Why Chronic Pain Patients are Misdiagnosed lists the various problems which prevent obtaining a thorough medical history. Also, it delineates the causes of the three flaws in diagnoses 1) missing a diagnosis 2) using a description (low back pain is not a diagnosis) and 3) overusing a diagnosis. Chronic pain patients are misdiagnosed 40%-67% of the time. This power point lists methods of obtaining proper diagnoses, documented by outcome studies, which prove the efficacy of these diagnostic methods. One case is point is the overdiagnosis of RSD or CRPS, where 71% of patients sent to the former president of the RSD Asssociation of America with the “diagnosis” of RSD actually had nerve entrapments, and no signs of RSD. Using proper techniques the return to work rate was dramatically improved with a reduction of medication use and doctors visits, resulting in large cost savings.

1. WHY CHRONIC PAIN
PATIENTS ARE
MISDIAGNOSED: and how to
make a proper diagnosis
Course 12
www.MarylandClinicalDiagnostics.com
Nelson Hendler, MD, MS
Former Assistant Professor of Neurosurgery
Johns Hopkins University School of Medicine
Past president –American Academy of Pain Management

2. Missed Diagnoses-Neck and Back Pain
• Hendler et al Overlooked Physical Diagnoses in Chronic Pain
Patients Involved in Litigation, Psychosomatics, ’93
• N= 60
• 67% were misdiagnosed “lumbar strain, cervical strain, chronic
pain syndrome, conversion reaction.”
• Hendler, et al, Overlooked Physical Diagnoses in Chronic Pain
Patients Involved in Litigation: Part II 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 a picture, but you can’t take picture
of “pain.”
• If you want to know “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).
• Failure to realize a single pathological condition
may have multiple clinical manifestations (Lyme
disease)
• Failure to take a careful history.
• Failure to understand the specificity and
sensitivity of tests.
• Relying on anatomical tests to make a diagnosis
rather than clinical judgment or physiological
tests.
• Not believing a patient.

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 wrong diagnosis
without any objective data to support it, i.e. RSD,
lumbar strain, fibromyalgia, psychogenic pain,
fibromyalgia, etc.
• The www.MarylandClinicalDiagnostics.com
Diagnostic Paradigm 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. 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.

10. 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.

11. 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.

12. 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?

13. 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.

14. 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

15. 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.

16. 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.

17. 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

18. 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).

19. 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

20. 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.

21. 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

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

23. 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).

24. 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%).

25. 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.

26. 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

27. 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.

28. 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?

29. When a Sprain or Strain Lasts More
than 6 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.

30. 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

31. 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.

32. 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)

33. 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

34. 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.

35. FIBROMYALGIA
(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.

36. Fibromyalgia Pain Points
The 18 fibromyalgia
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

37. 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.
(Abstract-Hendler, Murphey and Romero, Academy of Psychosomatic
Medicine, 2010)
• The overlooked diagnoses was rate 97%.

38. 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.

39. Thoracic Outlet Syndrome
• This is a very often overlooked diagnosis.
• There are two types of thoracic outlet syndrome.
• a) Vascular, which is found intra-operatively in
less than 10% of cases (Roos).
• b) Neuronal Compression of either lower plexus
or upper plexus or both.
• Thoracic outlet syndrome can be a combination
of both vascular and neuro.
• EMG/NCV are of no use to establish diagnoses

40. The Anatomy of Thoracic Outlet

41. Clinical Tests for Thoracic Outlet
Shoulder
Roos
Pressure
Adson

42. Vascular Flow Studies Comparing the Roos
Maneuver to the Adson for Thoracic Outlet
(same patient as his own control)
Blocked
blood
flow with
Roos
Still
blood
flow
with
Adson

43. 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. No attempt at
diagnosis. All are CPP
• Only through a multidisciplinary diagnostic program
do you establish diagnosis, and then tailor the treatment
for the disorder.
• Use the www.MarylandClinicalDiagnostics.com tests
to get diagnoses and treatment plans which recommend
the proper tests to use.

