Thursday, August 28, 2014

Pain, MRIs and Disability

Another study sponsored by Liberty Mutual concludes that early magnetic resonance imaging for diagnosis of back pain leads to higher costs and poorer outcomes.

The study, published in the August issue of the medical journal Spine, showed that when back pain patients went through MRI scans within the first month after injury, they were between 18 to 55 times as likely as the reference group to receive more diagnostic and invasive procedures.

Glenn Pransky, a co-author of the study and director of the Liberty Mutual Center for Disability Research, said that that MRIs can put patients in a mindset of trying to find a specific problem in their back and then seeking to fix it.

“People get hung up on thinking, ‘Oh, I’ve got this ruptured disc. That must be the problem. I won’t be well until somebody fixes that ruptured disc,’” Pransky said.

As many of us know, herniated discs and other spinal "abnormalities" are actually quite common.

Pain is complex, and the cause of pain is often illusive.

In an Aug. 20 webinar from managed care company Paradigm Outcomes, two physicians pointed out that pain can come from many places.

"When you look at somebody’s pain, they have the pain sensation − there could be nerve pain, there could be soft tissue-muscle-tendon pain," said Steven Moskowitz, senior medical director of Paradigm’s pain program. "They could have pain because they’re deconditioned and out of shape and stiff, and so it hurts to be stiff and to move when you’re stiff. And then they can have the emotional components of catastrophizing and being fearful of activity.”
Bowzer's pain started bending over for his cigar.

In his most recent book, Living Abled and Healthy, Christopher Brigham, MD, no stranger to workers' compensation and lead editor to the AMA 6th Ed. Guide for Rating Permanent Disability, examines people that have had catastrophic injuries or who grew up "less than able" but overcame these difficulties, and compares to folks who can't seem to surmount such obstacles.

[Disclosure - Brigham is a friend and I contributed a small part to the book.]

Brigham argues that our mind-body connections are surprisingly strong and that people in general discount the effect our emotions, psychology, feelings, perceptions, affect our physical being.

"If we believe something is helping us we will likely feel better. If we believe something is hurting us we will likely feel worse. Our attitudes define who we are and the choices we make determine our destinies."

Robert Aurbach, an attorney, researcher and international work comp expert now consulting in Australia, has noted that neuroplasticity - the brain's ability to reorganize itself by forming new neural connections - can play a big role in one's perception of ability versus disability.

Essentially, continued "training" to be disabled, rather than abled, forms neural connections that reinforce negative associations with pain.

The extent to which early MRIs contribute to the perception and emotion of disability has yet to be fully quantified, but the Liberty Mutual study suggests that it is not insignificant.

According to a 2013 report from the Bureau of Labor Statistics, sprains, strains and tears made up 38% of work-related injuries in 2012, making those the most common source of claims. In that category, the back was the most-often injured body part, making up 36% of sprains, strains and tears.

Essentially that means that 1/6th of all work injury claims are comprised of back related pain issues. How many of those end up worse because of diagnosis and treatment fostered by early MRI findings that might have otherwise been adequately (and perhaps more effectively and efficiently) treated conservatively isn't known but I suspect it is considerable.

The authors of the Liberty Mutual study found that MRI use for lower back pain patients wasn’t distributed evenly across the U.S. and they hope to continue the study to determine whether certain states are more prone to improper use of the scans.

I think it would also be interesting and beneficial to correlate that study with data and information about disability rates; my guess is that we (the grand collective "we") make people more disabled than they otherwise would be in our zeal to use medical technology and attempt to find easy answers to complex problems, like pain and disability.


I'm taking tomorrow, Friday August 29, and of course Monday, September 1, off for the Labor Day weekend and will return on Tuesday September 2. Remember that without the labor of the people in this country there would be no need for workers' compensation.


  1. So you tell us about a one sided study sponsored by Liberty Mutual. I know of a women here in Seattle that folks tried avoiding doing an MRI here low back pain... They ended up paying here a 2 million dollar settlement for not doing the MRI, led to her having even more harm. So this report is BS... and funded by the folks who do not want to cover the on the job injuries any more. INDUSTRY PROPAGANDA that is getting more folks harmed than if we just started treating these folks to start with. Stop doing test and studies and start treating the workers to start with. More money and being spent to deny workers then if we just helped them to start with.

    1. So once again were saying that were testing to much and that these test to folks getting treated, wow, folks actual getting helped and treated. Yet we want to do away with these expensive test that just make folks think there is something wrong with them than is. Hmm? So what about the folks who were like the lady above that really do have thing going on that the GOOD dr. can not see? Do we just throw those folks under the bus, for some patient abuse is OK once again? Seeing who we will save so much money by not doing the test to start with.... If you don't test then you don't see. Kind of lack if you don't see it then it must not be there? See no evil hear no evil then there must be no evil. So yeah makes sens, just don't test then youll never have to treat. Sounds like a money making deal to me.

