Why 40%-80% of Chronic Pain Patients Are Misdiagnosed and How to Correct That

Nelson H. Hendler, M.D.
Former Assistant Professor of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, US

Series: Pain Management – Research and Technology
BISAC: MED022000

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This book is authored by a former faculty member of Johns Hopkins University School of Medicine and the past president of the American Academy of Pain Management, and the Reflex Sympathetic Dystrophy Association of America. He previously has authored three books, 33 medical textbook chapters, and 59 articles. The book addresses conceptual methods of problem solving as they are applied to medicine. This book is designed to be the “freakanomics” for medicine. Many research reports document that 40%-80% (or more, for certain disorders) of chronic pain patients are misdiagnosed. The leading cause of this failure is inadequate history taking and the use of the wrong medical tests. Part of this problem is the failure to recognize the specificity and sensitivity, as well as the false negative and false positive rates, of medical tests in use today. As an example, there are many articles in the literature which document that the MRI, an anatomical test, missed the detection of a damaged vertebral disc up to 78% of the time. The book explores the use of physiological tests, such as facet blocks, root blocks, peripheral nerve blocks, and provocative discograms to supplement anatomical testing. Compiled into a step-wise fashion, this book addresses the issues and provides methods to correct these problems. The techniques of history taking and the application of the correct medical tests have been proven effective, based on dramatic improvement in patients documented by outcome studies, which are validated by third parties, (not just self-reported). This book offers information based on evidence based medicine, not opinion. It provides information on how to think, not what to think.

Foreword: by Donlin Long, MD, PhD, former professor and chairman of neurosurgery at Johns Hopkins University School of Medicine

Presently - Distinguished Professor Emeritus of Johns Hopkins University School of Medicine

Preface

Chapter 1. Acute versus Chronic Pain

Chapter 2. The Need for a Careful and Thorough History and How to Obtain One

Chapter 3. Statistics and Evidence Based Medicine

Chapter 4. Facial Pain from Various Sources-Diagnoses and Differential Diagnoses

Chapter 5. Psychological Aspects of Chronic Pain

Chapter 6. Differential Diagnosis of Complex Regional Pain Syndrome (CRPS)

Chapter 7. Neuro-Pharmacology of Chronic Pain

Chapter 8. Medical Tests Used to Diagnose Pain

Chapter 9. Commonly Overused Diagnoses

Chapter 10. Legal Issues

Chapter 11. The Doctor in Court

Chapter 12. Headaches-Migraine versus Muscle Tension versus Dental versus Tumors

Chapter 13. Why Chronic Pain Patients Are Misdiagnosed

Chapter 14. Unusual Causes of Chronic Pain

Chapter 15. How to Evaluate Research Articles on Chronic Pain

Chapter 16. Non-Surgical Chronic Pain Management

Chapter 17. Fraud Detection in Chronic Pain

Chapter 18. Measuring Pain

Chapter 19. Pain Clinics

Chapter 20. Duplicating a Chronic Pain Treatment Center

Chapter 21. Case Studies

Chapter 22. The Economics of Chronic Pain

Index

“Dr. Hendler's new book addresses the most critical concepts in pain diagnosis and management. He offers a rationale for the use of medication based on the type of tissue damage, which is a novel approach to the pharmacology of pain. It is the most logical system I have encountered. His explanation of the specificity and sensitivity of medical tests will help any physician diagnose patients more accurately. I highly recommend this book for all physicians, nurses, medical students, and anyone else in health care involved with chronic pain.” - Roberto Wenk, MD, anesthesiologist, Argentina´s WHO Focal Point, Cancer Pain Control Program, Member of the Board of Directors, World-Wide Palliative Care Alliance (WPCA), and President, Board of Directors, International Association for Hospice and Palliative Care (IAHP)

"Nelson Hendler’s newest book does an excellent job at explaining why so many people today remain confused about why they still have chronic pain after visiting so many doctors. In his new book, Hendler uses clear exposition and explanatory diagrams to explain the causes of pain, the diagnosis of pain, and the appropriate approach to pain treatment. This book will help the person in chronic pain as well as any physician trying to help understand that patient." - A. Lee Dellon, MD, PhD, Professor of Plastic Surgery and Professor of Neurosurgery, Johns Hopkins University School of Medicine

