These presentation covers the common reasons patients are misdiagnosed. It lists why the MRI is a bad test for detecting disc damage, and which is the correct test. It shows why many disoders are misdiagnosed through the use of incorrect testing, and lists the correct test. Finally, it uses evidence based medicine, to show what is the proper method of diagnosis, leading to correct treatment, and associated cost savings

1. WHY CHRONIC PAIN PATIENTS
ARE MISDIAGNOSED:
and how to make a proper diagnosis
Nelson Hendler, MD, MS
former Assistant Professor of Neurosurgery, Johns
Hopkins University School of Medicine,
past president –American Academy of Pain Management
Former Clinical Director-Mensana Clinic
www.MarylandClinicalDiagnostics.com

2. Missed Diagnoses-Neck and Back Pain
• Overlooked Physical Diagnoses in Chronic Pain Patients Involved
in Litigation, (Hendler, et al Psychosomatics, ’93)
• N= 60
• 67% were misdiagnosed “lumbar strain, cervical strain, chronic
pain syndrome, conversion reaction.”
• Overlooked Physical Diagnoses in Chronic Pain Patients Involved
in Litigation: Part II (Hendler, et al Psychosomatics,’96)
• N= 120
• 40% were misdiagnosed “lumbar strain, cervical strain, chronic
pain syndrome, conversion reaction”
• These 180 patients, from two studies, really had facet syndrome,
disrupted discs (internal disc disruption), thoracic outlet
syndrome, nerve entrapments, and radiculopathy, confirmed by
objective physiological testing.

3. Why Patients are Misdiagnosed
• Doctors don’t spend enough time with a patient taking a
careful history.
• Doctors rely on anatomical tests, such as MRI, CT, and
X-ray to make diagnosis
• Pain is a physiological condition.
• Physiology is measuring a response to a stimulus.
• Anatomy is taking pictures. There is no “picture of
pain”
• Is the oven hot? Would you use a photo or a
thermometer to determine this?
• Doctors need to use physiological tests, such as
provocative discogram, facet blocks, root blocks, nerve
blocks, bone scan, neurometer studies for sensory
nerves, Indium 111 scans, PET scan, etc.

4. Cause of Misdiagnoses (cont)
• Failure to recognize that a single clinical
manifestation may have multiple etiologies (a flat
tire) = convergence
• Failure to realize a single pathological condition may
have multiple clinical manifestations (Lyme disease)
= divergence
• Failure to take a careful history.
• Failure to understand the specificity and sensitivity of
tests. The MRI is a lousy test for disc disease-see later
• Relying on anatomical tests to make a diagnosis
rather than clinical judgment or physiological tests.
• Not believing a patient. Calling them psychosomatic.

5. Example of Flaws of Anatomical Tests
• ANATOMICAL TESTING BENEFIT:
• I have a pain in my thumb.
• Take a picture and find a vise on my thumb.
• Perform “visectomy” and the pain goes away.
• BUT - ANATOMICAL TESTING FAILURE:
• I have a pain in my thumb.
• I have hit my thumb many times with a hammer
• Take a picture, but no hammer is seen
• What caused the pain? You have to ask why.
• This demonstrates the need for a careful history

6. “Misdiagnosed” Definition
• Many patients are misdiagnosed. What is that?
• Misdiagnosis: The referring physician has not
mentioned a certain diagnosis (overlooked).
• The referring physician has used a descriptive
“diagnosis” such as “low back pain.”
• The referring physician has offered a diagnosis without
any objective data to support it, i.e. RSD, lumbar strain,
fibromyalgia, psychogenic pain, fibromyalgia, etc.
• The www.DiagnoseMyPain.com pain test establishes a
diagnosis, previously unmentioned by referring
physicians, which can be documented by objective or
interactive (blocks, provocative discograms, etc.)
testing.

7. What is Evidence Based Medicine?
It is using scientific evidence to prove a point.
• Meta analysis is a review of medical literature.
• Epidemiology reviews the incidence (number of new
cases a year) and prevalence (number of cases at any
one time) of a disease. It is the basis of actuarial data.
• Outcome studies report the results of surgery or
interventions. Selection criteria can influence results.
• Population definitions can alter results. There are
clinics that will not see claimants with active
litigation. Other clinics count “return to work” as
being back on the job only one day. There are
regional, genetic, and sociological differences, such
as educational background, training, language
fluency, age, etc. that influence reported results.

