AdMIRable Review Winter 2025

What’s Normal: The Cervical Spine

In This Issue

• What’s Normal: The Cervical Spine
• The Pain Conundrum in Injured Workers
• Case Law: Aggravation of a Preexisting Condition
• CPP Registry Reaches over One Hundred Physicians

Volume 14, WINTER Issue 2025

The Pain Conundrum in Injured Workers*

Jeffrey E. Hazlewood, M.D

This article is republished with permission from the author. It was first published by WorkCompCollege.com on October 29, 2024, and was edited by Abbie Hudgens, former Administrator of the Tennessee Bureau of Workers Compensation.

It is the nature of workers’ compensation injuries that they almost always involve pain, and many workers endure pain for the remainder of their lives. Successful treatment of that pain is complicated by several factors: some medical providers who look for easy or quick answers and sometimes the patients themselves complicate their treatment. The following scenarios provide examples of how the treatment of pain can go off track and how it can be different.

Scenario #1

Ms. Smith is a sixty-year-old woman who has suffered with chronic pain after a simple lifting injury 20 years ago. The initial MRI revealed no acute structural pathology (only degenerative bulging discs and annular tears) and indicated she had no more than a soft tissue injury. She never had surgery after her injury but was sent to pain management. For two decades, she received multiple interventional procedures (trigger point injections, epidural injections, sacroiliac joint injections, and nerve ablations), and several rounds of physical therapy. She was prescribed chronic opioids early on (despite all these interventional procedures). She is now on Fentanyl patches and Hydrocodone, Neurontin, Flexeril, and Ambien through a pain clinic, and Xanax and Cymbalta from her primary physician. She is overweight, has chronic depression and anxiety, is diabetic, and has untreated sleep apnea. Despite all this medication, she reports her pain level is eight out of ten, and she spends most of her days in her recliner. When her pain clinic closed, she was “miserable” because she felt she could not manage life without her pain pills. Now she has gone to a new pain management specialist.

What can the new doctor do to manage this type of complicated case? Does the doctor just continue the “status quo” medications Ms. Smith wants even though he knows she is not doing well on them? Does he continue the drugs she is on when all the medication treatment “guidelines” question continued opioid treatment because the risks far outweigh benefits? Or does the doctor do what is best for the patient in the long run by following the updated science and guidelines and provide more proven treatment, which has a better chance to improve Ms. Smith’s quality of life and function, as well as provide her safer treatment?

Scenario #2

About 10 years ago, a heart-tugging article appeared in a paper from the wife of a chronic pain patient who had committed suicide. Her husband had been on opioids for years when suddenly his pain clinic reduced his prescription dosages from a high level of opioids to much lower dosages. His pain increased significantly as his ability to function decreased. His wife said that her husband felt “there was no remaining hope” and that life was not worth living so he ended it. His wife blamed his death on “all the new state laws” that caused his doctors to stop prescribing opioids for chronic pain. She felt the law change was inhumane.

How could this man’s treatment been different to avoid this tragic outcome?

There were definite risks to the high dose opioids he had been taking. Pain management is much more than just writing opioids. His initial treating physicians could have initiated him on a safer level of opioids. They could have carefully explained the reasons behind national and state guidelines on opioid dosages and the dangers of using opioids for treating chronic pain. This man could have been encouraged to consider “alternative treatments” that were available and provided potential solutions that could improve his chronic pain, ability to function, and quality of life. In other cases, such alternatives have resulted in the reduction and even elimination of opioid usage.

Why were these patients in these scenarios and scores of others like them not given the pain management treatment that could afford them the best chance for a life worth living?

Some possibilities are:

Patients’ unrealistic assumptions

When patients come to a new doctor they often “just assume” that the new doctor will continue the same regimen of drugs they had been on for a long time. When the doctor does not give them the drugs or dosages they were previously given, they ask “Why then did they send me to a pain specialist if you’re not going to write my pain pills?”

