Chronic / institutional patient: Unfortunately, not everyone gets better even with the most thorough and well-intentioned treatment. When patients enter today's medicolegal maze, their outlook for recovery becomes progressively worse, regardless of their actual medical problem. Novack has defined the low back loser as a person who physically, psychiatrically, vocationally, and socially is permanently disabled due to low back pain and its treatment. He identified the following characteristics most commonly found in patients who failed to respond to treatment of low back pain after eighteen months.
| Work or accident related pain |
| Was mismanaged |
| Received excessive conservative management |
| Received excessive medications without relief |
| Showed psychosocial problems |
| Was treated surgically |
| Was obese |
| Reported more pain and neurologic deficit after treatment than originally after the accident |
| Showed drug dependence or addiction |
| Had less than average education |
These features clearly apply to many patients with chronic upper extremity medicolegal disorders. This scenario does not imply manipulative or malingering behaviour, but does suggest that in this context, further medical intervention is unlikely to result in satisfactory improvement.