    2. And don't even get me started on the Jarvick study the industry uses to cheat folks out of treatments as well. Dr.s being trained to misuse these test and not even apply them as intended by the study it's self. I know in one study they say folks with a herniated disc have a 30 percent chance the patient is lying about their pain. Yet for folks who only have a sprain there is a 70 percent chance the folks are not being honest about their pain. Yet Dr.s now days are being trained to put all back conditions under the sprain catagory even with it truly is a herniated disc. So many folks are being harmed by other star down there noses at them as though their not being honest when in fact it is the industry not being honest with folks so as to save money and push folks own moral agendas into our care, all while making a nice little profit off the misery all this arrogance creates. For most the folks making these test and these laws, have never ever labored a day in their lives. MORE industry propaganda that is leading to folks being harmed... So what about the folks that we do not do the MRI's on that we truly should have. Do just so oh well to that group of injured workers, and make them go through decades of court battles just to prove they were correct about their conditions to start with. I know for my herniated disc this great industry test and info have done nothing but stand in the way of me getting treated fairly and respectively for my on the job injury. This is not just in workers comp but our HMO's as well. This another accuse for the big insurers to get out of covering their end of the contractual agreements. War on the infirm and poor through our health care. NAZI's pushing their wills and way life on to other all based on BOGUS industry sponsored reports, packed with LIES, so as to help and continue abusing and defrauding patients iw's and insurance consumers. Just more punitive based care, or a lack of care in our health care industry today. A bunch of suits who never had to labor a day in their lives, dictating to those who actual do produce labor for our world. SAD to see this class war far go on.

    3. Or they could be in pain because that old disc that did not obsorb is touching the nerve root. I know for my own system I know when it is facia and when it is the disc touching the nerve root. But I only know this after study it all and going through never ending flare ups. Excersize acually makes my condition worse, so I have to find something in between. but for sure the MRI was correct in my condition and the Dr.s even say that I ought not be doing the job I was doing with my injuries.

      Yet the industry likes to blanket us all into this sprain catagorey, and heck if we just do away with MRI's well will be right 80 percent of the time, so who cares if were harming the other 20 percent. Wow what a way to addminister care.

    4. This is what happens when we listen to the industries own professionals who then go on to teach at our colleges. It is sickening that folks wold want to go with a Dr.s gut instincts over the actual picture that shows or rules out harm. And to tell folks when their nerve is being touched by a disc fragments that, that may not be what is causing you pain. IS just being an ASS HAT pandering to his corporate keepers. Any one who would not want pictures of one who is injured is only trying to cheat folks plain and simple. This is being done so that all bad back injuries can be called sprains and teh industry will not have to treat these patients. And if we can do away with the MRI's "THE OBJECTIVE PROF," then all the better, we can cheat more and more that way. And for the most part that will work for about 80 percent of the folks, but what about the other 20 percent that gets harmed by it? Is that just the cost of doing bis? Not doing test to rule out damage is a safe and prudent thing to do. You want to cut cost, Start with the inflated cost of the mri's themselves. And just for the record, here is what denying folks basic test and going with Dr.s instincts leads to in our world today. So yeah go ahead and believe this insure industry sell out.

      Group Health pays patient $2.5M to settle lawsuit

    5. By not doing the MRI's the industry is able to do away with the OBJECTIVE EVIDENCE in folks care so as to deny care. Selectively. Dr.s going with gut instincts and not the OBJECTIVE medical evidence in our care. Selectively. Only those the Great Dr.s Deem worthy get the care and treatments. Thus allowing class war far to continue even more so than it is now.

  2. I wonder if the study should include an assessment of those states where defensive medicine is praticed because of medical malpractice issues? That seems to me to be a significant contributor to overtesting. There a re published practice parameters for when MRIs should be performed and they set out a course and period of time for conservative treatment that should be followed absent an emergency. Why aren't more carriers enforcing those policies? This issue is also in step with the concepts of Obamacare where you give a patient a pil rather than expensive testing and treatment. Pain Is a very difficult item to even quantify or assess as people are so variable in their threshholds for enduring pain. Publications by pain management drs. sugest that not enough credence is given to those individual patient pain complaints which adversely impacts patient treatment and outcomes. In other words we are under treating pain yet we, as a country have more prescribed use of pain medications than any other industrialized country so how could we be under treating pain?

    I know I don't have the answers and certainly the medical profession doesn't either.

  3. Great article and good information to think about. Attitude along with the proper treatment plan are everything. Have a great holiday. Thank you for your contribution to the field.

    1. Yes, that and listening to the patients, and adhering to the "OBJECTIVE Factual Medical Evidence, i.e. MRI's, blood test, EKG's ect.... and not gut instincts. For punitive based care, doled out, based upon ones gut instincts, and not the objective medical facts, only pits providers against patients, and that's not good for any of us.

  4. Please be careful... A cohort study, by its very design, does not provide scientific evidence that a causal relationship exists. There is clearly a selection bias in this study. Since patients were not randomly assigned to the treatments in the study there is a terribly obvious selection bias here -- people with worse back injuries get MRI's.

    If there was a reason to believe MRI's are the cause of worsening injuries that would certainly be big news, but when you Goolge "MRI's worsen injuries" you see the real problem in Workers' Comp. "How can I make my injury worse so the MRI looks bad?"

    Obviously, there is no known causal relationship between the use of an MRI and worse medical outcomes.