"Pain is one of the most important manifestations of illness and is the main symptom what tends to undermine the quality of life. Its mismanagement creates very important physical, psychological and social consequences. Moreover, if we calculate the working days lost, has a relevant economic impact. If these considerations are added to the fact that the most disabling form of pain - chronic - affects about 25-30% of the population and is now considered a problem of high social impact, it is understood how the assistance of this clinical aspect is a real priority. Finding the most functional management model to ensure antalgic cure is not easy and often the process is made more difficult by the high percentage of misdiagnosing. The need to make the notions of diagnosis and treatment of chronic pain easier, clear and easy to apply, finds in this book its perfect expression. In this book Nelson Hendler carries out a careful and scrupulous examination of all clinical-therapeutic aspects of chronic pain, making the notions easy and accessible to both the specialist and the basic physician. It was an honor for me to collaborate with him in an international study on chronic vertebral pain and this allowed me to appreciate its expertise and professionalism, which make him one of the world's leading experts in this field." - Alessandro Landi MD, PhD, Neurosurgeon and Spine Surgeon, Professor of Neurosuregery, University of Rome, Sapienza, Italy

"I came to know Dr. Hendler as a student in the 1970's, when accurate diagnosis and specific treatment for chronic pain were emphasized, and I thought his approach was enlightened and consistent with the goals of my new profession. As health care delivery has since evolved, however, physician survival in practice has depended increasingly on regulatory compliance, coding (to be distinguished from accurate diagnosis) and business concerns, rather than critical scientific and clinical judgment. However, the traditional professional values are not only in the best interests of patients and the public health, but also cost-effective. This new book reminds us that these ideas can and should be maintained, refined and pursued anew." - Richard B. North, MD, Professor of Neurosurgery, Anesthesiology and Critical Care Medicine (retired); Johns Hopkins University School of Medicine; President, The Neuromodulation Foundation, Inc., Baltimore, MD

"Dr. Nelson Hendler and I have work together for many years and he has a comprehensive approach to diagnosis and treatment. I have found over the years that poor and/or missed Diagnosis is the rule not the Exception. Currently, the most common way of handling patients is time related and dealing with the major symptom. Therefore, the current mode is to diagnosis and treat as if all individuals with similar symptoms are the same. Dr. Hendler understands that this is not the case. Each individual is unique and must be Diagnosed and treated as an individual. History and examinations must take in all symptoms. All of Dr. Hendler's books reflect this point of view and are intended to get to the bottom of the causes and find the proper treatment." - Dennis E. Spurgin, DC, Former Dean of Chiropractic Education and Clinical Training, Los Angeles College of Chiropractic (a division of Southern California University of Health Sciences)

Click here to read the book review by - Tom Vesper, Esq., trial lawyer in Atlantic City, New Jersey

Chapter 1

[1] Hendler, N. 2000, Chapter 12 “Pharmacological Management of Pain, in Practical Management of Pain,” Third edition, edited by P. Prithvi Raj, 145-155, St Louis: Mosby.
[2] Hendler, N. 1982, Chapter 1 “The Four Stages of Pain.” in Diagnosis and Treatment of Chronic Pain, edited by Nelson Hendler, Donlin Long, and Thomas Wise, T, 1-8, Boston: John Wright/PSG.
[3] Purves, Dale; et al. 2004 Neuroscience. Massachusetts: Sinauer Associates, Inc.
[4] Baron, Ralph 2006 “Mechanisms of Disease: neuropathic pain—a clinical perspective.” Nature Clinical Practice Neurology 2: 232-236.
[5] Staud, Roland; et al. 2007 “Brain activity related to temporal summation of C-fiber evoked pain.” Pain (1-2 ed.) 129 (1–2): 130–142.

