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Interdisciplinary Treatment for Chronic Pain

December 2015

Featured Story

Contributed by Daniel Bruns, PsyD

Studies by the National Center for Health Statistics1 and the Centers for Disease Control2 confirm that pain is by far the most common reason why patients see a physician: something hurts. Although no data is available, given that the workers’ compensation system revolves primarily around the treatment of injury, the prevalence of pain in the workers’ compensation system is probably even higher than that observed in the primary care system.

In the United States population at large, at least 116 million US adults are burdened by chronic pain,3 and in a study of a random sample of community members, 27% reported having chronic low back pain.4 Pain is not only common, it is also an extraordinarily costly condition, with an estimated annual national economic cost of $560–$635 billion.3 Because of the challenges that pain presents to our society, the U.S. Institute of Medicine concluded, “Effective pain management is a moral imperative, a professional responsibility, and the duty of people in the healing professions” (p. S-3).3

Despite the prevalence of pain, training for professionals in the treatment of pain has been lacking. Remarkably, a study by the Institute of Medicine also discovered that no American medical school required a class in pain, and only 3.4% of schools offered an elective class in pain. As a result, medical schools do not expose the physician to the full scope of options for pain treatment, and until recently, have not informed medical students of the risks of opioids.3 Recently, however, efforts have been made to correct this, and peer-reviewed online CME coursework is now becoming available.5,6

In the U.S., the treatment of pain has relied heavily on the use of opioid pain medications. Opioids (a.k.a. narcotics) are powerful pain-relieving medications and are very widely used in the U.S.. For example, even though the US accounts for only 4.6% of the global population, the U.S. accounts for 99% of the global consumption of hydrocodone.7 While the humane treatment of pain is a professional responsibility, in the US the number of deaths from prescription pain medications each year exceeds the number of deaths from cocaine and heroin combined,8 and also exceeds the number of deaths from motor vehicle accidents.9 This rapidly growing rate of iatrogenic addiction10 and opioid-related deaths has been referred to alternately as a “crisis”11 or an “epidemic.”10

A common mistake in pain treatment is to think of pain as solely a symptom of tissue damage. In fact, pain is an extraordinarily complex sensory experience, with biological, psychological, and social components. Imaging studies of the brain show that while acute pain is primarily associated with activation of sensory areas of the brain, chronic pain is more closely associated with the brain’s emotion center.12,13 Because of that, effective treatments for pain must address both its psychological and biological aspects.3

A review of the evidence determined that psychological tests are the scientific equal of medical tests,14 and can sometimes exceed the ability of medical tests to predict the outcome of medical treatments for pain.15,16 Similarly, psychological interventions have been shown to be effective treatments for pain.17 Psychological treatments to improve pain-coping skills can produce improvements in functioning that equal those of surgery.18,19 However, one study found that surgery was 168 times more expensive than psychological treatments, and involved significant risks.20 In contrast, psychological interventions are safe, effective, and economical treatments for pain. Despite that, studies show that psychological treatments are generally underutilized.21

Unlike many states, Colorado’s system of medical treatment guidelines integrates medical and psychological treatments. This approach not only offered more comprehensive care, but produced an estimated $859 million savings in one year.20 Overall, the interdisciplinary approach to pain treatment has been shown to produce better outcomes while reducing expenditures, and that is why it has become the standard of care. 

References

1. National Center for Health Statistics. Vital health statistics: Reporting chronic pain episodes on health surveys. Vol Series 6: Cognition and survey measurement. Washington DC: Centers for Disease Control: US Department of Health and Human Services; 1992.

2. Centers for Disease Control and Prevention. Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2009. 2010; http://www.cdc.gov/nchs/data/series/sr_10/sr10_249.pdf. Accessed July 22, 2013.

3. Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington D.C.: National Academies of Science; 2011.

4. Smith BH, Elliott AM, Hannaford PC, Chambers WA, Smith WC. Factors related to the onset and persistence of chronic back pain in the community: results from a general population follow-up study. Spine. 2004;29(9):1032-1040.