8. Flaws in Meta-Analysis Research
• Richard Payne, MD (Clin. J. of Pain, ’86) at
Cornell-Memorial Sloan Kettering did a meta
analysis of patients with surgical sympathectomies
for the treatment of causalgia (CPRS II).
• He found the success rates reported in the
literature ranged from 12% to 97%.
• Sources of flaws in this analysis: diagnostic
criteria for causalgia, outcome criteria, surgical
skill, litigation, etc.? Each article was different.

9. The 6 blind wise men examining an elephant, in order to
describe it to their king. One man describes it as a large
butterfly, the other as a tree trunk, the third as a boa
constrictor, etc. The king can visualize an elephant, only by
integrating all the descriptions.

10. What is a “Chronic Pain Patient?”
• Chronic Pain Patient –each article is like blind
men describing an elephant. Each reports only
what was seen in their clinical setting, but
never sees the entire population.
• The type of patient is rarely mentioned in the
literature, i.e., litigant versus non-litigant.
• Selection criteria for a patient population is
essential for determining proper intervention
and meaningful outcomes.
• Some clinics lie and “cook” data to look better

11. Waddell Signs as part of a physical exam
• Waddell signs are five physical tests, like hitting a
patient on the head to see if their low back hurts, etc.
• Fishbain, et. al., (Pain Medicine, vol. 4, ’03) did a meta
analysis of 61 studies that reported using Waddell signs.
• Positive Waddell signs do not correlate with
malingering, secondary gain, hysteria, psychological
distress, abnormal illness behavior, nor somatic
amplification
• They do not discriminate organic vs. non-organic
problems, but they are misused that way.
• They do predict poor treatment outcome.
• There may be a real organic basis for positive signs.

12. Types of Tests Used for Validating
Pain and What They Measure
• Anatomical Tests: MRI, CT, 3D-CT, X-ray,
discogram, myelogram – a picture.
• Physiological Tests: Flex-Ex. X-rays, bone
scan, nerve blocks, root blocks, facet
blocks, provocative discogram, gallium
scan, Indium 111 scan, phentolamine test,
EMG/NCV, neurometers, 2 poster brace,
body jacket with thigh spika- a response.

13. Anatomical Versus Physiological
• Anatomical • Physiological
• Takes a picture of the • Measures body
body. response- interactive.
• EXAMPLE • EXAMPLE
• Oven on wall. • Oven on wall.
• Take a picture. • Put thermometer in
• Look at picture. oven.
• Can you tell if the • Look at thermometer.
oven is hot? • It says 375 F. Is it hot?

14. Specificity versus Sensitivity
• Sensitive Test • Specific Test
• Always detects presence • When positive, it detects
of a disease. only the disease in
• However, may also report question.
other diseases as the first • May overlook mild or
disease. variant forms of the
• Very sensitive, but not so disease.
specific- gives false • Very specific, but not so
positive readings sensitive- gives false
• Tine test for TB. negative results.
• Mantou test for TB.

15. Specificity versus Sensitivity
• Sensitive Test • Specific Test
• • Let’s catch a tuna.
Let’s catch a tuna.
• Use a big mesh net.
• Use a small mesh net.
• Everything in net will be
• Will catch a lot of fish, tuna.
and never miss a tuna. • Will catch large tuna, but
• Definitely will catch a small tuna, mackerel,
tuna, but will also get perch, and spot will not be
mackerel, perch and spot, in net, so no further
which will require further sorting needed. Will miss
sorting. some small tuna we would
have wanted to keep.
• False positive results. • False negative results.
• Sensitive but not specific
• Specific but not sensitive

16. Flaws with Cervical Radiographs
• Peterson, et. al. (Spine # 28 (2) pp 129-33, ’03).
• 180 patients, mean age 49, 44% male rated pain
on VAS 0-10 scale & Neck Disability Index
• Neck pain divided into no injury, injury (40.6%)
and those with litigation (5.1%).
• No correlation between levels of degeneration, or
severity, and self rated pain or disability ratings.
• Patients with injury had more pain and disability,
than patients without injury.
• Women reported more pain and disability.

