The IME was requested by the insurer through Acme Center to:

Services:

	Interview
	Mental Status
	Testing
	EMG Biofeedback Scan

Records Reviewed

	Morriston Hospital: July 12, 1993: Mill Nasa, PT Letter to Dr. Seller. Patient referred to physical therapy status post lumbar laminectomy. Evaluation findings indicated moderate limitation in all planes. Pain reported in right lumbar paraspinals with radiation down the right leg to the ankle. Patient discontinued in PT for continuing follow-up with Dr. Seller.
	Dr. Bob Loan: December 1, 1993 IME at Acme. Dr. Loan reports a 1992 MRI revealing large focal herniated disk in right central canal and right lateral canal at L5--S-1. Also mild concentric protrusion of L4--L5 disk believed to be of no significance. Report of myelogram/ct scan: ventral impression on dura at L4--5 level. Smaller impressions noted at L5--S-1 and L3--4. A major finding was the poor filling of the right S-1 nerve root.
	Dr. Bob Loan: Acme: January 24, 1994 Follow-up visit. Most significant is his report of degenerative disk disease with significant narrowing at L5--S-1. Scar tissue is apparent. There is a question as to whether the etiology of the pain is due to a recurrent disk or scar tissue or both. Some question is raised as to the suitability of a second laminectomy. considering the patient's predisposition towards scarring. Dr. Loan states that, should Mrs. Morrone elect not to undergo surgery, she will be limited to a light Duty classification.
	Oncological Hospital: November 20, 1995: Dr. Steven Hoten Operative report. Injection of right S-1 nerve root sleeve with local anesthetic and steroids. Earlier caudal epidural injection gave 25% relief.
	Dr. Bob Loan: February 1, 1996 Report indicates unusual circumstances in which patient's right L5-S1 segment showed a recurrent piece of herniated disk and excess scar tissue at L5--S-1 wrapped around entire right 2/3 of the thecal sac. Second laminectomy performed May, 1994. Prior to surgery, patient reported entire right foot and toes were numb. Numbness disappeared following surgery. Pain was reduced but there was a slow, progressive recurrence Patient has been on Medrol packs until Dr. Seller refused further prescriptions. She was then prescribed Tylenol with codeine and aquatic therapy. Patient continued to show antalgic gait protecting right leg. Severe tenderness and spasm found bilaterally from L4 through S-1 which did not relax with movement. Consistent findings with excess epidural scar tissue. There is no good way to treat individuals with this propensity. Dr. Loan also mentions that a major problem encountered by Mrs. Morrone is a significant depression related to her current life situation. She has been under the care of a psychologist who, he claims, as been helping. However, she has considerable anger and depression. Estimated functional capacities indicates limited sedentary capacity, reduced lifting and carrying capacity,
	Arnold Park Pain Management: Dr. Hoten: February 2, 1996 Reports leg pain better controlled due to nerve root sleeve injections. Occasional pain in calf and numbness in tones with some decrease. Continued back pain, especially in the morning. Sitting longer than 10--15 minutes produces increased pain. Considered a good euthymic 4 light duty, part--time work with restrictions.
	Elmhurst Hospital: Dr. Kane: (pages missing, received February 2, 1996) Impression of chronic low back pain post laminectomy. Will undergo aquatic therapy.
	Arnold Park Pain Management: Dr. Hoten: April 12, 1996 Patient continues to do relatively well. She is "Clearly very relaxed." Continues to work with psychologist, Dr. Brown.
	Elmhurst Rehabilitation Services: June, 1996--September, 1996 Patient reports improvement in back.