5. Goldman BL. Interdisciplinary Rehabilitation of the Injured Worker With Chronic Pain. [1.00 AMA PRA Category 1 Credit ™ Continuing Medical Education Webinar]. 2015; http://me.aapmr.org/diweb/catalog/item/id/680436/q/q=injured*20worker*20chronic*20pain&c=141.

6. Bruns D, Disorbio JM. The Assessment of Factors Associated with Delayed Recovery. A Biopsychosocial Paradigm. [1.00 AMA PRA Category 1 Credit ™ Continuing Medical Education Webinar]. 2015; http://me.aapmr.org/diweb/catalog?dp=0&c=141&q=biopsychosocial+paradigm&f1=1.

7. International Narcotics Control Board. Narcotic drugs: estimated world requirements for 2011­—statistics for 2009. 2010; http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3659213/ - ref6. Accessed October 1, 2015.

8. Centers for Disease Control and Prevention. CDC Grand Rounds: Prescription Drug Overdoses — a U.S. Epidemic. Morbidity and Mortality Weekly Report (MMWR) 2012; http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6101a3.htm?s_cid=mm6101a3_w. Accessed August 9, 2012.

9. Centers for Disease Control and Prevention. Prescription drug abuse and overdose: Public Health Perspective. 2012; http://www.cdc.gov/primarycare/materials/opoidabuse/docs/pda-phperspective-508.pdf. Accessed October 1, 2015.

10. Beauchamp GA, Winstanley EL, Ryan SA, Lyons MS. Moving beyond misuse and diversion: the urgent need to consider the role of iatrogenic addiction in the current opioid epidemic. Am J Public Health. 2014;104(11):2023-2029.

11. Dhalla IA, Persaud N, Juurlink DN. Facing up to the prescription opioid crisis. BMJ. 2011;343:d5142.

12. Hashmi JA, Baliki MN, Huang L, et al. Shape shifting pain: chronification of back pain shifts brain representation from nociceptive to emotional circuits. Brain. 2013;136(Pt 9):2751-2768.

13. Mansour AR, Farmer MA, Baliki MN, Apkarian AV. Chronic pain: the role of learning and brain plasticity. Restorative neurology and neuroscience. 2014;32(1):129-139.

14. Meyer GJ, Finn SE, Eyde LD, et al. Psychological testing and psychological assessment. A review of evidence and issues. Am Psychol. 2001;56(2):128-165.

15. Carragee EJ, Barcohana B, Alamin T, van den Haak E. Prospective controlled study of the development of lower back pain in previously asymptomatic subjects undergoing experimental discography. Spine. 2004;29(10):1112-1117.

16. Carragee EJ, Alamin TF, Miller JL, Carragee JM. Discographic, MRI and psychosocial determinants of low back pain disability and remission: a prospective study in subjects with benign persistent back pain. Spine J. 2005;5(1):24-35.

17. Hoffman BM, Papas RK, Chatkoff DK, Kerns RD. Meta-analysis of psychological interventions for chronic low back pain. Health Psychol. 2007;26(1):1-9.

18. Brox JI, Reikeras O, Nygaard O, et al. Lumbar instrumented fusion compared with cognitive intervention and exercises in patients with chronic back pain after previous surgery for disc herniation: a prospective randomized controlled study. Pain. 2006;122(1-2):145-155.

19. Brox JI, Nygaard OP, Holm I, Keller A, Ingebrigtsen T, Reikeras O. Four-year follow-up of surgical versus non-surgical therapy for chronic low back pain. Ann Rheum Dis. 2010;69(9):1643-1648.

20. Bruns D, Mueller K, Warren PA. Biopsychosocial law, health care reform, and the control of medical inflation in Colorado. Rehabilitation psychology. 2012;57(2):81-97.

21. Robbins H, Gatchel RJ, Noe C, et al. A prospective one-year outcome study of interdisciplinary chronic pain management: compromising its efficacy by managed care policies. Anesth Analg. 2003;97(1):156-162.

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Pointing Fingers: Are Passive Prosthetics After Digital Amputation Really Valuable?