17. Flaws with Static Cervical X-rays
• Most patients complain of worse pain when they
lean forward or backwards.
• Static (upright) X-rays do not demonstrate
movement between the vertebral bodies.
• Flexion-Extension X-rays show what happens to
the vertebral bodies when there is motion forward
and backwards.
• Like a partially broken twig- the defect is not
evident until the twig is put under tension.

18. Flaws with Just Anatomical Tests
• MRI- Jensen et. al. N. Eng J. Med, ’94, 98
patients with no back pain, but 27 had
protruding disc (28% false positive rate).
• MRI with Modic (vertebral end plate
changes)-21/23 patients had + provocative
discograms. BUT- in 90 patients with
positive provocative discograms, only 23%
had Modic changes, and 77% no changes in
MRI. (Braithwaite, et al, Eur. Spine J. ’98).
Therefore a 77% false negative rate for
MRI

19. Anatomy and Physiology of a Disc
• A disc is like a jelly donut.
• Pain fibers are found in the rear 1/3 of the annulus
(donut) (Bogduk and McGuirk, Pain Research and Clinical Management,
Vol. 13, p.121,Elsevier, 2002)
• A herniated disc has the jelly (nucleus polposa)
protrude from the donut (annulus).
• Pain fibers can be disrupted, without any anatomical
distortion of the annulus, so the MRI, CT and
Myelogram are normal. (Bogduk and McGuirk, Pain Research and
Clinical Management, Vol. 13, p.119-122,Elsevier, 2002)
• Pain from internal disc disruption (IDD) feels like a
herniated disc pushing on a nerve root with pain in a
radicular distribution.(Bogduk and McGuirk, ibid).

20. Herniated Disc vs. Internal Disc Disruption (IDD)
(Bogduk and McGuirk, Pain Research and Clinical Management, Vol. 13,
p.119-122,Elsevier, 2002)
• Herniated Disc Internal Disc Disruption
C C
O O
R R
D D
MRI- shows disc herniation MRI -no disc herniation
and cord compression nor cord compression

21. Provocative Discograms
• A physiological test, not an anatomical test.
• Saline is injected into the donut (annulus)
portion of the disc, where the pain fibers are.
• This injection distends the pain fibers.
• If this injection reproduces the pain in the
distribution the patient normally feels pain, this
is a positive test.
• Local anesthetic injected into the damaged disc
take away the pain the patient normally feels.

22. Disc Anatomy and Provocative Discogram:
Saline injection reproduces the pain, confirming
disc damage due to IDD, not seen on MRI
Normal Disc Internally Disrupted Disc (IDD),
with normal MRI
Pain
Pain
Herniated Disc Fibers
Internally Disrupted Disc
Fibers (IDD), with normal MRI
Needle
Annulus Provocative
Discogram
Nucleus Pulposa Saline

23. Comparison Herniated Disc versus IDD
• Herniated Disc • Internal Disc Disruption
Annulus
Nucleus
polpulsa
Pain Fibers Pain Fibers

24. Further Debate on MRI vs Discogram
• 53 pts. with pain had both MRI and
provocative discograms. 79.5% and 74.4%
of patients with concordant pain on
provocative discograms had no endplate
changes (Modic) on T1 and T2 MRI images
(Sandhu, et al, J. Spinal Disord, 2000).
• In 54 pts without pain, 24% had a “high
intensity zone on MRI. Provocative
discogram were + 69% of pts with Modic
changes, and + 10% of pts without MRI
findings. (Carragee et al, Spine, 2000).

25. Further Debate on MRI vs Discogram
(Simmons, et al, Spine ’91).
• 164 patients with back pain.
• MRI abnormalities and + provocative
discograms were found in 90/164 pts
(55%).
• MRI and provocative discograms
differed in 74/164 (45%) of the
patients.
• 108 discs on MRI classified as
abnormal were asymptomatic (37%).

