Blog 9: Crime and Punishment

In my core sports medicine days providing support for footballers and other athletes I would mostly be amazed at how brilliant the results were after even very serious injuries. I also think about people like Turia Pitt (thank you so much Turia – you have no idea how important you were to my recovery from a serious knee injury myself!) and Mark Inglis, and just go WOW, WOW, WOW- THAT IS SO AMAZING!!! Check the links and see for yourself  what can be achieved despite truly ‘catastrophic’  events.

In these people the ‘crime’, ie: the injury, was massive and even though I am sure that these people, like many others similarly, are not pain and problem free, the ‘punishment’ in terms of the overall outcome is relatively small.

In my journey through my general community consulting, and especially in about 15 years and over 2,000 detailed compensation case reviews, my observations are mostly precisely the opposite.

All too often the ‘punishment’ far exceeds the ‘crime’.

ie: the original injury does not merit the eventual outcome.

If Dostoyevsky was still around he could write a fairly contrary sequel.

But before you become too impressed with my literature knowledge I have a confession to make. The only version I read of the classic novel, ‘Crime and Punishment’, was the Classics Illustrated version. I found an image via Google to put here:

dostoyevskyFor those who are too young to remember, or are simply unaware of what these were, they were essentially comic book adaptations of such time-honoured novels. I had a whole pile of them which I can unfortunately no longer find.

The best way to impress this perspective is with some real examples, I am advised there are privacy issues if by same extraordinary chance anyone recognises themselves accurately. I will therefore exercise some discretion in varying the story accordingly but I genuinely believe this point needs to be made in the best possible way.  I am hopeful that there will be acknowledgement of the intention to help others not to follow the same path unconsciously.

For those who will no doubt argue that these are just unfortunate examples of recognised complications please be assured that there is an extraordinary abundance of very similar stories in my travels. My observations are that I am not alone and my colleagues seem to see similar cases frequently. The worsening statistics of persistent pain are not just explained by age and cancer. The greatest group in persistent pain in Western Society is back (and other musculoskeletal) pain, and the problem has grown across age groups, even children.

I often quip that the pathways I review are predictable like a formula movie script; all you have to do is fill in new names.

It is important to comprehend the extraordinary influence of the ‘context’ of an injury and not the ‘pathology’ or injury severity necessarily. The three chosen stories will be abbreviated severely; many ‘gory’ details will be omitted but they are burnt  in my mind and in my documentation. Each one could make a Dostoyevsky novel sequel on their own if published fully as could so many others.

It would be reprehensible of me to ignore these repeated patterns and not try to influence importantly needed change.

example numero uno:

A fellow in his 50s who simply rotated his upper body at work one day in a non-manual job, and he felt a sharpish pain in his knee which subsequently worsened. For some bizarre reason, that would never be justified clinically, an x-ray and CT scan were done in the first week and an orthopaedic opinion and MRI obtained within a month. I’m sure it will come as no surprise to anyone that a meniscal ‘tear’* was seen. Actually they are seen in about 60% of men who have no idea it is there**. Try to get those odds for a big return in a gambling situation. Nevertheless, a letter was received from ye stated orthopaedic surgeon stating that the scan “confirmed a meniscal tear” and funding for an arthroscopy was requested on the basis of “failed conservative therapy”. Failed conservative management after less than a month …. hmmmm.

To cut a long story short a meaningful return to work and function has never been achieved. There is persistent pain, pain related disability and inability to fully extend the knee ever since the first surgery with no structural reason to explain this movement block. There has been no meniscal ‘locking’; not ever. Further management has consisted of about 5 orthopaedic surgical opinions, 5 scans in total and despite non-progressive changes a second arthroscopy was done and there is intent to do a third prior to a partial knee replacement for minor ‘fraying’ of a compartment. Now let me reassure all – on a comparison basis either of my 56 year old knees both clinically and radiologically would seriously trump this fellow’s knee condition structurally, and I enjoy regular latin and ballroom dance lessons with my beautiful wife and lots of other activities unimpaired.

All from rotating to one side while standing at work.

Score: Crime = 1/10. Punishment = at least a 6-7/10 with more to come.

And I haven’t even mentioned the research which advises that arthroscopic surgery for situations as these is actually not worth the risk***.

* I would ban the word ‘tear’ in radiological reports and orthopaedic descriptions unless stringently concordant with a serious trauma and acute changes are overtly recognisable eg: bleeding. The word ‘tear’ implies  a causative event which is a big problem in a ‘there is someone to blame’ context. The vast majority of ‘tears’ are simply just human ‘wrinkles’ on the inside and undeserving of this nocebo-laden qualification.

**Incidental Meniscal Findings on Knee MRI in Middle-Aged and Elderly Persons. Englund et al. N Engl J Med 2008; 359:1108-1115

***Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. Thorlund et al. BMJ. 2015 Jun 16

example deux:

A fellow in his early 30s who wrote “felt a twinge in my back” (that is such a common one so there is no way quoting it can set up a privacy infringement if thought to be recognised by somebody). This occured while sweeping the floor at work.

