2006;9(3):346-59, http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1415-790X2006000300009&lng=en).

[2] Kristina Lynch, My back is hurting my practice, Part I, AGD Impact, Feb. 2006.

References:

1. Spine-health, https://www.spine-health.com/.
2. Mayo Clinic, http://www.mayoclinic.org/.
3. The Neurological Institute of New York,
http://columbianeurology.org/about-us/neurological-institute-new-york.
4. John Hopkins Medicine, http://www.hopkinsmedicine.org/.
5. WebMD, http://www.webmd.com/.

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Chronic Pain and Anxiety Disorders

Chronic pain by itself is often debilitating, and the struggle to obtain a correct diagnosis, effective pain management, and ongoing treatment can be stressful and overwhelming.  As we discussed in a previous post, depression often co-occurs with chronic pain, and can further complicate treatment.  The same is true of anxiety disorders.

Chronic Pain Disorders Associated with the Co-Occurrence of Anxiety

Like depression, anxiety is more likely to co-occur with certain conditions, such as:

It is no secret that physicians and dentists have stressful and demanding careers.  One Cardiff University study showed that of 2,000 British doctors, at various stages of their careers, 60% had experienced mental illness.[1]  Often practitioners ignore or fight through both chronic pain and anxiety and show up to work, to the point of endangering themselves or others before acknowledging their disability or seeking adequate treatment.

While anxiety alone can result in an inability to practice, either indefinitely or in the short-term, it is also quite common in those suffering from chronic pain to experience an anxiety disorder.  Anxiety disorders are also the most common type of psychiatric disorders in the United States, with 19 million adults affected.[2]

Chronic Pain and Anxiety—Worse Together

Facing a long-term or permanent disability can be anxiety provoking for a physician, who must (1) face giving up a career he or she invested so much time and financial resources to establish; (2) seek a correct diagnosis, course of treatment, and adequate pain management; and (3) often struggle with adapting to the loss of a previously enjoyed quality of life.  Conversely, chronic pain is also common in people with anxiety disorders,[3]  with up to 70% of people with certain medical conditions (including hypertension, diabetes, and arthritis) had an anxiety disorder first.[4]

Regardless of whether anxiety or chronic pain came first, individuals suffering from anxiety can experience pain that is particularly intense and hard to treat.[5]  In a 2013 study, 45% of 250 patients who had moderate to severe chronic joint or back pain screened positive for at least one of the common anxiety disorders (generalized anxiety, social anxiety, PTSD, OCD).  Further, those that had an anxiety disorder reported significantly worse pain and health-related quality of life than their counterparts without anxiety.[6]

Symptoms of Anxiety[7]

There are several anxiety disorders and, while the below list is by no means exhaustive, sufferers of anxiety often exhibit the following symptoms:

Generalized Anxiety Disorder

  • Difficulty controlling worry
  • Restlessness, feeling wound-up or on edge, irritability, muscle tension
  • Being easily fatigued and problems with sleep
  • Difficulty concentrating or having their minds go blank

Panic Disorder

  • Sudden and repeated attacks of intense fear
  • Feelings of being out of control during a panic attack
  • Intense worries about when the next attack will happen
  • Avoidance of places where panic attacks have occurred in the past

Social Anxiety Disorder

  • Feeling highly anxious about being around other people (including having a hard time talking to them, blushing, sweating, trembling, or feeling sick to your stomach)
  • Feeling self-conscious in front of others and worried about feeling humiliated, embarrassed or rejected, or fearful of offending others
  • Worrying before an event and/or avoiding places where there are other people
  • Having a hard time making and keeping friends

Post-Traumatic Stress Disorder

  • Flashbacks, bad dreams, difficulty sleeping, frightening thoughts, angry outbursts
  • Avoiding places, events, objects, thoughts, or feelings that are reminders of the traumatic experience and trouble remembering key features of the traumatic event
  • Being easily startled and feeling tense or “on edge”
  • Negative feelings about oneself or the world, and distorted feelings like guilt or blame
  • Loss of interest in enjoyable activities

Obsessive Compulsive Disorder

  • Fear of germs or contamination
  • Unwanted or forbidden thoughts, including aggressive thoughts towards others or self
  • Having things symmetrical or in perfect order; excessive clearing and/or hand washing; ordering and arranging things in a precise way; repeatedly checking on things; compulsive counting

Treatments for Anxiety

Some of the treatments that have been successful in addressing anxiety in those with chronic pain include:

  • Cognitive-behavioral therapy (CBT)
  • Psychodynamic therapy (talk therapy)
  • Support groups
  • Relaxation or meditation training
  • Alternative treatments, such as acupuncture and hypnosis
  • Exercise
  • Medication

Chronic pain sufferers who recognize any of the above-referenced symptoms in themselves should talk to their doctor to address these serious issues.