Or a patient has a surgery followed by a prolonged period of taking opioids (often high dosages), and then after 3-6 months, the surgeon tells them “I can’t write the prescriptions anymore because of the new laws, but the pain specialist will.”

Now, the new pain specialist must convince the patient of the risks of opioids, especially high dosages which include:

• respiratory depression, which can especially occur when taken in conjunction with other centrally acting agents that are sedating (muscle relaxers, anxiety and depression medications, sleeping pills, and nerve pain medications).
• potential addiction and physical dependency as tolerance increases for the prescribed drugs.
• opioid hyperalgesia (a paradoxical condition when the patient’s pain taking opioids over time can increase rather than decrease).
• depression caused by these medications (they can be “downers” emotionally).
• sexual dysfunction.
• cognitive dysfunction.
• and many others.

The treating provider MUST gain the TRUST of the patient to try the recommended treatments. Then the pain specialist must attempt a slow weaning of the opioids while installing alternative treatments. There are several types of non-opioid treatment in the literature to successfully manage chronic pain, which are supported by “science.” Some examples are:

• Non-opioid medications – there are anti-depressants that can work on both musculoskeletal pain as well as nerve pain, AND they work on the depression and anxiety that is so often experienced by chronic pain patients.
• Cognitive Behavioral Therapy – typically a psychologist works with patients to reteach them to accept the pain, not give in to it, and to learn how to “turn the volume down on the pain” so they can become more functional. The psychologist works on “fear-avoidance” and “catastrophizing” tendencies that so many long-term opioid using patients have.
• Acupuncture – has been shown to be beneficial in many types of pain and is much safer than taking so many pills.
• Yoga / “Mindfulness” – treatments are combination of exercise, stretching, and meditation and are safe treatments.
• Progressive exercises and nutritional management with weight loss – so many patients do not understand that movement will not harm them, but NOT moving will. Anti-inflammatory diets have also been shown to have a beneficial effect on chronic pain.
• Electrical modalities – TENS units/H-wave units are simple modalities that many times can provide excellent pain control and avoid the use of harmful medications.

Such alternative treatments have a much better chance of long-term success in treating these centralized chronic pain syndromes.

The patient’s lack of understanding that false-positive findings on imaging studies can lead to misinterpreting the “pain generator”

This misunderstanding about what exactly causes the pain can consequently lead to a patient’s demand for inappropriate treatment of their pain.

In the first scenario above, the findings on the imaging studies were probably not caused by her injury, which means, more importantly, they were probably not causing her symptoms. In cases like this, the pain specialist should explain that the findings are sometimes “normal for your age” and are not caused by the injury, much less causing the pain the patient is having. Patients often state, “I have read my report and it states I have a torn disc (annular fissure/tear) or a bulging disc.” Patients may assume the findings were caused by the work injury. If they had never had MRI’s or x-rays of their back, they would have been unaware of existing degenerative back issues. They become confused and often distrustful because the doctors “all say different things” in terms of explaining what is causing their pain. The doctor should explain to the patient that the literature clearly documents the incidence of false positives/age related changes, such as disc bulges and even herniations that do not correlate with patients work injuries. Doctors may not feel it is worth the conflict they will experience when they try to discuss these issues with their patients. Sometimes they are not aware of the literature indicating this information about “false positive imaging study findings.”

In Ms. Smith’s scenario, she had a minimal mechanism of injury, no findings on imaging studies of “acute injury” structurally, yet her life morphed into years of treatments. In the end, Ms. Smith was totally miserable and non-functional. The pain generator had become “centralized” and could no longer be identified as a structural musculoskeletal or nerve injury. Consequently, opioids and injections and even potential surgery would not be successful. The pain was driven by the opioids themselves (opioid hyperalgesia), which can happen in cases of long-term use like Ms. Smith’s.