44. “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.

45. Patient variables that influence outcomes
• 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

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

47. Patient Variables-Do they matter?
• In a private clinic study of 120 patients, the average IQ
of a litigant patient (Workers Compensation or auto
accident) was 93.6 (75-121), (Psychosomatics ’96).
• The average age was 39 (17-70) (ibid).
• The average duration of pain was 3.63 years (.1-30).
• How do you return to work a 75 IQ, semi-literate truck
driver, with a 10th grade education, with active workers
compensation litigation, who is 58 years old, and has
arachnoiditis for 3 years causing back pain?
• Patient selection impacts outcome statistics.

48. 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 ( Occ. Med, ’68, 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.

49. Type and Stage of Litigation
• An article in 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-matched for diagnosis
• 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 influenced outcome

50. Outcome Studies using
www.MarylandClinicalDiagnostics.com approach
• Johns Hopkins Hospital reduced their workers
compensation cost 54% by making their injured
employees see only Johns Hopkins Hospital
doctors instead of local community doctors
Bernacki EJ, Tsai SP. Ten years' experience using an integrated workers' compensation management
system to control workers' compensation costs. J Occup Environ Med. 2003 May;45(5):508-16.
• The diagnoses of the Diagnostic Paradigm from
www.MarylandClincalDiagnostics.com have a
96% correlation with Johns Hopkins Hospital
doctors.
Hendler, N, Berzowsky, C and Davis, R Comparison of Clinical Diagnoses to Computerized Test
Diagnoses, Pan Arab Journal of Neurosurgery, pp:8-17, October, 2007.
•

51. Outcome Studies using
www.MarylandClinicalDiagnostics.com approach
• Workers’ compensation patients out of work for 2 years
or more had a return to work rate of less than 1%
( Occ. Med, ’68, Occupational Low Back Pain, ’84).
• Using www.MarylandClinicalDiagnostics.com tests on a
group of patients out of work for an average of 4.9 years,
one clinic had a return to work rate of 19.5% for
workers’ compensation patients, 62.5% for auto accident
patients, a 90% reduction in use of narcotic medication,
and 45% reduction in doctors visits. Hendler, N.: "Validating and
Treating the Complaint of Chronic Back Pain: The Mensana Clinic Approach." Clinical
Neurosurgery. Vol. 35, Chap. 20:385-397, eds. Black, P., Alexander, E., Barrow, D., et. al.,
Williams and Wilkins, Baltimore, 1988.
• Cost savings ranged from $20,000 to $175,000
http://www.slideshare.net/DiagnoseMyPain/patient-cost-savings-documented-with-letters

52. Methods to Avoid Misdiagnosis
• See www.MarylandClinicalDiagnostics.com
• The Pain Validity Test can predict, with 95%
accuracy, who will have moderate or severe
abnormalities on objective medical tests, and can
predict, with 85% accuracy who will not (1).
• The Diagnostic Paradigm will give a physician
diagnoses which have a 96% correlation with
diagnoses of Johns Hopkins Hospital physician (2)
• The Treatment Algorithm list the proper tests to use
to confirm the diagnoses, and proper treamtments
(1)Hendler, N. and Baker, A., An Internet questionnaire to predict the presence or absence of organic pathology in chronic back, neck and limb
pain patients, Pan Arab Journal of Neurosurgery, Vol. 12, No. 1, pp: 15-24, April, 2008.
(2) Hendler, N., Berzoksky, C. and Davis, R.J. Comparison of Clinical Diagnoses Versus Computerized Test Diagnoses Using the Mensana
Clinic Diagnostic Paradigm (Expert System) for Diagnosing Chronic Pain in the Neck, Back and Limbs, Pan Arab Journal of
Neurosurgery, pp:8-17, October, 2007.