Chapter 2

[1] Cohen, J. T., Manor, Y. 2011. “Swallowing disturbance questionnaire for detecting dysphagia.” Laryngoscope Jul;121(7):1383-7.
[2] Stiell, I. G., Greenberg, G. H., McKnight, R. D., Nair, R. C., McDowell, I., Reardon, F, Stewart, J. P., Maloney, J. 1993. “Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation.” JAMA March 3, 269 (9):1127-32.
[3] Hendler, N. and Baker, A., 2008 “An Internet questionnaire to predict the presence or absence of organic pathology in chronic back, neck and limb pain patients.” Pan Arab Journal of Neurosurgery Vol. 12, April No. 1: 15-24.
[4] Evans, B. J., Stanley, R. O., Mestrovic, R., Rose, L., 1991. “Effects of communication skills training on students' diagnostic efficiency.” Med Educ. Nov 25(6):517-26.
[5] Maguire, G. P., Clarke, D., Jolley, B. 1977 “An experimental comparison of three courses in history-taking skills for medical students.” Med Educ. May 11(3):175-82.
[6] Teutsch, C. 2003 “Patient-doctor communication.” Med Clin North Am. Sep 87(5):1115-45.
[7] Dellon, A. L., Hendler, N., Hopkins, J. E. T., Karas, A. C., Campbell, J. N. 1986 “Team Management of Patients with Diffuse Upper Extremity Complaints.” Maryland Medical Journal. October, Vol. 35, No. 10:849-852.
[8] Long, D., Filtzer, D., BenDebba, M., Hendler, N. 1988, “Clinical Features of the Failed-Back Syndrome.” Journal of Neurosurgery. July, Vol. 69, pp. 61-71.
[9] Hendler, N., Kozikowski, J., Schlesinger, R., Schlesinger, J. 1991 “Diagnosis and Treatment of Muscle Tension Headaches.” Pain Management. March/April, Vol. 4, No. 2:33-41.
[10] Hendler, N., Zinreich, J., Kozikowski, J. 1993, “Three-Dimensional CT Validation of Physical Complaints in `Psychogenic Pain Patients.” Psychosomatics. January/February, Vol. 34, No. 1:90-96.
[11] Hendler, N., Kozikowski, J. 1993 “Overlooked Physical Diagnoses in Chronic Pain Patients Involved in Litigation.” Psychosomatics November/December, Vol. 34, No.6:494-501.
[12] Hendler, N., Kozikowski, J., Morrison, C., Sethuraman, G. 1995 “Diagnosis and Management of Sacroiliac Joint Disease.” Journal of the Neuromusculoskeletal System Winter, Vol. 3, No.4:169-174,
[13] Hendler, N., Bergson, C., Morrison, C.: 1996 “Overlooked Physical Diagnoses in Chronic Pain Patients Involved in Litigation, Part 2.” Psychosomatics November/December, Vol. 37, No.6: 509-517.
[14] Hendler, N. 2002 “Differential Diagnosis of Complex Regional Pain Syndrome.” Pan Arab Journal of Neurosurgery Oct., pp. 1-9.
[15] Dellon, A. L., Andronian, E., Rosson, G. D., 2009 “CRPS of the upper or lower extremity: surgical treatment outcomes.” J. Brachial Plex Peripher Nerve Inj, Feb 20: 4 (1):1-4.
[16] Hendler, N. 2005 “Overlooked Diagnoses in Electric Shock And Lightning Strike Survivors.” Journal of Occupational and Environmental Medicine Aug. Vol. 47, No. 8, pp. 796-805.
[17] Hendler, N., and Romano, T. 2016 “Fibromyalgia Over-Diagnosed 97% of The Time: Chronic Pain Due To Thoracic Outlet Syndrome, Acromo-Clavicular Joint Syndrome, Disrupted Disc, Nerve Entrapments, Facet Syndrome and Other Disorders Mistakenly Called Fibromyalgia.” Journal of Anesthesia & Pain Medicine October, Volume 1: Issue 1, October, pp: 1-7.
[18] Hendler, N., Berzoksky, C. and Davis, R. J. 2007 “Comparison of Clinical Diagnoses Versus Computerized Test Diagnoses Using the Mensana Clinic Diagnostic Paradigm (Expert System) for Diagnosing Chronic Pain in the Neck, Back and Limbs.” Pan Arab Journal of Neurosurgery October, pp:8-17.
[19] Landi, A., Davis, R., Hendler, N., Tailor, A. A., 2016 “Diagnoses from an On-Line Expert System for Chronic Pain Confirmed by Intra-Operative Findings.” J Anesth Pain Med, Vol. 1, 1:1-7.
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[21] Gottschalk, A, and Flocke,, S, 2005 “Time Spent in Face-to-Face Patient Care and Work Outside the Examination Room” Ann Fam Med November 1, vol. 3 no. 6 488-493.
[22] Hendler, N. 1988, Chapter 20 Validating and Treating the Complaint of Chronic Back Pain: The Mensana Clinic Approach, In Clinical Neurosurgery. Edited by P. Black, E. Alexander, D. Barrow, et al. Vol. 35: 385-397, Baltimore: Williams and Wilkins.
[23] Talo, S., Hendler, N., Brodie, J. 1989 “Effects of Active and Completed Litigation on Treatment Results: Workers' Compensation Patients Compared with Other Litigation Patients.” Journal of Occupational Medicine March, Vol. 31, No. 3:265-269.
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[26] Long, D., Davis, R., Speed, W., and Hendler, N., 2006 “Fusion For Occult Post-Traumatic Cervical Facet Injury.” Neurosurgery Quarterly September, Vol. 16, No. 3: 129-134.