December 2015

Clinical Corner

Contributed by Carlton Clinkscales, MD, and Kelli Brazier, BA

In the Colorado Workers’ Compensation environment, finger amputations, by a variety of mechanisms, are commonly seen. They are most often treated by hand surgeons and hand therapists. While replantation is an option for a few select patients, not all are candidates. Many cases of isolated digital amputation “successfully” replanted are in fact “failures” due to stiffness, pain, numbness, and cold sensitivity. However, some patients with lost digits may experience emotional pain and difficulty. In some of these instances, passive (non-moving) digital prostheses may afford some credible benefit. 

It should be noted, however, that a discussion of passive cosmetic digital prostheses for partial hand or finger loss is vastly different from that of functional prostheses following loss of the entire hand or a portion of the upper extremity. This is a brief introduction to the potential issues involved in decision-making for patients after a partial finger, total finger, or partial hand amputation.

Prosthetic replacements currently available for these types of amputations are usually made of silicone, molded to the individual and, to some degree, artistically matched to the host part. Usually they rely on suction, but other techniques such as a wire coil base have been used. As passive devices, these do not bend or flex. Importantly, no degree of sensation is offered by any of the current prosthetic options. 

The benefits of cosmetic digital prostheses are primarily aesthetic, but emotional improvement during the rehabilitation program and potential long-term psychological value can be gained. In certain circumstances, there may also be social value in visually presenting a “whole” hand. 

Digital cosmetic prostheses are available in a variety of forms, ranging from a shaped, hard plastic mold to a highly individualized and realistic silicone proxy. John Claude Pillet is an established innovator and advocate of these particular prostheses. Many other programs have followed his lead. Hanger Inc. prostheses are currently the most readily available provider in Denver, Colorado.

Not all patients tolerate their digital prostheses well, however. As passive devices with weak attachments that make them somewhat insecure, they often get in the way of more normal hand activities. Lack of function and absent sensation often limit long-term use. In addition, over time the materials wear and discolor. As such, the high recurring costs for these devices are difficult to justify. 

Generally speaking, cosmetic prostheses for injured workers are not indicated. There may be special circumstances where a certain individual might benefit from a trial use. These should be limited to cases where there is a demonstrated emotional need or an isolated, documented, cosmetic requirement for specific social circumstances such as public speaking. This is best addressed by the designated provider.

Dr.  Clinkscales is a board-certified hand and orthopaedic surgeon with Hand Surgery Associates (303.744.7078). He spends most of his time at Littleton and Swedish hospitals where he treats a variety of hand and upper extremity trauma and reconstruction. 

References

1. White W. Why I hate the index finger. HAND. 2010;5(4):461-465.

2. Healio.com. The Psychology of Losing a Limb.  2002. Available at: http://www.healio.com/orthotics-prosthetics/prosthetics/news/online/%7B20bb0ac6-5ae1-4c65-b8e7-281ca1821228%7D/the-psychology-of-losing-a-limb. Accessed July 15, 2015.

3. Goyal A, Goel H. Prosthetic rehabilitation of a patient with finger amputation using silicone material. Prosthetics and Orthotics International. 2014;39(4):333-337.

4. Reddy R. Acrylic Finger Prosthesis: A Case Report. Journal of Clinical and Diagnostic Research. 2014.

5. Leow M, Pereira B, Kour A, Pho R. Aesthetic life-like finger and hand prostheses: prosthetic prescription and factors influencing choices. Annals Of The Academy Of Medicine, Singapore. 1997;26(6):834-9.

6. Aydin C, Nemli S, Yilmaz H. Esthetic, functional, and prosthetic outcomes with implant-retained finger prostheses. Prosthetics and Orthotics International. 2012;37(2):168-174.

7. Pillet J. Esthetic hand prostheses. The Journal of Hand Surgery. 1983;8(5):778-781.

8. Pillet J. And thus, the hand revealed its beauty. Journal of Hand Therapy. 1997;10(4):258-261.

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Pinnacol's New Path

December 2015

From Pinnacol's Medical Director

“We cannot solve our problems with the same thinking we used when we created them.” - Albert Einstein

I’m coming to like this quote more and more. It seems to sum up a lot of what’s happening here at Pinnacol these days.

I just joined Pinnacol a few months ago and I’m still getting my bearings, but every day I find myself more and more impressed with the people here.