26. Errors in MRI interpretation for
Symptomatic Discs
• False + rate - MRI is 24%-37% in pts
without pain.
• False neg. rate - MRI in pts with +
provocative discograms ranges from
77%-79%.
• False positive rate for provocative
discogram is 10%, i.e. produced pain
at an asymptomatic disc.

27. EMG/NCV: The wrong physiological test.
Patient has pain (sensory) not weakness (motor)
Motor fibers Sensory fibers Damaged compression
sensory fibers
• Cross section of nerve, • Cross section of nerve,
normal damaged by compression
EMG/nerve conduction measures gross electrical activity of a nerve. 90% of electrical activity is
from motor fibers. It takes a lot of pressure for a long time to damage motor nerves. Small sensory
fibers can be easily damaged in a short period of time, but since they have so little electrical
activity, the damage doesn’t show up on EMG/nerve conduction studies. Current perception
threshold test (Neurometer studies) can measure sensory fiber activity

28. 3D-CT versus Regular CT
(Zinreich, Long & Davis: J. Comput Assist. Tomography 1990)
• Study of 100 patients, without previous surgeries,
with negative direct axial CT or 2-D multiplanar
CT reconstructions.
• 3D-CT reconstructions found occult boney
pathology 56% of time missed by CT.
• Study of 100 patients, with previous fusion, with
negative direct axial CT or 2-D multiplanar CT
reconstructions.
• 3D-CT reconstructions found occult boney
pathology 76% of time missed by CT.

29. Sprains and Strains
• Sprains are defined as stretching ligaments which hold joints
together (Bonica and Teitz -The Management of Pain p 375,
1990).
• Strains are defined as over-extension of a muscle, which move
bone, with separation of muscle fibers (ibid, p.376).
• Sprain cause an average of 7.5 days restricted activity, 2 days
of bed disability, and 2.5 days work loss (DHHS # PHS 87-
1592, 1987).
• Spasm is an epi-phenomena, due to protective mechanism of
gamma motor reflex loop, a spinal cord reflex. This means the
spasm is not really the problem, but a result of the problem.
What are the underlining problems that cause spasm ?
• You cannot have a sprain or strain that lasts 2
years! It must be something else! What could it
be?

30. When a Sprain or Strain Lasts More
than 2 weeks-What is it?
• If a ligament pull off a bone, there is excessive
motion around a joint.
• This caused muscle spasm, because the muscles now
have to do the work of ligaments to hold the bones
together.
• When a disc is damaged, and there is a loss of disc
space height, then there is less tension on the
ligaments that hold vertebrae together, and there is
excessive motion at that vertebral segment.

31. Mechanics of a Vertebral Segment
Normal Size
Neural Foramin
Normal Disc
Height
Vertebral slippage
due to reduced disc
space height and lax
ligament
Normal Vertebral Body
Alignment
Ligament holding vertebral
bodies together

32. Mechanics of a Vertebral Segment
Taut
ligaments
hold Normal Segment Damaged Segment
vertebral
bodies
Body
together
Moves
Direction of
force
Shock Flat disc results in
absorbing disc narrowing of space
holds vertebral Two contravening and loose ligaments.
bodies apart forces. Vertebral Vertebral bodies
bodies do not move. move.

33. Facet Syndrome
(Empting, Hendler, Kolodny, & Kraus, Tips on hard to manage pain
syndromes, Patient Care, pp.26-46,April 30, 1990)
• Pain in neck and shoulders and upper arm, or
low back, and back of thigh.
• Worse with extension, better with flexion.
• Temporary relief by facet blocks, at the level
above, at the level, and level below, since the
facet is innervated by three levels.
• Facet denervation has 40% chance of 2 years
of relief (North, R, Sequelae of facet denervations Pain, ’01)

34. Facet Blocks and Denervation
(Empting, Hendler, Kolodny, & Kraus, Tips on hard to manage pain
syndromes, Patient Care, pp.26-46,April 30, 1990)
Normal Size
Neural Foramin
Normal Disc
Height
Vertebral slippage due to
reduced disc space height Facet
and lax ligament Block
Normal Vertebral Body
Alignment
Ligament holding vertebral
bodies together