	Gould Radiology Associates: July 14, 1995 Disk herniation at L5--S-1 level with large free fragment extending to the right lateral recess.
	Arnold Park Pain Management: October 3, 1996 Considered improved over last year. Considering injection of sacroiliac with local anesthetic.
	Arnold Park Pain Management: July 19, 1996 Considered improved over last year. Soreness in low back at end of day. Pronounced tenderness over sacroiliac joints bilaterally. Radicular pain is resolved.
	Gould Hospital: October 9, 1996 Trigger point injection.
	Arnold Park Pain Management: Dr. Hoten: October 25, 1996 50% benefit from sacroiliac joint injection. Buttocks pain has decreased.
	Arnold Park Pain Management: Dr. Hoten: December 3, 1996 Excellent response to Medrol dose pack. Reports spasms in November with pain radiation down legs. Dr. Hoten continues to find her suitable for limited, sedentary employment.
	Arnold Park Pain Management: Dr. Hoten: February 4, 1997 S-1 nerve root injection November, 1995 and sacroiliac injection October, 1996. Pain has begun to increase. Still involved in aquatic therapy. Severe pain in early morning. Awakens from sleep between 4--6 a.m. Another Medrol pack prescribed. Another S-1 nerve root and sacroiliac joint injection procedures considered.
	Arnold Park Pain Management: Dr. Hoten: April 1, 1997 Pain reported as stable. Patient continues to use Tylenol No. 3 BID.
	Marvin J. Brown, Ph.D., Licensed psychologist Apparently the report stemming from a psychological evaluation, this is an abbreviated report of 1.5 pages. The mental status and clinical observations are extremely abbreviated as well. There is no history. Psychological testing included the Multiaxial Pain Inventory. I do not know this test although there is a Yale Multidimensional Pain Inventory (MPI). No clear identifying information is provided nor are the test results added to this brief report. In addition, the Personality Assessment Inventory was administered, this test also being unclear. There is a NEO Personality Assessment Inventory, but once again this is not made clear. According to Dr. Brown, the PAI indicated a "Moderate level of idiosyncratic responding, often due to confusion or reading difficulty." The clinical scales show, according to Dr. Brown, show a high level of somatic preoccupation, high levels of anxiety and depression, some identity confusion and poor concentration/confusion. Dr. Brown offers no multiaxial diagnosis, nor does he present any Axis I classifications.
	Rebecca Smith, Ph.D.: (there is nothing found in Dr. Smith's letterhead to indicate in which field she has earned a doctorate nor her specialty): May 7, 1997--November 5, 1997 Once again, a formal report is lacking. Clinical impressions and diagnoses are not found among these notes. Depression is identified and the intervention is largely directed towards relaxation and hypnosis. Intervention notes are skimpy, sometimes as little as 3 sentences.
	Acme Center: December 1, 1997: Louise Kost, RN Mrs. Morrone sustained a low back injury lifting during her employment with Ness Rehabilitation Hospital on October 23, 1992. May 11, 1993: partial hemilaminectomy and excision of herniated disk (L5--S-1) performed by Dr. Seller Mrs. Morrone is presently being treated by Dr. Steven Hoten of Arnold Park Pain Management Associates. He has recently recommended a dorsal column stimulator. Earlier this summer he apparently believed the claimant to be capable of sedentary employment with short hours initially. Claimant also continues to receive psychological services through Hermione Smith, Ph.D. Apparently relaxation therapy and self--hypnosis are part of the treatment plan.