Pinnacol has taken on a new challenge, one that is both simple and epic. The idea is simple: Fundamentally change how we care for employees in Colorado. But the reality of that challenge is huge. It will take us years to achieve and take us down roads we’ve never traveled before.

This is Pinnacol’s new path:

  • Better understand the needs of every employee we cover at work.
  • Support all of them in maintaining and improving their health and wellbeing.
  • Do everything we can to prevent illnesses and injuries but,
  • If they should be injured, help enable quality, patient-centered, compassionate care.

We’re very excited about this new road, but we can’t do it alone.

  • Our dialogue will be crucial to our success. Whether you have a complaint, a question or a bold new idea, I want to hear it. My door (and my email inbox) is always open to you.
  • If you want to change the world of workers’ comp, then this is your time.

You’ll be hearing a lot more soon about our new way of caring for employees but in the meantime feel free to reach out to me anytime with your thoughts and ideas. Together, we’re going to build something great.

Sincerely,

Rick May, MD
Orthopedic Surgeon
Senior Medical Director
Pinnacol Assurance
rick.may@pinnacol.com
Cell: 303.618.4366

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Reminder About Prescription Medication Dispensing

December 2015

Workers' Comp Coordination

Pinnacol Assurance allows medical clinics that dispense medications to provide a one-time, 14-day supply of medication to injured workers at the time of the injured worker’s initial visit. It is not appropriate for a clinic to continually dispense medications to an injured worker throughout the life of his or her claim. 

The intention of this policy is to provide the injured worker a convenient way to obtain the necessary medication immediately following an injury, and permit time for Pinnacol’s pharmacy benefit manager, Helios, to receive the patient information necessary to provide for the injured worker’s ongoing medication needs.

It’s important to note that a physician who dispenses a controlled substance from his or her clinic is not required to submit such information to the PDMP. The law requires only Pharmacy Board-registered pharmacies to submit controlled substance dispensing information to the PDMP. When medications are dispensed directly from a clinic, please remember that PDMP safety precautions are not in place to keep our injured workers from harming themselves and possibly others.

For the safety of our injured workers and their families, please adhere to the one-time, 14-day rule when dispensing medication(s) from your clinic.

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Pinnacol Broadens Focus to Employee Health and Wellness

December 2015

Workers' Comp Coordination

We’re thrilled about the recent launch of our new health and wellness strategy, a natural extension of our mission that will enable even better care for Colorado’s employees.  

Those of you who attended our recent SelectNet conference got a sneak peek from Pinnacol Vice President of Medical Operations and Healthcare Strategy Karyn Gonzales who introduced our evolving approach to preventing workplace injuries and improving patient outcomes.   

Research conducted on our successful worksite wellness program confirms a link between employees’ health and wellness and the frequency and severity of workplace injuries. That’s why we’re expanding our health and wellness efforts by broadening our worksite wellness program to make it available to all Pinnacol policyholders, at no cost, and enhancing care coordination for your patients. 

Care Coordination for Patients

Internally, we’re incorporating health risk factors that have the greatest impact on workplace injuries into our care management processes.

In addition, we’re pleased to announce new care coordination efforts with Aetna. For policyholders that are also Aetna customers, their employees can benefit from care coordination between Pinnacol and Aetna. 

This collaboration is the first of several we’re developing with other health plans, as well as health provider groups, in the coming months. These collaborations allow us to coordinate care between primary care providers and occupational medicine specialists. As a result, we can help to:

Protect patients from potentially dangerous drug interactions

Reduce duplicative tests, procedures and medications

Create better outcomes for injured employees

Improve employee’s overall health and wellbeing

We’re also building partnerships with community organizations, so that we can help connect employees to the right resources to manage health conditions before they affect productivity or complicate recovery from an injury.  New community partners include Colorado QuitLine (resources to quit tobacco) and the Carson J. Spencer Foundation (suicide prevention resources for policyholders in high-risk industries).

Our ultimate goals are to help Colorado employees stay healthy and well, reduce the frequency and severity of their injuries, better coordinate their care when they are injured, and get them back to work as quickly and safely as possible. 