35. Missed Diagnoses of CRPS I (RSD)
• Of 38 patients referred to a private clinic with the
diagnose of RSD (CRPS I) (Differential Diagnosis of CRPS I, Pan Arab
Journal of Neurosurgery, ’02) only 1/38 (3%) had pure CRPS I
(RSD) without any other illness.
• 10/38 (26%) had CRPS I (RSD) with nerve entrapment.
• 27/38 (71%) had no signs or symptoms compatible with
CRPS I (RSD). They had just nerve entrapment(s).
• Dellon (J Brachial Plex Peripher Nerve Inj. 2009) found, in 40 patients
referred for CRPS, 80% had just nerve entrapment.
• CRPS (RSD) is over-diagnosed 71%-80% of the time.

36. FIBROMYALGIA
(Hendler, et al-Academy of Psychosomatic Medicine .abstract 2010)
• A review was conducted of 38 patients referred with the diagnosis
of fibromyalgia.
• The diagnostic criteria for fibromyalgia was not met in 37 of 38
patients.
• Therefore, 97.3% of patients were misdiagnosed by referring
doctors as having fibromyalgia, when they did not have it (errors
of commission).
• Additionally, referring physicians made only 7/50 diagnoses
(including fibromyalgia) that were confirmed by objective testing
or diagnostic criteria, which means 86 % of the time they made
diagnoses that were not confirmed.
• Referring physicians also failed to diagnose 133 medical
conditions that were confirmed by objective testing, for a failure
to diagnose rate of 94.3% (errors of omission).
• Of the patients misdiagnosed with fibromyalgia, i.e. told they had
fibromyalgia when they did not, 94.2% of them were women.

37. Fibromyalgia Pain Points
The 18 fibromyagia
pain points of which
11 of 18 are needed
to establish the diagnosis
of fibromyalgia, as long
as the pain at the location Pain Point
is unexplained by some
other disease.
Control
Point

38. Fibromyalgia Criteria and Misdiagnoses
• The patient must have pain in at least 11 of 18 points
unexplained by some other disease
• The patient must have disturbed sleep.
• The patient must experience chronic fatigue.
• Normal blood and laboratory tests.
• In 38 patients referred with fibromyalgia, 37 did not
meet diagnostic criteria. 133 other diagnoses were
confirmed on objective tests, and explained the pain.
(Hendler, et al =Abstract-Academy of Psychosomatic Medicine, 2010)
• The overlooked diagnoses was rate 97%.

39. Fibromyalgia Pain Points or
Something Else?
Occipital Nerve
Clavicular-sternal Entrapment
dislocation
Acromo-Clavicular Joint
Epicondylitis Impingement
C3-C4 disc
Control
Lumbar Facet Syndrome
Point
These diagnoses
were confirmed by
Chondromalacia objective testing in
37 patients
misdiagnoses with
fibromyalgia.

40. Individualized Treatment Plans
• No one monomodal program is suitable for all “chronic
pain patients (CPP).”
• Using a single modality will produce good results in some
patients, and no results in others, without diagnostic
effort. All are treated the same- a “cookie cutter” clinic
• Only through a multidisciplinary diagnostic program do
you establish diagnosis, and then tailor the treatment for
the disorder, using “evidence based medicine” results.
• Use the www.DiagnoseMyPain.com test to get the correct
diagnoses so your doctor can order the proper tests &
efficacious treatments = “evidence based medicine”

41. “Flat tire” patients
• Concept in physiology: Convergence- multiple
nerves supply a single muscle.
• Divergence: a single nerve supplies multiple
muscles.
• A single manifestation may have multiple
etiologies-like a flat tire-nail in tread, leaky valve
stem, tire off rim or combination of 3.
• A single symptom like pain in last 2 fingers, may
be C6-7 disc, thoracic outlet or ulnar nerve
entrapment or combination of all 3.
• Treatment plans must focus on diagnosis, consider
differential diagnosis, and be individualized.