Chapter 3

[1] http://en.wikipedia.org/wiki/Lies,_damned_lies,_and_statistics.
[2] Huff, Darrell, 1993. How to Lie with Statistics (Reissue Edition) pp 14-18, New York and London: W. W. Norton and Company.
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[4] Charan, J., and Biswas, 2013. T. How to Calculate Sample Size for Different Study Designs in Medical Research? Indian J Psychol Med. Apr-Jun; 35(2): 121–126.
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[8] Hendler, N. and Baker, A, 2008 “An internet questionnaire to predict the presence or absence of organic pathology in chronic back, neck and limb pain patients.” Pan Arab Journal of Neurosurgery, Volume 12, April, No. 1: 15-24.
[9] Herzog, C., Birkhäuser, M. H., 1980 “Tuberkulin-screeningtests in der Praxis. Offene Vergleichsuntersuchung von Tine-Test und Monotest versus Mantoux 1:1000 bei 119 ambulanten Patienten” [Tuberculin screening tests. Open comparative trial of Tine-Test and Monotest versus Mantoux 1:1000 (10 TU) in 119 outpatients]. Schweizerische medizinische Wochenschrift (in German). 110 (48): 1817–21.
[10] Steiner, P., Rao, M., Victoria, M., James, P. 1980 “A Comparative Study of the Old Tuberculin Tine Test and the PPD-Tine Test.” Clinical Pediatrics. 19 (6): 389–1.
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[12] Chaturvedi, N., Cockcroft A., 1992, “Tuberculosis screening among health service employees: who needs chest X-rays?” J Soc Occup Med.42 (4): 179–82.
[13] Froeschle, J., Ruben, F. L., Bloh. A. M. 2002 “Immediate Hypersensitivity Reactions after Use of Tuberculin Skin Testing.” Clinical Infectious Diseases 34 (1): e12–e13.

Chapter 4

[1] Long, D., Davis, R., Speed, W., and Hendler, N. 2006 “Fusion For Occult Post-Traumatic Cervical Facet Injury.” Neurosurgery Quarterly, Vol. 16, September, No. 3, pp. 129-134.
[2] Hendler, N. 2002 “Differential Diagnosis of Complex Regional Pain Syndrome.” Pan Arab Journal of Neurosurgery. Oct: 1-9.
[3] Hendler, N., Bergson, C., Morrison, C. 1996 "Overlooked Physical Diagnoses in Chronic Pain Patients Involved in Litigation, Part 2." Psychosomatics, Vol. 37,Nov.-Dec. No.6: 509-517,
[4] Dellon, A. L., Andronian, E., Rosson, G. D. 2009 “CRPS of the upper or lower extremity: surgical treatment outcomes.” J. Brachial Plex Peripher Nerve Inj, Feb 20: 4 (1):1-4.
[5] Hendler, N. 2005 “Overlooked Diagnosis in Electric Shock and Lightning Strike Survivors.” Journal of Occupational and Enviromental Medicine, Vol. 47, Aug. No. 8, pp. 796-805.
[6] Hendler, N., and Romano, T. 2016 “Fibromyalgia Over-Diagnosed 97% of The Time: Chronic Pain Due To Thoracic Outlet Syndrome, Acromo-Clavicular Joint Syndrome, Disrupted Disc, Nerve Entrapments, Facet Syndrome and Other Disorders Mistakenly Called Fibromyalgia.” J Anesth Pain Med, Volume 1: Issue 1: 1-7.
[7] Laura Landro, The Biggest Mistake Doctors Make, The Wall Street Journal, Nov. 17, 2013.
[8] Guralnick, W., Kaban, L., and Merrill, R. 1978 “Temporomandibular joint afflictions.” New England Journal of Medicine, Vol. 299, July 20, No. 3, pp 120-129.
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[12] Empting, L., Hendler, N., Kolodny, L., Kraus, H. 1990 “Tips on hard to manage pain syndromes.” Patient Care April 30: 26-46.
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Chapter 5