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Important Rule Changes Affecting Workers’ Compensation Billing

December 2015

Billing/Administration

Pinnacol Assurance wants to ensure that you are aware of some important billing changes. The Colorado Division of Workers’ Compensation (DOWC) recently issued final utilization standards and the final Colorado Workers’ Compensation Medical Fee Schedule that affect all workers’ compensation billing and will go into effect January 1, 2016. Among several significant changes are that these rules and regulations require payers to adopt Medicare’s Resource-Based Relative Value Scale (RBRVS) method of payment. You should be aware of regulatory changes that will affect your billing, coding and processes, and make any necessary business adjustments now to ensure a smooth transition.

The DOWC set out to ensure that the transition to the new fee schedule and payment system would be budget-neutral overall; however, providers should examine the rules closely and analyze specifically how fee schedule changes may impact their payments for certain specialties. Under the new fee schedule we will continue to pay significantly more than average Medicare payment rates for workers’ compensation-related services. Pinnacol is working to ensure its systems and processes accommodate the rule changes, and we expect no payment disruptions. 

Key rule changes and reminders:  

  1. All rule changes are effective January 1, 2016.
  2. All workers’ compensation payers will be required to adopt the Medicare RBRVS payment method.
  3. Physician assistants and nurse practitioners will be reimbursed at 85 percent of fee schedule for workers’ compensation-related services. They will be eligible to follow special requirements in order to be reimbursed at 100 percent. Rule 18-5(A)
  4. An authorized treating physician must evaluate the injured worker by the third visit. Rule 16-5 (A)(6)  
  5. The DOWC and Pinnacol Assurance strongly encourage all providers, including nurse practitioners and physician assistants, to participate in Level 1 training to gain a better understanding of the Colorado workers’ compensation system’s unique treatment guidelines and legal and administrative rules. In addition, completing Level 1 accreditation along with accreditation for the DOWC’s Quality Performance and Outcomes Payment (QPOP) program will enable providers to receive additional reimbursement. Rule 18-5(G)(6)(C) 
  6. Chronic opioid drug tests are required prior to initial long-term opioid prescription issuance and must be randomly repeated at least annually. Rule 18-5(G)(5)
  7. Three new elements of documentation are required for functional assessments for pre- and post-spinal and SI joint injection. Rule 18-5(G)(6)
  8. Stand-alone pathology services performed at a facility can now be reimbursed using L1 modifiers. Hospital bill types are allowed payment for any clinical laboratory services when these lab services are unrelated to any other outpatient services performed that day. Modifier L1 should be appended to the billed laboratory services. Rule 18-6(J)(6)(D)
  9. In addition to the rule changes, we want to inform you that we can receive both ICD-9 and ICD-10 codes. It’s important to note that while the DOWC does not currently require ICD-10 compliance for workers’ compensation billing, providers may be required to use ICD-10 in the future, and the ICD-9 codes will no longer be updated.

We will continue to communicate key changes and recommendations. For questions about the rule changes, please contact the DOWC.

Division of Workers’ Compensation, 303.318.8700 (metro area), 888.390.7936 (toll-free) or cdle_workers_compensation@state.co.us

For Pinnacol claims-related questions, contact sandra.mansfield@pinnacol.com.

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Single-Payer Health Ballot Issue

December 2015

In The News

You may have heard about a voter initiative – Amendment 69 – that recently qualified for the 2016 ballot, aiming to create a single payer health care system in Colorado.

This Denver Post story provides some additional background.

Pinnacol Assurance is gravely concerned about the impact of this constitutional amendment on workers’ compensation, because it would subsume workers’ comp into the overall health care payment system.

While Pinnacol advocates for breaking down the silos between health care and workers’ comp, such alignment must preserve the safeguards that workers’ comp provides to injured workers, their employees, and the providers who treat them. The ambiguous wording of the amendment raises significant questions about its impact on Colorado’s workers’ comp system, which is one of the best in the country.

Pinnacol’s legal team is analyzing the amendment in detail, and we will continue to update you as more information becomes available.