An unwillingness of the treating providers to learn from evidence-based literature and incorporate that learning into their practice

This can lead to inappropriate treatment of their patients’ pain.

Medical providers must be educated and convinced that opioids usually do not have long-term success but do have significant risks. It is much easier and less stressful for providers (and their patients) to just continue the opioids and spend minimal time with their patients. There are even documented cases of doctors writing extremely high dosages of opioids without considering other alternatives to pain management and being resistant to any change – even when presented with “the science” indicating the danger of opioids. Patients can be very insistent about getting high dosage opioids, which also makes it difficult for providers to refuse their demands.

Also, there is the financial disincentive for spending the extensive time required to explain the problems with opioids to their patient and to discuss other options. The resistance of the medical provider to “change course” can be attributed not only to ignorance of the updated literature, but also arrogance. Some doctors do not like being told they are wrong. Overcoming this “mindset” of some medical providers can be difficult. Compounding the problem, traditional teaching in medical schools has not placed an emphasis on alternative treatments. Sadly, this mindset can have deadly consequences for patients.

In summary

The appropriate management of chronic pain patients, in workers’ compensation especially, is usually very “complicated.” However, if providers spend the appropriate time in educating and listening to patients, try to successfully determine the true pain generators, study the evidence-based medicine literature, and consider alternative treatments to opioids, successful outcomes can often be achieved for patients with far less chance of harm in the long run. Success for patients in such cases makes dealing with all the complications worth it. There is no need for patients to believe they will be condemned to lives of misery without opioids. And yes, the sad outcome of the gentleman in the second scenario did not have to happen. He did not have to “lose hope.” With appropriate care, he could have gone on to have a good quality of life and not suffer in such pain forever when his opioids were decreased. Our task is to prevent his tragedy from happening to others with workers’ compensation injuries.

Dr. Jeffrey E. Hazlewood practices Physical Medicine and Rehabilitation / Pain Management in Lebanon, TN, and is an Associate Staff Member at Vanderbilt Wilson County Hospital in Lebanon. After receiving his medical degree from the University of Tennessee, Memphis, he completed his residency at the University of Alabama, Birmingham, where he was chief resident. A Fellow of the American Academy of Physical Medicine and Rehabilitation, Dr. Hazlewood is Board Certified in Physical Medicine and Rehabilitation with a subspecialty Board Certification in Pain Medicine. He also is a Certified Lifecare Planner. He is a member of the Medical Impairment Rating Registry and has received training on the 5th and 6th Editions of the AMA Guides to the Evaluation of Permanent Impairment. He also teaches 6th Edition Impairment Rating course to doctors and attorneys. His society memberships include the American Academy of Physical Medicine and Rehabilitation, the American Association of Neuromuscular and Electrodiagnostic Medicine, the American Academy of Physician Lifecare Planners, the Tennessee Medical Association, The Tennessee Pain Society, the American Medical Association, and the Rotary club. He is an experienced speaker on various aspects of pain management and topics in Worker’s compensation and Lifecare Planning. Dr. Hazlewood also previously served as an assistant medical director for the Tennessee Division of Worker’s Compensation. He primarily is a treating physician, but also performs Medical Record Reviews (regarding causation, ratings, and appropriate pain management per evidence-based medicine guidelines) and IME’s.

A primer on the legal approach to aggravations of preexisting conditions

By Jane Salem, staff attorney, Nashville

Last summer, the Tennessee Workers’ Compensation Appeals Board wrote, “This appeal highlights the often daunting challenge of quantifying causation in circumstances where an employee is alleging a work-related aggravation of a pre-existing condition.”

Daunting indeed and an understatement. For over a century, courts have been wrestling with these cases, and it remains a hot topic to this day. The good news is, additional guidance is coming soon from the full Tennessee Supreme Court.

Looking back

The Supreme Court first considered the issue in Tennessee Eastman Corporation v. Russell in 1924, just five years after the Workers’ Compensation Law took effect.