42. Patient variables that influence results
• Age
• Sex
• Ethnic background- Harold Merskey MD
• Legal status -active or complete, type of suit
• Education or I.Q.
• Vocational experience
• Pre-morbid personality
• Stage of pain -acute versus chronic- 4
stages

43. Outcome Studies from Mensana Clinic
• Established in 1978 –over 10,500 patients seen.
• 75% of residential patients were from 47 states and 8
foreign countries.
• From 1999 to 2004 there were 2,488 new evaluations.
• 11% had no litigation, 43% were workers compensation,
44% were auto accident cases, 2% not recorded.
• 9% electric shock or lightning strike, 6% referred as “RSD”.
• While insurance companies report less than a 1% return to
work rate if claimant is out of work more than 2 years, the
clinic had a 19% return for workers comp, 62% for auto
accidents, 90% reduction in medication, 45% less doc visits

44. Cost Savings
• There are two tests on
www.MarylandClinicalDiagnostics.com
• The Pain Validity Test predicts with 85%
accuracy which claimant will not have an
abnormality on medical testing-detect fraud
• The Diagnostic Paradigm and Treatment
Algorithm give proper diagnoses, and lists
the correct medical tests to prove medical
pathology, leading to the correct care.

45. Cost Savings
• In a pilot study with CNA Insurance, they found
using the Pain Validity Test would save an
average of $1,654 per claim, same quarter
savings.
• Using the Diagnostic Paradigm and Treatment
Algorithm, cost savings between $20,000 to
$175,000 for long term cases have been
documented. For proof, go to SlideShare.net
• http://www.slideshare.net/DiagnoseMyPain/pati
ent-cost-savings-documented-with-letters

46. Patient Variables in Chronic Pain
• Non-litigant patients: 6% are exaggerating pain
patients (Hendler et al, Psychosomatics, ’79).
• Long Term Disability patients: 10% are exaggerating
(Hendler-unpublished insurance study).
• Auto Accident and Workers Compensation patients:
13% were exaggerating (Hendler et al, Pain, ’85,
Hendler, et al, J. Occ. Medicine,’88, Hendler, et al J.
Neurolog & Ortho. Med. & Surgery, ’85, Hendler,
Clinical Neurosurgery, ’89).

47. Type and Stage of Litigation
• Fact- workers compensation patients out of work
for 2 years or more, return to work less than 1% of
the time (McGill, J. Occ. Med, ’68, Snook and
Jersen, Occupational Low Back Pain, ’84).
• The current Interpretation of this statistic in
Medical Literature is:
• They have “compensation neurosis, secondary
gain, financial disincentives, personality flaws,
depressive equivalents, unmotivated, using the
system.” No-one ever says they are misdiagnosed.

48. Type and Stage of Litigation
• Talo, Hendler and Brodie (J. of Occupational Med.
’89) compared 83 patients out of work (X = 4.9
yrs.) who had active or complete auto accident
litigation or workers compensation litigation.
• They found that after proper diagnosis and
treatment, there was no difference in the return to
work (RTW) rate of patients with active or
completed litigation- however-
• Workers compensation patients 19.5% -RTW
• Auto Accident patients 62.5%- RTW
• Therefore- the type of litigation influence outcome

49. Ways to Obtain Proper Diagnosis
• Take careful history to establish proper diagnosis.
• Test at www.MarylandClinicalDiagnostics.com
asks 72 questions with 2008 possible answers.
• The diagnoses given by the Diagnostic Paradigm
have a 96% correlation with doctors from Johns
Hopkins Hospital & Mensana Clinic (Hendler and Davis-
Pan Arab J. of Neuorsurgery-2007)
• The test costs $800, and results are sent to you in
5 minutes after claimant completes it.
• Contains recommendations for the correct test
which your doctor can follow to get good results.

50. Conclusions
• Chronic pain patients are misdiagnosed
• Doctors order the wrong tests
• The proper diagnosis can be obtained by taking
a careful history.
• The proper diagnosis can be confirmed by using
physiological tests
• The Diagnostic Paradigm diagnoses have a 96%
correlation with diagnoses of doctors from
Mensana Clinic/Johns Hopkins Hospital.
• Go to www.MarylandClinicalDiagnostics.com