Category: Workers’ Compensation

What’s the difference between an MRI and an X-RAY?

Workers' Compensation

X-rays are inexpensive, quick, and usually done right in the doctor’s office. They use a theoretically dangerous ionizing radiation to create images of bones and dense tissue. In the small doses that you receive during a few x-rays there’s probably nothing to worry about. An MRI is expensive (30-40 times as expensive as an x-ray), takes about 30 minutes, and the equipment is often not available in the average doctor’s office although more and more orthopedic surgeon’s offices are equipped with them. An x-ray is far better than an MRI at detecting fractures in a bone, but an MRI is far better at spotting damage to a soft tissue like a ligament, tendon, or disk. As a practical matter, workers’ compensation adjusters like to avoid the expense of an MRI unless other options have been exhausted first.

This doesn’t mean there is no way that the adjuster will promptly authorize an MRI. If there is overwhelming evidence of a disk injury she may well go ahead and do it. But don’t be surprised if there is a delay. This delay can be lessened if you let us push the issue down at the Industrial Commission.

What is evidence based medicine?

Workers' Compensation

This could be answered on two levels. Mind you our answers, being those of workers’ compensation lawyers, may not be the answers which doctors would give you.

The first level, that of medical journals and the like, evidence based medicine is an attempt to make medicine more of a system using the “current best evidence in making decisions about the care of individual patients.” On the second level, the level of evidence based medicine as it seems to be practiced by doctors who speak at Industrial Commission conferences and treat a lot of injured workers is to put great emphasis on all the scientific aspects of the examination and significantly less emphasis on what a patient is telling them. At least that is what is reported to us by many patients.

What it comes down to is that a lot of injured workers are really lousy at explaining how they got hurt and where precisely they hurt and what makes the pain increase or decrease. Accordingly, their complaints have little value in terms of science. On the other hand physical examinations and tests like x-rays, CT scans, and MRIs are accorded great scientific value.

A doctor may discount what you are telling him if he cannot confirm it scientifically. That sort of stinks if your adjuster won’t authorize the MRI, which would provide that confirmation. In terms of putting evidence based medicine into practice for treatment options a doctor may emphasize the statistical results of other patients around the world and less on the potential benefit in a given patient. The problem with all this is that if your body doesn’t respond to a course of treatment like 95% of the rest of the world does it doesn’t make you a liar. It means you’re an exception. Exceptions are known to exist. It’s unfair to dismiss a patient just because they are an exception.

In a perfect world evidence based medicine sounds like a great idea. In the real world of competing interests and power struggles we’ve seen it misused and sometimes does nothing other than providing a fancy name for an excuse to not pay attention to you.

What is attendant care?

Workers' Compensation

In it’s simplest form it’s what it sounds like: someone who attends to, or pays attention to, you. When you’ve got the flu it’s good to have someone who will check on you, get you some medicine, and bring you something to drink when you want it. That’s what loved ones do. Now say you had a total knee replacement and cannot walk or stand for any meaningful length of time. And throw into the set of facts that you are single and live alone. You need someone to take care of you. There is no way your are going to heal if you are having to abuse yourself taking care of your every day activities. The adjuster needs to pay for attendant care. It’s part of getting you better just like therapy, medications, and surgery.

Let’s take this scenario a step further. Everything is the same except that you are married. What’s the adjuster going to do? In at least 99% of the thousands of cases we’ve handled the adjuster expects your spouse to take care of you. If that means he or she takes time off of work without pay or uses up vacation or Family Medical Leave Act time the adjuster doesn’t really mind. We think this is wrong. Just because you have family who loves you doesn’t mean the insurance company shouldn’t pay for your medical care.

Largely through the efforts of one insurance company – after losing a case in the Court of Appeals about attendant care – the 2011 laws placed strict regulations on attendant care. We’ve become adept at making sure our clients are in compliance with these new (and in our opinion unnecessary) rules. The key thing is that your doctor needs to document the need specifically, for a limited period of time, in advance of the surgery. If things are done correctly your loved one will be compensated for the services he or she provides. Keep in mind, though, that the compensation rate is what a home health aide would get paid – usually about $10.00 – even if that’s less than what your spouse makes on their job. Every little bit helps though.

What is pain management?

Workers' Compensation

Wikipedia gives as good a definition as any: Pain management is a branch of medicine employing an interdisciplinary approach for easing the suffering and improving the quality of live of those living with pain. That’s well and good but what does it mean in the context of workers’ compensation?