[1] Michael Brooks, Why doctors’ mental health should be a concern for us all, NewStatesmen, April 11, 2016, http://www.newstatesman.com/politics/health/2016/04/why-doctors-mental-health-should-be-concern-us-all

[2] What are Anxiety Disorders?, Global Medical Education, https://www.gmeded.com/gme-info-graphics/what-are-anxiety-disorders

[3] Chronic Pain, Anxiety and Depression Association of America, April, 2016, https://www.adaa.org/understanding-anxiety/related-illnesses/other-related-conditions/chronic-pain

[4] Global Medical Education, Supra.

[5] Celeste Robb-Nicholson, M.D., The pain-anxiety-depression connection, Harvard Health Publications, http://www.health.harvard.edu/healthbeat/the-pain-anxiety-depression-connection

[6] Health Behavior News Service, part of the Center for Advancing Health, Chronic pain sufferers likely to have anxiety, ScienceDaily, May 8, 2013, https://www.sciencedaily.com/releases/2013/05/130508213112.htm

[7] Definitions according to National Institute of Mental Health: https://www.nimh.nih.gov/index.shtml

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Chronic Pain and Depression

Chronic pain is often difficult to diagnose and treat.  Consequently, those who suffer from chronic pain typically must also deal with a significant amount of stress, due to repeated failed treatments, numerous medical appointments, interruption of work and enjoyable activities, and the inability of their friends or family to understand their physical limitations.  This can, in turn, cause or worsen depression.  When depression occurs alongside chronic pain, it can make dealing with and treating the pain even harder.

Chronic Pain Disorders Associated with the Co-Occurrence of Depression

While mental health conditions, including depression, can often be disabling in and of themselves, they are unfortunately also quite common in those suffering from chronic pain.  Depression is more likely to co-occur with certain conditions, such as:

  • Back Pain
  • Neck Pain
  • Joint Pain
  • Arthritis
  • Migraines
  • Fibromyalgia

Studies show that rates of depression are high in residents and medical students (15%-30%) than rates in the general population, and the risk of depression continues throughout a physician’s career.[1]  According to a British study, 60% of dentists reported being anxious, tense, or depressed.

Dentists, doctors, and other medical professionals place extreme amounts of pressure on themselves because the stakes of their professions are so high.  In addition to perfectionism and self-criticism, other predictors of depression in doctors include:  lack of sleep, stressful interactions with patients and staff, dealing with death, constant responsibility, loneliness, and making mistakes.[2]

Often practitioners work through both chronic pain and psychiatric disorders for some time before acknowledging their disability or seeking adequate treatment.  In the case of depression, this can be due in part to the social stigma that surrounds it.  For all of these reasons, depression may go undiagnosed or seem less of an immediate concern to those suffering from chronic pain.  However, if you are experiencing symptoms of depression and chronic pain, studies show that it is important to treat both, because chronic pain can become much more difficulty to treat if the depression is allowed to progress unchecked.

Chronic Pain and Depression—Worse Together

Facing a long-term or permanent disability can trigger depression—this is especially understandable for doctors or dentists who have put years into medical school and establishing their careers, only to become disabled and have to step away from a profession that has become a significant part of their identity. Depression can also precede chronic pain.  For example, several studies have examined the link between depression before the onset of back-pain.[3]

Regardless of which came first, together they are formidable to treat.  Major depression is thought to be four times greater in people with chronic back pain than those in the general population, and studies show that individuals suffering from both chronic back pain and depression experienced a greater degree of impairment than those with either depression or back pain alone.[4]

Treatments for Depression

Focusing solely on pain management can prevent both the patient’s and treating physician’s ability to recognize that a psychiatric disorder is also present.  Yet, even with correct diagnoses, both issues can be difficult to treat together.[5]  For instance, those who suffer from both chronic pain and mental illnesses can have a lower pain threshold as well as increased sensitivity to medication side-effects.[6]  Some treatments that have proved successful in addressing depression in those with chronic pain include:

  • Cognitive-behavioral therapy (CBT)
  • Psychodynamic therapy (talk therapy)
  • Relaxation or meditation training
  • Acupuncture
  • Hypnosis
  • Exercise
  • Medication

Symptoms of Depression

  • Little interest or pleasure in doing things
  • Feeling down, depressed, or hopeless
  • Trouble falling asleep or sleeping too much
  • Feeling tired or having little energy
  • Poor appetite or overeating
  • Trouble concentrating
  • Feeling bad about yourself, or that you are a failure or have let yourself or others down
  • Thoughts that you would be better off dead, or hurting yourself in some way

Chronic pain sufferers who recognize any of the above-referenced symptoms in themselves should talk to their doctor to address these serious issues.

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[1] Robert P. Bright, MD, Depression and suicide among physicians, Current Psychiatry, April 10, 2011.

[2] Id.

[3] William W. Deardorff, PHD, ABPP, Depression Can Lead to Chronic Back Pain, Spine-health.com, Oct. 15, 2004, http://www.spine-health.com/conditions/depression/depression-can-lead-chronic-back-pain.

[4] William W. Deardorff, PhD, ABPP, Depression and Chronic Back Pain, Spine-health.com, Oct. 15, 2004, http://www.spine-health.com/conditions/depression/depression-and-chronic-back-pain.

[5] Celeste Robb-Nicholson, M.D., The pain-anxiety-depression connection, Harvard Health Publications, http://www.health.harvard.edu/healthbeat/the-pain-anxiety-depression-connection.

[6] Anxiety and Depression Association of America, Chronic Pain,  https://www.adaa.org/understanding-anxiety/related-illnesses/other-related-conditions/chronic-pain.

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fMRI Brain Scanning: The Future of Proving Pain?

Many disability claimants suffering from chronic, intense pain are surprised and disheartened when their reported pain levels are received with skepticism by their insurance company.  Since pain is a subjective feeling, treating doctors typically ask patients to self-report their pain on a scale of 0-10, so that they can diagnose and treat the pain.  Unfortunately, most insurance companies are unwilling to accept self-reported pain levels and will often try to downplay the severity of the claimant’s pain, citing a lack of objective evidence.

Recently, researchers have developed a technology called functional MRI scans, or fMRIs, for short, which may provide a new way to objectively verify the existence of pain.  In this post, we will examine this technology and discuss how it might be used in the context of disability claims.

I.  What is an fMRI?

fMRI scanning is a noninvasive technique used by doctors to map and measure brain activity.  More specifically, fMRIs are used to measure and observe increases in MR signal caused by neural activity in the brain.  The fMRI data is then analyzed to determine which parts of the brain were active during the scan.  The data is then compared to known neurological signatures, or “biomarkers,” to determine if there are any correlations between the neural activity in the brain and the symptoms reported by the patient (such as chronic pain).

II. The Use of fMRI Scans to Prove Pain

Recently, a number of companies and researchers are focusing on using fMRI scans to produce objective evidence of pain.  For instance, Dr. Joy Hirsch, a professor at the Yale School of Medicine, claims to have developed a test that is capable of distinguishing real, chronic pain from imagined pain.

fMRI scans are also now being used to support the cases of claimants in disability cases. For example, a woman in New York recently used an fMRI scan to convince her insurer, after two years of litigation, that her disability claim never should have been denied.  An fMRI scan was also recently used in the case of Carl Koch, a truck driver from Arizona who suffered severe burns when the hose of his tanker broke loose and sprayed him with molten tar.  Mr. Koch visited Dr. Hirsch, who used functional brain mapping to conclude that Mr. Koch’s pain was real.  When the judge ruled that Dr. Hirsch’s testimony would be admissible at trial, the case settled for $800,000 – an amount ten times higher than the company’s original offer.

III. What the Skeptics Say

The use of fMRI scans to prove pain remains controversial. Some critics argue that the techniques being used in litigation have little support in existing publications.  Others, such as Tor Wager, a professor of psychology and neuroscience at UC Boulder, contend that the sample size in available studies is too small.  Proponents of fMRI refute both of these claims, arguing that a number of credible studies support the validity of their methods.

