17th Annual Worker Compensation Seminar

Please report any concerns or offenses taken to the COMPLIANCE OFFICER

Dan Hein 901 756-0068Email address: Dhein@mskgroup.org

ROCKEFELLER

Tennessee Workers’ Compensation Reform

Jeff Francis Assistant Administrator Workers’ Compensation Division, Tennessee Department of Labor and Workforce Development   A native of middle-Tennessee, Jeff received his B.B.A. degree in

Marketing from Austin Peay State University in 1983 and his Master’s Degree in Labor Studies from the University of Massachusetts in 2000.

  As a Program Coordinator for the Tennessee Department of Labor and

Workforce Development from 2004 until April 2008he developed and managed the Medical Impairment Rating Registry.

  He is now the Assistant Administrator of the Workers’ Compensation

Division of the Tennessee Department of Labor and Workforce Development. His responsibilities include the budgeting, Human Resources, Information Systems, and Claims and Coverage aspects for the Division. He has been married to his college sweetheart for over 27 years. They have a married daughter teaching the third grade and a son who recently graduated from MTSU, who recently came off his dad’s payroll.

Proximal Humerus Fractures: Evaluation

and Management

Malingering

Kenneth A. Grinspun, MDMOG Work Comp Seminar

April 16, 2014

DefinitionPrevalenceDetection/AppreciationTreatment Strategies

Bane of work comp!We all know it’s there, but what can we do about it?Why do patients malinger/magnify?How do we spot them earlier?How can we decrease the aggravation?How can we decrease costs?

Proving malingering Confronting malingering

The moment a malingerer is confronted, the traditional doctor patient relationship breaks down

Treating malingeringStaying on the same team

IME’s, 2nd opinions...

“Clinicians may be reluctant to address this behavior directly, even if there is strong evidence, because they are afraid of the consequences (e.g., mislabeling someone, being threatened, or being sued) [Binder & Iverson, 2000]Social media pushback

Not much, just half a page!Use the term with cautionUnder normal circumstances the clinician rarely gets sufficient evidence for such definitive labelingSuggests using the term symptom magnification because its more clinically accurate and less likely to create disputes

“The essential feature of malingering is the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as avoiding military duty, avoiding work, obtain financial compensation, evading criminal prosecution or obtaining drugs.”

Unconscious MotivationSomatoform ConditionsSchemasFactitious DisordersOther Physical Diagnoses

AgingMissed DiagnosisDoctor Bias

Symptom MagnificationSymptom Magnification

Malingering is defined as conscious motivationUnconscious motivation means patient is not entirely faking, but problems are not simply physicalA lot like teenagersCapacity to cope with adversity

Physical symptoms are not intentionalExample: paralysis of limb

High order abstraction of a person’s understandingFrequently wrongOne study showed it’s the best predictor of RTW

94% RTW if good understanding33% RTW if poor understanding

Examplesdegenerative disc disease progression“I want to be 100% before I return to work”friends/family/attorney experiences with work comp and/or disability

It reminds me of dealing with a teenagerStrong convictionQuestionable foundation

Psychological (as opposed) to intentional motivation in order to assume the sick roleMunchausen

Pain associated with aging isn’t always gradualArthritis does make people more susceptible to injuryPeople may not be as “tough” as the used to be

1990’s TKA dissatisfaction - 10%2010’2 TKA dissatisfaction - > 20%

Job descriptions that are clearly not in line with a person’s age

Getting old isn’t painlessDifficult to distinguish pain from aging and work injury

Fortunately, not very commonPsychiatric patients can have medical problemsMRI’s, nerve studies can be very helpful

Work comp doctors vs. Attorney doctorsReluctance to be the “bad” guy

Hoover Commission - 1993 California20-30% of work comp claims are fraudulentcites financial incentives to fake injury/stressno objective measurements/testing

2009 Study - Prevalence of malingering for chronic pain in the context of a medico-legal setting with financial incentive

20-50%clinical diagnostic systems used

AFL-CIO 20122%used malingering as the measurement

“The reality of course is that no one knows what the real numbers are.”