In Russell, the employee worked the night shift in a distillery and was found dead one morning, appearing to have fallen from a platform. The employer argued he suffered from “epileptic fits,” but the trial court found he wasn’t epileptic. Instead, the judge concluded the employee had been “previously injuriously affected physically by the fumes and odors arising from the vats or stills,” and that this likely happened again, causing the deadly fall.

The high Court didn’t cite case law from other states but relied on treatises—books by learned scholars—to find the injury compensable: “[A] pre-existing weakness or disease will not prevent the injury from being the result of an accident, if the accident is the immediate cause of the injury,” they wrote. Further, “an acceleration or aggravation of a pre-existing ailment may be a personal injury, in the sense of the compensation laws.”

Fast-forward to 1948. In Swift & Co. v. Howard, the Supreme Court held, “When an employer employs a workman he takes him as he is and assumes the risk of having a weakened condition aggravated by some injury which might not hurt or bother a perfectly normal, healthy person.” (Emphasis added). The principle of taking the employee “as is” remains good law. The Appeals Board cited it in summer 2023 in a case that was appealed to a Supreme Court Special Workers’ Compensation Panel. The employee unsuccessfully challenged the constitutionality of the Reform Act of 2013 before a Supreme Court Panel in Worrell v. Obion County School District.

More than three decades after Swift, the Supreme Court narrowed the compensability of work aggravations in Boling v. Raytheon Co. In this 1969 opinion, the high Court made a distinction for cases where the aggravation resulted solely in an increase in pain. They wrote, “what we have here is an employee with a disabling injury or disease not related to employment, but the employment does aggravate the disabling injury or disease by making the pain worse. This situation does not constitute an ‘accident’ as this word is used in our workmen’s compensation statutes.”

The high Court placed another limitation in 1987 in Smith v. Smith’s Transfer Corp. The justices concluded that the employee’s “work for defendant aggravated her pre-existing condition by making the pain worse but it did not otherwise injure or advance the severity of her [preexisting condition] or result in any other disabling condition. Thus, we find plaintiff did not sustain an injury by accident within the meaning of the Worker’s Compensation Act[.]”

More than two decades passed until the full Supreme Court released Trosper v. Armstrong Wood Products in 2008. In Trosper, the justices settled the question of what an employee must show for an aggravation to be compensable. They noted inconsistent results from earlier appellate cases and gave the following rule:

“[T]he employee does not suffer a compensable injury where the work activity aggravates the pre-existing condition merely by increasing the pain however if the work injury advances the severity of the preexisting condition or if as a result of the pre-existing condition the employee suffers a new distinct injury other than increased pain then the work injury is compensable.”

Looking ahead: compensability under the ‘New Law’

Shortly after passage of the Reform Act in 2013, the newly-created Appeals Board questioned the viability of Trosper, in a case where compensability was challenged at the interlocutory (nonfinal) stage of a case. The Board pointed out that the Trosper Court applied the remedial construction to find the injury compensable. The Reform Act did away with that and requires courts to construe the workers’ compensation law fairly and impartially. The Act also defined “injury” to exclude “the aggravation of a preexisting disease, condition, or ailment unless it can be shown to a reasonable degree of medical certainty that the aggravation arose primarily out of employment.”

The Appeals Board reversed the trial court’s ruling after an expedited hearing that the employee was likely to show he would prevail at trial that his aggravation of a preexisting condition arose primarily out of employment. The case is Miller v. Lowe’s Homes Centers, Inc., released in 2015.

Judges on the Court of Workers’ Compensation Claims haven’t cited Trosper ever since. But notably, a Supreme Court Panel did just a couple years ago in Edwards-Bradford v. Kellogg Company, a case where the date of injury was after the new law took effect.

Last summer in The AdMIRable Review, we informed you that a complex case involving the aggravation of an employee’s preexisting knee osteoarthritis was heading to a Tennessee Supreme Court Workers’ Compensation Panel.