[1] Wise, T., Hall, W., Wong, O., 1982 Chapter 2 “Factors Determining the Acute Pain Response.” in Diagnosis and Treatment of Chronic Pain, Edited by Nelson Hendler, Donlin Long and Thomas Wise, 9-22, Boston: Wright-PSG.
[2] Hendler, N., 1982 “Chapter 1: The Four Stages of Pain.” in Diagnosis and Treatment of Chronic Pain, Edited by Nelson Hendler, Donlin Long and Thomas Wise, 1-8 Boston: Wright-PSG, 1982.
[3] Kübler-Ross E., 1975 “On death and dying.” Bull Am Coll Surg. Jun;60(6):12, 15-7.
[4] Long, D., Davis, R., Speed, W., and Hendler, N, 2006 “Fusion for Occult Post-Traumatic Cervical Facet Injury.” Neurosurgery Quarterly, Vol. 16, Sept. No. 3, pp. 129-134.
[5] Hendler, N. Differential Diagnosis of Complex Regional Pain Syndrome. Pan Arab Journal of Neurosurgery. Oct., 2002 pp. 1-9.
[6] Hendler, N., Bergson, C., Morrison, C. 1996 “Overlooked Physical Diagnoses in Chronic Pain Patients Involved in Litigation, Part 2.” Psychosomatics, Vol. 37 Nov.-Dec. No.6: 509-517,
[7] Dellon, A. L., Andronian, E., Rosson, G. D., 2009 “CRPS of the upper or lower extremity: surgical treatment outcomes.” J. Brachial Plex Peripher Nerve Inj, Feb 20: 4 (1):1-7.
[8] Hendler, N., 2005 “Overlooked Diagnosis in Electric Shock and Lightning Strike Survivors.” Journal of Occupational and Enviromental Medicine, Vol. 47, Aug. No. 8:796-805.
[9] Hendler, N., and Romano, T. 2016 “Fibromyalgia Over-Diagnosed 97% of The Time: Chronic Pain due to Thoracic Outlet Syndrome, Acromo-Clavicular Joint Syndrome, Disrupted Disc, Nerve Entrapments, Facet Syndrome and Other Disorders Mistakenly Called Fibromyalgia.” J Anesth Pain Med, Volume 1: Issue 1: 1-7.
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[37] Hendler N., Viernstein M., Gucer P., Long D. 1979 “A preoperative screening test for chronic back pain patient.” Psychosomatics. Dec:20(12):801-8.
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[40] Hendler, N., Kozikowski, J. 1993 “Overlooked physical diagnoses in chronic pain patients involved in litigation.” Psychosomatics 34(6):494-501.
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Chapter 6

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Chapter 7

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Chapter 8
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Chapter 9

[1] Hendler, N, and Romano, T. 2016 “Fibromyalgia Over-Diagnosed 97% of The Time: Chronic Pain Due To Thoracic Outlet Syndrome, Acromo-Clavicular Joint Syndrome, Disrupted Disc, Nerve Entrapments, Facet Syndrome and Other Disorders Mistakenly Called Fibromyalgia.” J Anesth Pain Med, Vol.1, # 1, pp.1-7.
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[4] Bonica, JJ, and Teitz, D. 1990, in The Management of Pain, Lea & Febiger; 2nd edition, p. 375-376.
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Chapter 10

[1] Nigel Kent, tel. 604.643.3135 npk@cwilson.com, Insurer Bad Faith Damages: A USA-Canada Comparison, 2005 Clark Wilson LLP.
[2] © 2005 Clark Wilson LLP www.cwilson.com Nigel Kent, T. 604.643.3135, p. 5.

Chapter 12

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Chapter 13

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Chapter 14

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Chapter 15

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[16] Gertzbein, SD, Hollopeter, MR. 2002 “Disc herniation after lumbar fusion.” Spine (Phila Pa 1976). Aug 15;27(16):E373-6.
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[18] Hendler, N, 1989 “Chapter 20 -Validating and Treating the complaint of Chronic Pain: The Mensana Clinic Approach.” in Clinical Neurosurgery, Edited by P Black, et al. Vol. 35, pp. 385-397. Williams and Wilkens: Baltimore.
[19] Talo, S., Hendler, N, Brodie, J. 1989 “Effects of Active and Completed Litigation on Treatment Results: Workers Compensation Patients Compared With Other Litigation Patients.” J. of Occupational Medicine, Vol. 31, pp. 265-270.
[20] Hendler, N., Talo, S. 1989 “Chapter 2 -The Role of the Pain Clinic.” In Current Therapy of Pain. edited by Kathy Foley and Richard Payne, 14 – 22. B.C. Decker, Inc: Toronto and Philadelphia: B.C. Decker, Inc.

Chapter 16

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Chapter 17

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Chapter 18

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Chapter 19

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Chapter 21

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The book will be of great value to medical students, nursing students, physical therapy student, law students, chiropractic students, and to practicing physicians, especially neurosurgeons and orthopedic surgeons, nurses, physical therapist, physician assistants, nurse case managers at insurance companies, Third Party Administrators, trial lawyers, self insured companies,

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