th
17
Annual Worker
Compensation Seminar
Please report any concerns
or offenses taken to the
COMPLIANCE OFFICER
Dan Hein 901 756-0068
Email address: Dhein@mskgroup.org
ROCKEFELLER
Tennessee Workers’
Compensation Reform
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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, MD
MOG Work Comp Seminar
April 16, 2014
Definition
Prevalence
Detection/Appreciation
Treatment 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 malingering
Staying 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 caution
Under normal circumstances the clinician
rarely gets sufficient evidence for such
definitive labeling
Suggests 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.”
Symptom Magnification
Unconscious Motivation
Somatoform Conditions
Schemas
Factitious Disorders
Other Physical Diagnoses
Aging
Missed Diagnosis
Doctor Bias
Malingering is defined as conscious
motivation
Unconscious motivation means patient is
not entirely faking, but problems are not
simply physical
A lot like teenagers
Capacity to cope with adversity
Physical symptoms are not intentional
Example: paralysis of limb
High order abstraction of a person’s
understanding
Frequently wrong
One study showed it’s the best predictor
of RTW
94% RTW if good understanding
33% RTW if poor understanding
Examples
degenerative 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 teenager
Strong conviction
Questionable foundation
Psychological (as opposed) to intentional
motivation in order to assume the sick
role
Munchausen
Pain associated with aging isn’t always
gradual
Arthritis does make people more
susceptible to injury
People 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 painless
Difficult to distinguish pain from
aging and work injury
Fortunately, not very common
Psychiatric patients can have medical
problems
MRI’s, nerve studies can be very helpful
Work comp doctors vs. Attorney doctors
Reluctance to be the “bad” guy
Hoover Commission - 1993 California
20-30% of work comp claims are fraudulent
cites financial incentives to fake injury/stress
no 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 2012
2%
used malingering as the measurement
“The reality of course is that no one
knows what the real numbers are.”
Surveillance
Psychological Tests
History
Physical Examination
Isokinetic Testing
Possibly the only way to “prove”
malingering
Disadvantages
expensive
time consuming
hard to catch someone “in the act”
Many tests have been developed
MMPI - Minnesota Multiphasic Personality
Inventory
TOMM - Test of Memory Malingering
Opinions vary
None are conclusive
Based on probabilistic evidence
Rare or bizarre symptoms
Symptoms worsen or don’t improve with
time/rest
Symptoms begin after a latency period
Multiple symptoms
Hostility - “Why am I not getting better?”
Drama - tears, family members present
Friends/relatives with history of disability
or having reaped financial benefit from
claims
Substance abuse, especially of
prescribed analgesics and sedatives
Attorneys
Vague or implausible history
Discrepancies in injury history/
inconsistent pain description
Elaborate imagery to describe pain
Emergency room visits
Pain rated 9 or more out of 10
Symptom Proliferation
Total Body Pain
Unable to move legs/ collapsing/
sudden numbness
Shaking
Tears
Blames 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
irritable
Patient critical of previous doctor
Symptoms worsen despite treatment and
rest
Setback as return to work date
approaches
Multiple return to date extensions
Waddell’s signs
skin tenderness
simulation tests (pressing on the head)
distraction testing
regional disturbances
exaggerated pain response
Studies of Waddell’s signs
One sign present in 47% of patient’s whose work
status did not improve
One sign present in 12% of patient’s whose work
status did improve
https://pdsmemphis.haikulearning.com/wmay/math2013-2014/cms_page/view/10802919
Strange limp
Glove/stocking pain or numbness
Give away weakness
Variable grip
Patient grabs examiners hand
Perhaps the only test for malingering
supported by empirical evidence
Performed with a constant speed of
angular motion but variable resistance
Pre-employment physicals
Some of these patients never should have been
hired to do the job they are being asked to do
Thorough history and exam
Treat a diagnosis
Avoid nebulous pain diagnosis
Avoid suggesting an incorrect diagnosis
Confirm diagnosis (MRI, EMG/NCS)
Improved understanding of malingering vs.
symptom magnification
Be alert to signs/red flags
Set expectations with the patient
Address schemas as they arise
Use exam and diagnostic tests
Confirm (Isokinetics, second opinion)
Accept that some unhappy resolutions are
inevitable
Call
Email
Lower Extremity
Fractures
ACL Injuries
Christopher Ferguson, MD
Memphis Orthopaedic Group
ANTERIOR CRUCIATE
LIGAMENT
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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
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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
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Stronger
More pain post op
Increased surgical time
Standard choice for
younger patients
ALLOGRAFT
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Less surgical time
Less morbidity
Faster rehab
More expensive
Higher failure rates
Risk of infection
 AUTOGRAFTS
 ALLOGRAFTS
• Patellar tendon
• Patellar tendon
• Hamstrings
• Hamstrings
• Quad tendon
• 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 preinjury level of function
 Significant
athletes
risk of re-injury in young
Thank you