In the case, Edwards v. Peoplease, the Appeals Board split. The majority cited several post-Reform Act cases and gave guidance for trial judges: “[A] court can consider several probative factors in determining whether a work-related accident contributed more than fifty percent in causing the need for medical treatment, including but by no means limited to: (1) evidence that employee was asymptomatic prior to the work accident but became symptomatic after the work accident; (2) evidence that the employee had no functional limitations to the injured body part prior to the work accident but had functional limitations after the work accident; and (3) evidence, or a lack of evidence, of an ‘anatomic change’ to the body part or condition in question.”

The majority concluded the trial court erred by finding that the primary cause of the employee’s need for bilateral total knee replacements was a work accident, not the employee’s underlying severe osteoarthritis.

The dissent, however, concluded that sufficient evidence supported the finding that the work accident caused new or increased symptoms that led to functional limitations and that the need for the knee replacements was “hastened” by the work accident.

Notably, the Appeals Board in Edwards didn’t cite Trosper or Edwards-Bradford.

The big news now is that instead of a Supreme Court Panel, the full Tennessee Supreme Court will decide the case.

The full Court rarely hears workers’ compensation cases anymore. It also hasn’t tackled a case involving an aggravation of a preexisting condition in nine years and not since passage of the Reform Act. In that time, however, plenty of aggravation cases have been before the Appeals Board and Panels—which shows how truly “daunting” these cases can be. They’re often medical-intensive. Also noteworthy is the fact that the high Court asked the parties to brief the issue of how medical testimony showed be considered by an appellate court. Is the trial court’s decision considered “de novo” (of new) or for an abuse of discretion? The outcome of that question is important because it might affect a party’s decision on whether to appeal an order.

Perhaps the Supreme Court will tell us in Edwards if/when Trosper applies. Regardless, Edwards is likely to be the next seminal case on the topic, for application for decades to come. We’ll let you know the outcome in an upcoming issue of The AdMIRable Review.

CPP Registry Reaches over One Hundred Physicians

In late February, the Certified Physician Program (CPP) Registry reached an important milestone by appointing its one hundredth physician. Over the fall and winter, the number of applications for appointment to the CPP and MIR Registries increased significantly. The lion’s share of these applications came from mostly larger groups and a few independent clinics who see the benefits to increased reimbursements.

Physicians who seek appointment to the CPP Registry must complete a free online course entitled Best Practices for Treating and Evaluating Injured Workers. They must also be certified in the AMA Guides, 6th Edition, through an approved vendor. Because of the cost and time commitment, AMA Guides, 6th Edition, certification is often the greatest hurdle that physicians face when seeking appointments to the CPP and MIR Registry.

The recent surge of physician applications is due primarily to the Bureau providing free on-site training to groups of 10 or more. If requested, the Bureau may provide this free training to one or more neurologists, psychiatrists, pulmonologists, ophthalmologists, urologists, dermatologists, and otolaryngologists that are interested in treating injured workers. To be eligible for the free AMA Guides training, physicians must first (1) register and take the Bureau’s Best Practices for Treating and Evaluating Injured Workers course, and (2) submit an application for appointment to the CPP.

The length of a training session depends on the specialty and includes a test. For more information regarding these training sessions, please contact Jay.Blaisdell@tn.gov.

Submission Guidelines

AdMIRable Review accepts electronic submission for articles related to Tennessee Workers’ Compensation. Manuscripts prepared in accordance with the American Psychological Association (APA) guidelines are preferred. Submission of a manuscript implies permission and commitment to publish in AdMIRable Review. Submission and inquires should be directed to AdMIRable Review, Editorial Staff, at Jay.Blaisdell@tn.gov.

AdMIRable Review, Tennessee Bureau of Workers’ Compensation, 220 French Landing Drive, Suite 1-B, Nashville TN 37243, p. 615-253-5616, f.615-253-5263

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