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Phantom Limb Pain

September 2015

Featured Story

Contributed by Robert I. Kawasaki, MD
Board Certified, Physical Medicine and Rehabilitation
Managing Member, Colorado Pain and Rehabilitation

Phantom limb pain (PLP) is a fascinating problem where patients with amputations experience severe pain in the limb that no longer exists. Patients describe their pain with neuropathic qualities “tingling, sharp, shooting, or electrical” and nociceptive qualities “cramping, squeezing, and dull”. The pain can involve the entire limb, or be localized to one region of the missing limb.

Between 2006-2012 the workers’ compensation system in Colorado averaged 106 amputations annually. The most common work-related amputations involved full or partial loss of fingers. Less commonly, amputations involved an arm, leg, foot, toe, nose or ear.

Among patients with amputations, 60%-80% patients experience PLP within the first week after amputation, lasting typically around six months. Some studies have reported prevalence of PLP and development of chronic pain after amputation as high as 85%.

Higher degrees of trauma, severity and duration of pain in the extremity prior to and after amputation has been correlated to increased severity and chronicity of PLP. A musculoskeletal, neurological and vascular examination for PLP includes gait assessment, range of motion, residual limb length and circumference, skin integrity, sensory and motor function. Differential diagnoses for post amputation pain includes infection, skin breakdown, heterotopic ossifications, fractures, myofascial pain, DVT, stroke, radiculopathy, Complex Regional Pain Syndrome (CRPS), neuromas and other peripheral nerve entrapments. 



Treatment includes proper stump care, early application of prosthesis and physical therapy. Modalities include massage, TENS units, range of motion, acupuncture, edema control and desensitization techniques.

Non-opioid pharmacological treatment of PLP include medications commonly used for neuropathic pain and conditions such as CRPS:

Opioid medications can be effective in reducing PLP. Pain psychological and addiction risk screening should be utilized. Monitoring is required, including urine toxicology and frequent PDMP review. For acute pain, short-acting opioids may be appropriate in tapering doses. For PLP patients with chronic pain, conversion to long-acting opioids should be considered. Department of Regulatory Agency Policy for Prescribing and Dispensing Opioids and Division of Workers’ Compensation Medical Treatment Guidelines for Chronic Pain should be followed.

Interventional pain procedures may include:

Surgical indications are rare:

Emotional distress after amputation can be significant, with high risk of adjustment disorder, posttraumatic stress disorder and chronic pain syndrome. A full pain assessment with risk screening should be included per pain management guidelines. A comprehensive psychological assessment, including cognitive, emotional, interpersonal and vocational status, should be performed. Early emotional support, psychological evaluation and cognitive behavioral intervention are highly recommended.

PLP is an unfortunate, common problem for post amputation patients. Treatment options are similar to neuropathic pain, CRPS, and chronic pain guidelines.

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Presurgical Psychological Evaluations Explained

September 2015

Clinical Corner

Contributed by Daniel Bruns, PsyD

At first glance, the idea of a presurgical psychological evaluation seems counter-intuitive. How could a psychological evaluation possibly predict the outcome of an orthopedic surgery? Surprisingly, though, research has shown that psychological evaluations are reliable predictors of the outcome of numerous types of surgery.1,2 How can this be?

We generally think about surgery as an objective solution to an objective medical problem. For example, an objective problem might be that a patient is suffering from a herniated lumbar disc, and the goal of surgery is to fuse two vertebrae together to alleviate this problem. In most cases, though, the ultimate goal of surgery goes well beyond the objective goal of achieving a successful fusion. The most common goals of surgery are helping the patient to return to work, to reduce opioid use and hopefully to be satisfied with medical care. Of these three goals, the first two are behaviors and the third one is an attitude. When it comes to predicting changes in attitudes and behaviors, it makes sense that psychological tests would be stronger predictors than MRIs or CT scans. Consistent with this, in the case of spinal pain, psychological tests have been shown to be more predictive of surgical outcome than MRIs.3,4 Beyond that, a thorough review of the evidence determined that psychological tests are the scientific equal of medical tests.3

A recent study of lumbar fusion surgery found that even though surgery was objectively successful 84% of the time, following the surgery 49% of the patients had worse pain, 44% were dissatisfied with their outcome and 38% were totally disabled at follow-up.5 Similarly, another study found that opioid pain medication use actually increased following lumbar fusion surgery.6 This illustrates an important point: It is possible for an orthopedic surgery to simultaneously be an objective success and a behavioral failure. To prevent this possibility, it is helpful to evaluate nonmedical risk factors prior to surgery.

