Articles from prior issues of The Advocate

September/October, 2001

Tips for Evaluating and Understanding Pain
by Linda Foster, Missouri DDS

THOSE WHO ATTENDED THE recent MADE conference had the special privilege of hearing a presentation on the musculoskeletal system by Dr. Janie Vale, a medical consultant in the Jefferson City office. Dr. Vale has practiced clinical occupational medicine for twenty years and has brought to the Missouri DDS a vast knowledge of the ways in which pain can cause limitations in the ability to function. The discussion was limited to two of the common physical complaints we as disability examiners hear most often, back impairments and fibromyalgia.

BACK IMPAIRMENTS:

The most commonly affected area of the back in younger people is L5-S1. Around age 35-40, L4-L5 will begin to become more painful. Much older individuals are more likely to develop problems in L2-3-4. This particular area is functionally much more severe than L4 to S1 and will cause the greater amount of complaints of difficulties with bending and sitting. In addition, individuals with higher-level disc disease don’t do as well postoperatively.

One of the primary causes of back problems is the size of the back muscles. The job of the muscle is to stabilize the spine, but compared to the size of most other body muscles, the spine muscles are fragile and thin. The best way to strengthen the spine muscles is by extending them. Unfortunately, most of our tasks require forward flexing rather than back extension. Dr. Vale also suggested exercises that will involve motion of all four quadrants, such as walking, biking or swimming to help improve hydration in our discs.

By age twenty to twenty-four our bodies begin to loose dedicated blood flow to the disc; so by age 24 our space between discs begins to shrink and shorten. Our discs also lose fluid during the day, causing us to be slightly shorter by the end of the day.

Special tips for the disability examiner

1. Don’t just focus on the Impression at the conclusion of a report, but read the entire body of your x-ray and MRI reports. Radiologists are trained to feed information to the surgeon, but they are not trained in functioning, so the impression will often not include all the necessary points.

2. Individuals with spinal stenosis have a legitimate impairment that will cause pain while sitting, standing or walking. They will prefer to perform all tasks in a leaning position, and will often report needing to lean on a cart while shopping for groceries or on the sink while washing dishes.

3. Patients with first or second level thoracic spine disc disease will commonly and legitimately complain of difficulties while sitting, reaching or working overhead.

4. In SLR (straight leg raising) testing, an individual who indicates an inability to raise to 45 degrees is likely malingering.

5. Keep handy at your desk a diagram that explains to correlation between spine nerves and muscle function. This can often be a tool to support a claimant’s allegation of limitation.

6. Degenerative disc disease of the cervical spine is more limiting than one would think because it feeds a pain message to the entire spine and will also cause leg pain.

FIBROMYALGIA:

Dr. Vale describes fibromyalgia as a generalized, persistent idiopathic musculoskeletal pain condition associated with the presence of numerous tender points that reliably differentiate it from other rheumatic conditions. Tender points (and these are tender points, not trigger points) are localized areas that are exquisitely tender to light touch. Of the eighteen tender points, a person would need eleven points to substantiate a diagnosis of fibromyalgia. Dr. Vale emphasized that tender points should be symmetrical and that the patient should also have non-tender points.

The vast majority of fibromyalgia cases are preceded by a persistent localized or regional pain condition, which appears to start breaking down the patient’s chemical condition. An example of this would be a person with an injury to an arm or leg who later begins complaining of multiple other body pains. Fibromyalgia is the end stage of the condition. Fibromyalgia is characterized by wide spread pain in all four quadrants of the body, for at least three months duration, accompanied by a decreased pain threshold. A person with true fibromyalgia will have at least five of the following: sleep disturbance, morning stiffness, fatigue, poor immediate recall, poor concentration and decreased ability to multi-task. There is no cure for fibromyalgia at this time. Dr. Vale reports that weight loss does seem to help decrease the pain, but since most patients with fibromyalgia are in pain, it is difficult for them to exercise. The medications used for a patient with Fibromyalgia are not intended to cure, but rather, to restore the chemical that the particular patient seems to be missing. For instance, sleep disturbance appears to be the most common complaint of patients with fibromyalgia. Due to this, the first medication a physician will usually try is Amitriptyline (Elavil), which is known to restore Seratonin and normalize sleep patterns.

Special tips for the disability examiner:

1. A patient will often appear to have symptom magnification, but it should be remembered that part of the definition of fibromyalgia is a decreased tolerance to pain.

2. Individuals with true fibromyalgia will have a decrease in ability to function and will often not be able to perform the same level of exertion as their usual job. Dr. Vale recommended that, generally, an RFC for the next lower level of functioning would be appropriate.