In the background worker and boss were having some problems due to absenteeism and it was probably likely that the employment was to be terminated.

There were also some background psychological concerns which will not be elaborated.

Protective back spasms ensued, radiation into the leg but no neurological changes, scans, disc bulges, surgeons, medication, interventional pain management etc, etc; a fairly typical current structurally obsessed management pathway (even by the so called ‘pain management experts’).

The result is failed spinal surgery x 2, including a fusion) and a third is being contemplated. In adition there is now a serious medication toxicology concern situation including a likely addiction condition developing with a daily morphine equivalent intake of about 60mg per day* and rising, in addition to valium and other medications. The last (and the third) surgeon’s letter concluded “He may have a problem which is treatable by proper surgery …”

All from sweeping the floor.

Score: Crime = 0.5/10. Punishment = at least a 8/10 with more to come.

*Isn’t it interesting how consensus positions have come to accept 100mg, and I have even heard up to 180mg, of morphine equivalent a day as ‘reasonable’ for pain management in similar situations. Just think about this for a minute – that is about 2.5 to almost 5 times the amount normally given to people after major traumatic surgery. Having had morphine after surgery on 2 occasions myself I note that it worked beautifully at regular doses. Does anyone stop to think that the treatment resistance in so many is due to central processes?? All you have to do is ask these people how much relief they get from absurd doses and they will most often say that the pain goes from 8-9-10/10 to about 4-6/10. Anyone heard of a placebo construct response or just a mind ‘numbing’ / ? euphoric effect?? And when the pain relief is perceived as insufficient what is usually done? “Here have a higher dose …! And eventually we will try to get you off these because they are addictive.”

Tercero:

Fellow in mid 20s who fell on a single occasion at work on a slippery floor indoors many years ago. Now, even though this is a trauma please consider this in perspective. This was a fall from standing height of standard impact without anything else to make it outstanding in severity. How many times do we do that in our lives and in sporting situations.

Once again summarising a long, tragically pain-literacy-deficient management pathway he had a first spinal operation to take the pressure of a nerve*, followed by a fusion one year later because the pain didn’t go away. He had a spinal cord stimulator device inserted eventually. This is done for end stage pain relief focussing on pain again technologically, with limited success rates. Seems if your brain wants you to have pain nothing really helps you. So, with persisting pain he then had more surgery. He underwent a bone graft with more metal fixation for an x-ray discovered ‘non-union’ of his previous fusion surgery (pssst – even these are seen abundantly in asymptomatic people proportionately in follow up of fusion surgery** attesting to the wonderful adaptability of the human construct, ie: body and mind, in certain situations).

*Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial. Peul et al. BMJ. 2008 Jun 14;336(7657):1355-8: “CONCLUSIONS: Early surgery achieved more rapid relief of sciatica than conservative care, but outcomes were similar by one year and these did not change during the second year.”

Anyone sniffing a placebo construct response here?

*Methods of evaluating lumbar and cervical fusion. Gruskay et al. Spine J. 2014 Mar 1;14(3):531-9: “… many cases of pseudarthrosis are asymptomatic …”

This fellow had typical interventional and pharmacy based pain management (can you guess that I am not a big fan?) similar to the previous case above but he definitely developed dependency issues to a bizarre cocktail of expert pain physician prescribed drugs for treatment resistant pain.

This case review was done as part of a high risk pharmacy project to attempt to influence and offer funding for safer management. I called his GP to discover that this poor fellow had died of complications related to his drug dependency.

He died several months previously.

He died alone.

He died in his mid 50s after enduring 3 decades of standard contemporary management for his perceived ‘disc bulge’ injury in a compensable, ‘there is someone to blame for my injury’ context.

There were no family or friends sufficiently interested in his person’s life to even let his insurance company know or claim further benefits in his ‘death’ claim as is usually done.

Score: Crime = 2-3/10. Punishment = well …… you decide.

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kalfried

I attained Fellowship of the Australian College of Sports Physicians in 1995 and have gained extensive experience in this field both before and after that milestone. I worked for five years in the Victorian snowfields, before joining the Melbourne Football Club (AFL) in the mid 1990's. I was a medical officer there for a total of 15 years with Dr Andrew Daff, as well as another 2 years with the Collingwood Football Club in the VFL. I was appointed as the AFL Australian International Rules team doctor in 2011 and 2013. I have also supported other elite sporting teams including the Australian Diamonds netball team in 2012. My main current appointment is with the TAC and WorkSafe as a medical advisor on the Clinical Panel and on various projects, and I am also an Independent Medical Examiner. In addition to general sports medicine I have developed a particular interest in the neuroscience of pain, the potential to 'de-sensitise' persistent pain, the biopsychosocial management model and exercise & conditioning prescription.

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