IV. The Future of fMRI Scans in Disability Cases

It’s easy to see how fMRI scans could prove useful in a disability claim.  For example, many dentists suffer from musculoskeletal disorders, particularly in their spines, that cause chronic, debilitating pain.  However, as noted above, these types of claims can be particularly difficult, because many insurance companies refuse to accept a claimant’s self-reported pain levels and limitations.  Co-workers, family, and friends can provide statements describing how the dentist’s pain is affecting his performance at work and his quality of life, but once again, insurance companies will typically similarly claim that such statements are “objectively verifiable” evidence of the pain.  Sometimes a cervical or lumbar MRI can identify potential causes for the pain, and/or a functional capacity exam (FCE) can help document the limitations the pain is causing—but these types of reports are also commonly challenged by insurance companies intent on denying benefits.

In such a case, an fMRI scan illustrating the doctor’s pain might serve as an additional, objectively verifiable method of establishing the existence of chronic pain.  Whether or not insurance companies are willing to accept fMRIs as reliable evidence of pain remains to be seen, and will likely depend, in large part, on how willing courts are to accept fMRIs as admissible evidence of pain.  If, in the future, this technology continues to develop and become more precise, and courts and juries demonstrate a willingness to accept fMRIs as proof of pain, fMRIs may eventually be enough to convince insurance companies to accept legitimate disability claims without ever setting foot in a courtroom.

REFERENCES:

  1. UC San Diego Sch. of Med., What is fMRI?, available at http://fmri.ucsd.edu/Research/whatisfmri.html.
  1. Sushrut Jangi, Measuring Pain Using Functional MRI, The New England Journal of Medicine, available at http://blogs.nejm.org/now/index.php/9863/2013/04/10/.
  1. Steven Levy, Brain Imaging of Pain Brings Success to Disability Claim, EIN Presswire (June 29, 2016), available at http://www.einpresswire.com/article/333249721/brain-imaging-of-pain-brings-success-to-disability-claim.
  1. Kevin Davis, Personal Injury Lawyers Turn to Neuroscience to Back Claims of Chronic Pain, ABA Journal (Mar. 1, 2016), available at http://www.abajournal.com/magazine/article/personal_injury_lawyers_turn_to_neuroscience_to_back_claims_of_chronic_pain.
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New Genetic Testing Predicts Most Effective Medications

In today’s pharmaceutical market there are countless prescription drugs marketed to people suffering from disabling conditions, and many of these drugs promise breakthrough relief not offered by their competitors. Individuals suffering from chronic pain and mental health disorders such as anxiety, PTSD, depression and bipolar must often take potent drugs for prolonged periods of time to get relief from their symptoms. But the search for relief can be incredibly frustrating – every person responds differently to the same drugs, and oftentimes powerful side effects can overshadow any relief.

For an individual suffering from the chronic and disabling pain brought on by severe spinal stenosis, there are several forms of treatment available – many of which are non-invasive. If other non-invasive treatments are unsuccessful, suffering through the side effects of several drugs in search of relief can be demoralizing. Powerful opioids can cause severe nausea, vomiting, dizziness, and/or constipation in certain individuals. The compounding effects of trying several different drugs can have a significant effect on one’s physical and mental health.

Recently, however, a genetic testing company has developed a simple test that will help countless individuals avoid dealing with unwanted side effects while cycling through different medications in their quest for relief.

Genesight has developed breakthrough genetic tests for both narcotic analgesics (pain medications) and psychotropic medications (treating mental health disorders). By taking a simple cheek swab, the company is able to analyze your DNA and determine which medications are match for your specific genetic profile. A clinical study of Gensight’s testing and analysis showed that patients were twice as likely to respond to the recommended medication.

This testing will likely be welcome news among those for whom relief is elusive. For many individuals suffering from disabling conditions, medications are very rarely the magic bullet that brings complete relief.  Symptoms may be so severe that no drug will ever be one hundred percent effective. More often, relief means alleviation of one’s symptoms just enough to get through the day without interminable pain or crippling anxiety while suffering only the more mild side effects. Genesight’s testing may offer hope for these individuals – people who will likely never be able to return to their previous career or their own occupation, but are in search of just enough relief from their symptoms to lead and enjoy a normal life.

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