SurveillancePsychological TestsHistoryPhysical ExaminationIsokinetic Testing

Possibly the only way to “prove” malingeringDisadvantages

expensivetime consuming

hard to catch someone “in the act”

Many tests have been developedMMPI - Minnesota Multiphasic Personality InventoryTOMM - Test of Memory Malingering

Opinions varyNone are conclusiveBased on probabilistic evidence

Rare or bizarre symptomsSymptoms worsen or don’t improve with time/restSymptoms begin after a latency periodMultiple symptomsHostility - “Why am I not getting better?”Drama - tears, family members present

Friends/relatives with history of disability or having reaped financial benefit from claimsSubstance abuse, especially of prescribed analgesics and sedativesAttorneys

Vague or implausible historyDiscrepancies in injury history/ inconsistent pain descriptionElaborate imagery to describe painEmergency room visitsPain rated 9 or more out of 10

Symptom ProliferationTotal Body PainUnable to move legs/ collapsing/ sudden numbnessShakingTearsBlames life problems and mood on physical condition

“I’ve worked all my life” (asserts former independence)Pain has changed entire life“I just want to get rid of the pain and get on with my life”“I fear I will be unable to work again”Has family member phone for medications (passive dependency)

Patient angry at employer/ generally irritablePatient critical of previous doctorSymptoms worsen despite treatment and restSetback as return to work date approachesMultiple return to date extensions

Waddell’s signs skin tendernesssimulation tests (pressing on the head)distraction testingregional disturbancesexaggerated pain response

Studies of Waddell’s signsOne sign present in 47% of patient’s whose work status did not improveOne sign present in 12% of patient’s whose work status did improve

https://pdsmemphis.haikulearning.com/wmay/math2013-2014/cms_page/view/10802919

Strange limpGlove/stocking pain or numbnessGive away weaknessVariable gripPatient grabs examiners hand

Perhaps the only test for malingering supported by empirical evidencePerformed with a constant speed of angular motion but variable resistance

Pre-employment physicalsSome of these patients never should have been hired to do the job they are being asked to do

Thorough history and examTreat a diagnosis

Avoid nebulous pain diagnosisAvoid suggesting an incorrect diagnosis

Confirm diagnosis (MRI, EMG/NCS)

Improved understanding of malingering vs. symptom magnificationBe alert to signs/red flagsSet expectations with the patientAddress schemas as they ariseUse exam and diagnostic testsConfirm (Isokinetics, second opinion) Accept that some unhappy resolutions are inevitable

CallEmail

Lower Extremity Fractures

ACL Injuries

Christopher Ferguson, MDMemphis Orthopaedic Group

ANTERIOR CRUCIATE LIGAMENT

Primary restraint to preventing the tibia from “sliding forward” with knee motion

Secondary restraint for “side bending” knee stability (varus/valgus stress)

Valgus stress with tibial rotation

Hyperextension of the knee

Sudden direction change with weightbearing (“Cutting”)

Contact sports

History• Mechanism of injury• Reported knee

instability

Decreased ROM Swelling Instability on exam Anterior drawer test,

Lachman’s test, Pivot shift

Xray Findings• Usually

normal• “Segond

Fracture”

Meniscal tears Articular cartilage

injuries and bone contusions

Collateral ligament injuries

ACL, PCL, … (knee dislocations)

Protect the knee• Meniscus (25% injury at 5 yrs w/o surgery)• Articular cartilage damage • Other ligaments

Return to previous level of activity

Rehab• Quad/hamstring

strengthening• Proprioceptive

training

Bracing

Timing of surgery Graft choice Surgical technique

AUTOGRAFT

Stronger More pain post op Increased surgical time Standard choice for

younger patients

ALLOGRAFT

Less surgical time Less morbidity Faster rehab More expensive Higher failure rates Risk of infection

AUTOGRAFTS• Patellar tendon• Hamstrings• Quad tendon

ALLOGRAFTS• Patellar tendon• Hamstrings• Achilles• Ant/Post Tibialis• Quad tendon

Patient selection Pre-op knee motion Placement of

tunnels Appropriate graft

selection Adequate fixation Rehab Patient compliance

Poor ROM Arthrofibrosis Graft failure Persistent pain DVT Infection

Early ROM Progress quickly to full weightbearing Quad and hamstring strengthening Return to full activity at approximately 6

months is common May take 18 months for knee function to

maximize

Good to excellent outcomes in > 90% of cases

Less than 50% of athletes return to pre-injury level of function

Significant risk of re-injury in young athletes

Thank you