Psychological, social and behavioral variables are known to affect the outcome of surgery and other medical treatments,7 and they do so in various ways:

The Chronic Pain Treatment Guidelines published by the Colorado Division of Workers’ Compensation make recommendations about how and when to conduct presurgical psychological evaluations. These guidelines require or strongly recommend psychological evaluations for patients suffering from chronic pain or delayed recovery, and for patients prior to lumbar fusion, artificial disc surgery, spinal cord stimulation, discography, facet rhizotomy, IDET, some shoulder surgeries, and back surgery if Waddell signs are > 2.16

Under the guidelines, when performing a presurgical psychological evaluation, the first task of a psychologist is to look for what are called “primary risk factors.”16 Primary risk factors are psychosocial risk factors that are so severe that the presence of just one could preclude the patient from benefiting from the proposed surgery. Examples of primary risk factors would include suicidal impulses, daily use of methamphetamines or paranoid psychosis associated with mania. Patients exhibiting primary risk factors are generally thought to be too psychologically unstable to benefit from elective surgeries or to comply with treatment generally. Even though primary risk factors are extreme, one recent national study found that of patients in rehabilitation for pain or injury, over 10% exhibited one or more primary risk factor.7

Consider a case of a patient who suffers from both back pain and suicidality. Of the two, the suicidality is the more serious condition, as it is potentially fatal, whereas back pain is not. Because of that, treatment of the suicidality should take priority over the treatment of the back pain. Overall, when primary psychological risk factors are present, the patient is so psychologically unstable that there is a high risk that a surgery would have a poor outcome. It should be pointed out here that some surgeries are performed because of a medical emergency, such as a lumbar surgery for cauda equina syndrome to prevent paraplegia. In cases where there is a high level of medical necessity, the surgery is performed, and any associated psychosocial risk factors are managed perioperatively.

Under the guidelines, a presurgical psychological evaluation should also assess “secondary risk factors.”16 If primary risk factors could be thought of as “red flags,” secondary risk factors could be thought of as “yellow flags.” Secondary risk factors are moderate but significant psychosocial risk factors for surgical outcome. Examples of secondary risk factors would include moderate depression, moderate anxiety, job dissatisfaction, long-term use of prescribed opioids and excessive disability. Virtually all patients with a disabling injury will have one or more secondary risk factors. Unlike primary risk factors, where the presence of one severe risk factor may exclude the patient from being considered as a surgical candidate, in the case of secondary risk factors, it is the overall number of risk factors present that is assessed. When patients are exhibiting an elevated number of secondary risk factors,7 alternative, more conservative treatments should be considered. The presence of primary and secondary risk factors have been found to be associated with a poor outcome from medical treatment generally.

The goal of a presurgical psychological evaluation is to identify primary and secondary risk factors, and based on that and other findings, recommend the best care plan for a patient. Surgical patients with a high level of psychosocial risk are much more likely to be dissatisfied with their care.7 For these patients, conservative care is often a better alternative to elective surgical procedures. Interestingly, studies have found that a psychological pain management treatment called cognitive behavioral therapy (CBT), which is sometimes combined with physical therapy, can produce outcomes equal to surgery.17,18,19 Even though surgery and CBT are equally effective for back pain, surgery can cost up to 168 times more than CBT and is associated with both adverse outcomes and risk of death. If the presurgical psychological evaluation suggests that the patient is at high risk for being unhappy with the surgical outcome, there is little reason to expose that patient to the risk of surgery. It is important to remember, though, that the presence of a high level of psychosocial risk factors does not mean that the patient will never be a candidate for surgery, as in many cases these risk factors can be addressed through appropriate treatment.

Overall, while studies have shown that patients with a high level of psychosocial risk are unlikely to benefit from surgery alone,1,2,7 these patients can often benefit when an interdisciplinary approach to care is used that integrates psychological and medical interventions.18,19 By helping to identify the best treatment plan for a patient, presurgical psychological evaluations play an important role in the treatment of injured workers.

View references for this article here.

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