Clinical Interview

	PHYSICAL: Attire was neat, hygiene was good.
	Motor behavior demonstrated a mildly antalgic gait and stiff posture, bracing, grimacing, moving stiffly, pain posturing
	Level of responsiveness: alert, but easily distracted
	Manner: appropriate, attempted to appear calm.
	Attitude: Cooperative, distant, indecisive, passive, rapport--good
	Signs of Emotional distress: Anxiety and depression
	Primary facial expression during interview: Neutral to worried, anxious
	Eye contact during interview. Tended to look elsewhere, more due to distraction that avoidance
	Speech quantity: Talkative
	Speech quality: Circumstantial, rambling, vague
	Mood: neutral to depressed
	Affect: Anxious, depressed, emotional
	Thought processes: Confused, scattered
	Thought content--preoccupations: somatic symptoms
	Thought content--possible delusional aspects to somatic ideations.
	Attention: Distractible
	Concentration: Impaired
	Orientation: X3
	Memory functions: possible deficit in recent and remote memory
	Estimated intellectual abilities: Below average
	Fund of information: consistent with background
	Level of abstraction: concrete, personalized
	Marital status: divorced
	Reliability of patient information: questionably: patient prone to overreact and exaggerate, reporting multiple health concerns
	Results of examination: reliable and valid
	Insight: lacking TESTING Results depict that Mrs. Morrone falls into the Agitated-Depression phenomenological type. Her somatic anxiety score is 16, indicating the probability of an unfavorable response to conventional treatment as the score is greater than the average urban female. Results support the patient's complaints of (somatic) anxiety. However, the response pattern demonstrated clear emotional overreactivity and ownership of too many symptoms, indicating clinical levels in all 6 syndromal areas. This 47 year old, divorced woman with some high school education, reports her most recent problems as Ill-Tired and Moodiness; difficulties appear to have taken the form of an Axis I disorder of undetermined course. Her high scores may represent an anxious plea for help as a consequence of her inability to cope with current life stresses. However, results must be considered invalid. Other evaluations are necessary to appraise her current mental state. This is the "idiosyncratic" response pattern mentioned by Dr. Brown, but neither examined nor identified. A behavioral health measurement portrays Mrs. Morrone as extremely inhibited, introverted and emotionally reactive. She shies away from social contacts and lacks self-confidence. She is openly emotional, with emotions of all types  surfacing quickly. There is a moody, unpredictable response to frustration. At times she is downcast and displays fatigue and lassitude. Her moods may shift rapidly, becoming irritable and annoyed. When life events are progressing well, her moods stabilize and she may be pleasant and friendly, seeking to meet the needs of others. However, under even moderate stress, she is likely to become sulky and disgruntled, complaining that things never go well, and voicing unhappiness. These changeable moods keep the patient both physically and psychologically in an unstable state, thereby setting the ground for an increased susceptibility to psychosomatic ailments. She may be preoccupied with health, overreacting to real illnesses and expressing complaints about relatively minor ailments. She may exhibit symptoms dramatically to gain attention and support. Based upon the above, if there is a medical history of a periodic or persistent pain disorder it is highly probable that traditional outpatient services will lead to a poor result as emotional and psychosocial factors contribute here. A treatment program using behavior modification and psychotherapy are likely to be more effective than medical treatment alone. Biofeedback Physiological Assessment Equipment: Dual Channel EMG: Narrow filter (Silver/Silver chloride electrodes) Impressions: Abnormal profile. Excessive unilateral, frontalis tension would be associated with reported headaches and probably associated with stress. Asymmetry: Of 7 possible asymmetries, Mrs. Morrone showed 3, or 43 %. Averaging readings on both sides, a clear difference is seen, with bracing or splinting notably on the left to a Moderate level. This is worse upon standing, at T10 (bilateral) and L3 (left). Left Right 12.6 3.5 6.1 4.3 1.7 1.7 2.2 1.8 10.1 11.5 1.6 1.3 10.8 4.5 6.44 4.09 It should also be noted that, upon performing the scan, the bracing of the left was visible in the T10 area and appears to be a longstanding, postural compensation. DIAGNOSES AXIS I: Adjustment Disorder With Mixed Anxiety and Depressed             Mood 309.28             Pain Disorder Associated With Psychological Factors              307.80 AXIS II: No diagnosis, hysterical & avoidant features   V71.09 Axis III: (See medical reports) Axis IV: Primary Support; Occupational problems; Health,     Psychosocial and Environmental Problems: Moderate AXIS V (GAF) Emotional Rating Scale         Present: 50         Highest in past year: 50 COMMENTS & RECOMMENDATIONS This woman is coping with the effects of injury and subsequent surgeries as well as a congenital predisposition towards scarring. Personality aspects appear to play a detrimental role in her rehabilitation. Personality features should be examined in greater depth to formulate future treatment and planning. Mrs. Morrone should have been referred for psychiatric consultation as she appears to require an antidepressant in addition to the Buspar prescribed for her. It is interesting that, according to her report, only her general practitioner recognized her anxiety to the extent that an anxiolytic was prescribed. Although depression was identified by Dr. Loan February, 1996, antidepressant medication was not prescribed for pain, stress or depression. Due to the lacunae in psychological information, vitas for Drs. Brown and Smith were requested through Acme following the 12/10/97 examination. As of this date, they have not been received. Dr. Brown's report is overly abbreviated; the mental status and clinical observations are extremely abridged as well and there is no history. Psychological test results are not added. I found no treatment records for Dr. Brown, although he allegedly used biofeedback in his treatment over a number of months. He also presents no multiaxial diagnosis or Axis I classifications. Similar problems are found in Dr. Smith's reports: she does not supply clinical impressions, diagnoses, GAF scores or a rationale as to whether Mrs. Morrone is appropriate for hypnosis and relaxation and why. CONCLUSIONS A somatosensory examination could prove clinically useful. I recommend further psychological testing to assess personality factors and that this is done verbally, to avoid the inconsistent responses that may be due to distractibility or reading limitations. She should also be evaluated psychiatrically for medication, as suggested above. Medical reports indicate that Mrs. Morrone could return to some form of sedentary employment, at least on a part-time basis. This may be correct medically, but she is psychologically inappropriate an action of this type at this time and requires preparation, both in terms of psychological/psychiatric and vocational counseling. Regarding intensity of care, referral to a pain management program could be helpful, providing more and diverse treatment exposure. The records do not indicate effective interventions thus far, making continued treatment with the present provider questionable, beyond support alone. However, personality should be assessed and medication considered prior to any further referral. While appropriate, a dorsal stimulator may not be indicated at this time. It would be more feasible to provide antidepressant medication and effective psychotherapeutic intervention before dealing with this issue. On the issue of caring for her grandchildren, she has, I believe, one infant grandchild less than a year old. This does not suggest that she is capable of working in childcare. Although she may have reached maximum medical improvement, psychological barriers have not been appropriately addressed as indicated above.