Overlooked Physical Diagnoses in Chronic Pain Patients

This study examined 120 chronic pain patients who were involved in litigation. Chronic pain for this study group was defined as that lasting one year or more, and all patients in the group were involved in worker's compensation or personal injury litigation.

The patients had been referred to the authors' clinic for evaluation. Thirty percent of the patients had been referred with a "diagnosis" of "chronic pain/unknown etiology" or "psychiatric pain/no diagnosis;" 10% were referred with the diagnosis "lumbar or cervical strain." Thus 40% of the patients had an inaccurate or incomplete diagnosis at study entry.

All 120 patients were then given a battery of evaluations and tests. These included: "MRI, 3-D CT, QFM [Quantitative Flowmeter, a "physiologic measurement of blood-flow velocity determined by Doppler measurements of arterial flow differences with position change." Used to diagnosis thoracic outlet syndrome and subclavian steal.], thermography, electromyogram (EMG), nerve conduction velocity (NCV), CT, X rays (including flexion-extension), bone scan, myelogram, gallium scan, and blood studies." All patients were also counseled by the clinic Director, and were given psychological tests. Each patient saw an average 3.62 referrals from other specialists.

A total of 884 tests were performed on the 120 patients—76% of these tests revealed abnormal findings. The tests most likely to show abnormalities were: EMG (87% abnormal); nerve blocks (85%); MRI (82%); thermography (82%); CT (80%); NCV (79%); flexion-extension X rays (75%); myelogram (71%); QFM (83%); and 3-D CT (69%).

The authors compared the initial diagnoses to the final diagnoses and the results are striking:

Early psychological evaluation of these patients by the research team suggested that "98% of the patients had an organic origin for their pain complaints. In addition, 94.2% of the truly objective pain patients had demonstrated a marked physical abnormality responsible for their pain. It is evident from these figures, that without a thorough diagnostic evaluation, the label of psychogenic pain could be misapplied to an inadequately diagnosed patient, creating a self-fulfilling prophecy."