We usually see pain management coming when a surgeon is done with you but you still have problems functioning and with pain. The surgeon may see his role as ending after the operation. It is up to a different specialty to handle the long-term results and recovery from this. While that could seem like the surgeon is just handing you off to someone else it’s not that simple and it’s not that callous.

In a deposition we took a prominent pain management doctor testifies that 80% of patients with chronic pain (that is defined as pain which last for six months or more) will develop clinical depression. Our bodies are not designed to put up with pain for that long. As much as we all want to see people get 100% better sometimes that doesn’t happen. People learn to live with pain. They do this sometimes with medications, sometimes with therapy and exercise, sometimes with counseling, and often with a combination of all that. Truthfully, managing all this is a skill set completely different than performing surgery.

Clients shouldn’t feel neglected or abandoned when their surgeons refer them to pain management. What we do see happen, though, is that pain management specialists can seem to exhibit a certain sense of prejudice. A lot of injured workers have reported that their pain doctors view them skeptically. It’s almost as if it’s ok to be in pain management if you have cancer but if you are there after a failed back surgery you should buck up and stop your whining and nothing cures like some tough love or a kick in the butt. If true such an approach is reprehensible in our minds.

Our best advice to clients in this predicament is to avoid playing into stereotypes and prejudices. As we’ve said repeatedly it is important to retain your credibility with your doctor. That means you’re complaints and self-assessments should be accurate, clear, and not exaggerated. It’s important to note that we’ve seen plenty of medical records with references to “non-organic pain” or “non-physiological pain” and “symptom magnification.” Many of these doctors are clued in for evidence that you are not being accurate or honest. When it comes to an issue like pain, which cannot be measured with a thermometer or an MRI, you word has to be 100% solid.

What is a functional capacities evaluation?

Workers' Compensation

A Functional Capacities Evaluation, or FCE, is theoretically a test that fairly and accurately evaluates a person’s capacity to work at certain levels over a lengthy period of time. There are a number of different FCE systems in place but they share certain things in common.

First, a therapist will likely explain what is expected and tell you that you do not need to perform any tasks that you feel you cannot safely do. She or he will interview you to confirm what your injury is.

Second, the therapist will likely perform a series of physical tests moving you around and asking you to do things while distracting you by speaking to you or having you answer questions. The purpose of this is to see if you unconsciously move without pain when you have already told them it hurts to move.

Third, the therapist will perform an extensive number of validity tests. Some, such as a test that tests your ability to squeeze a handgrip, are designed to see if you are giving full effort, have a significant support among medical literature. Others, such as a series of tests given to people complaining of back pain, have been repudiated by the designer of the test.

Fourth, the therapist will prepare a report which will be given either to your doctor or to your rehabilitation nurse. While we have seen an instance of a rehabilitation nurse falsifying the FCE results before giving them to the doctor we believe this to be a rare occurrence.

An FCE can be very beneficial to an injured worker to the extent that it demonstrates to a doctor what you can and cannot do. The downside of the FCE, in our experience, is that the therapist has a tremendous amount of flexibility in deciding if you’ve given full effort. Nothing, we repeat, nothing will destroy your relationship with a doctor like a FCE report which says you gave less than full effort.

What causes us a lot of concern is that some physical therapy groups aggressively market their FCEs to insurance adjusters as a way to bring claims to a close. That, to us, seems like a thinly veiled promise to either recommend little to no restrictions or to declare someone to be giving submaximal effort. We reviewed a report from one such group that stated in the opening and closing paragraphs that the patient had failed some validity tests and had given submaximal effort. When we combed through the full report (which, by the way, was not given to either the doctor or us… we had to subpoena it) we discovered that the client had passed 27 of 30 validity tests. So yes, it was true that he had failed three. And yes in English “three” is “some” but we believed this to be a clear effort to paint a negative picture about a very honest injured worker. Another example we’ve seen repeatedly is a therapist asking a patient about his pain level before and then after the test was done. According to this particular FCE protocol if your pain is 5/10 when you start the FCE your pain should be no more than a 7/10 when you finish. If you say it’s an 8/10 then you get dinged for symptom magnification. Why? Because the FCE protocol says your pain should only go up by two points. Huh?

A substantial amount of literature supports the theory that an FCE should be performed twice. It’s well documented that a person’s performance may appear submaximal strictly due to the unfamiliarity of the situation. We’ve personally had many clients whose second performance has no trace of submaximal effort reported – even though the overall demonstration of strength did not change one bit.

Finally, many believe that indisputable evidence such as temperature, blood pressure, and heart rate are more reliable indicators of effort than the subjective impression of therapists who market their testing to workers’ compensation adjusters.