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A study by TJ Murray, OC, MD, FRCPC, FACP, Professor of Medicine Department of Medicine (Division of Neurology) Dalhousie University
INDEX (SUMMARY OF RECOMMENDATIONS)
"God whispers to us in our pleasures, speaks in our conscience, but shouts in our pains ......."
CS Lewis "The Problem of Pain"
Everyone experiences pain. Many life events, like stubbing your toe, or banging your elbow, or burning your hand, cause sudden pain. The painful stimulus results in sudden reflex, emotional and behavioral responses to stop or withdraw from the cause of pain. This is the common experience of acute pain. Occasionally, pain is chronic, persisting long after healing should have occurred. The condition of chronic pain is the subject of this report. While reading this report it is important to keep in mind that chronic pain is different than acute pain, and all the characteristics we normally associate with acute pain are not the basis of chronic pain.
Because the understanding and management of chronic pain is complex, and because it has been an unsolved, difficult problem for all involved, this report was requested. No one will be surprised that we will not provide simple answers to the long standing questions that have not had solutions. Rather, we will provide a reasonable understanding of chronic pain, so that reasonable policies can be based on current concepts and understanding.
I have tried to be as objective as possible, taking the stance that I am on no one's "side" in this matter. Although commissioned by the Workers Compensation Board of Nova Scotia, I have tried to approach the problem of chronic pain as a clinical issue, leaving the policies that might result to others.
The method of this study was as follows. The medical literature was reviewed over many months, beginning with 1700 citations on Medline and dozens of books on the subject. A summary report of the medico-legal research was prepared (Appendix B). No attempt was made to produce a textbook, but to note current and important writings on the subject. Only then did I return to the specific questions asked of the study by the Workers Compensation Board. From this background I attempted to give answers to the questions, as best I and the data could provide. As the questions and answers overlapped in areas, they were sometimes combined. I addressed the initial draft of the questions and answers to a respected group of specialists, who deal with chronic pain, and sought their comments and advice. I met with an advisory committee of WCB for their comments. Although I received valuable comments at these meetings, the opinions and conclusions of the report are my own.
TJ Murray, OC, MD, FRCPC, FACP
Director, Dalhousie MS Research Unit
Professor of Medical Humanities
Dalhousie University
BRIEF SUMMARY OF THE REPORT
"Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of tissue damage."
The International Association for the Study of Pain LaRocca, 1992
"Pain is a hurt we feel"
Richard A. Sternbach
Pain is a unique personal experience that cannot be fully shared by anyone else. We cannot transmit pain, but we can communicate pain by words or by behaviour.
The understanding of pain is complicated further by the fact that the same painful stimulus may be perceived differently by different people, and differently by the same people at different times. The person's reaction to the circumstances surrounding the pain experience and the interpretation of the pain meaning may also be different. Although pain is personal, private and unique, there is often a demand from others that pain and pain situations be objective, public and reproducible. Although pain is personal, subjective and difficult to quantify, it still can be studied, like other similar phenomena like memory and vision.
Acute pain is protective. In most instances a local cause is easily recognized, such as a cut finger or sore joint, even though the pain is perceived in the central nervous system. This type of pain responds to analgesic and narcotic medications, and the response to such pain may be modified by cultural and psychodynamic factors. The emotional and psychological aspects of acute pain relate to how threatening or damaging the person thinks the process may be. The reaction to a severe pain in our ankle is different from a mild or moderate chest pain. A football player may continue to play despite a fracture, while a stressed person may leave work because of a headache. The mechanisms involved in acute pain are well studied, and although interesting and important, acute pain is not the subject of this report.
Chronic pain is not protective (Bonica, 1990). It has very complex and multifaceted features, and cannot be understood by simply applying the concepts of acute pain and its causes and treatments. Chronic pain does not respond well to analgesics and narcotics and is resistant to most traditional therapies for pain. There may not be an easily definable local cause. Only a third of the patients note an event or injury as initiating the pain and in most of these instances, the pain seems out of proportion to the suspected underlying disorder or trauma The presence of mild depressive overtones, and other psychological features in many of the patients has led to a suspicion that psychological mechanisms underlie this disorder. As we shall see, it is much more complex than that, as many of the accompanying features may be a result of having chronic pain.
Chronic pain is an important medical and social problem for three major reasons. It is distressing to patients, as it alters their lives and sometimes their employment, and it responds poorly to treatment. Chronic pain is a common condition that has huge financial costs to society. Finally, despite its frequency and large costs, it is difficult to understand and manage, and eventually becomes a source of stress and misunderstanding to all concerned. Chronic pain is frustrating for everyone - the patient, their family and friends, their employers, the insurance and compensation agencies, the courts and their physicians. Because the patients often don't respond to treatment, and the patient and the physician continue to search for a local cause, and a logical specific treatment. The search is unsuccessful in 94% of cases (Swanson), so the frustration increases.
The human suffering and costs to society in lost time and productivity, compensation and legal costs, medical treatments and personal costs measured in billions of dollars annually (Spitzer, 1993). Although less than ten percent of all pain patients go on to become chronic, the chronic pain patients account for three quarters of the overall costs of health care and compensation for pain, and represent a increasing group of very distressed, suffering people.
Lastly, it has been difficult to know how to understand and evaluate people with chronic pain, and how to fairly treat and compensate them (fair to the patient and family, fair to the employer, fair to society). Chronic pain is felt only by the patient, is difficult to assess and measure, and is a recognizable problem only because the patient says it is there. It is clearly a complex and multifaceted problem, and so defies simplistic attempts to categorize or pigeon-hole cases as "organic or psychological", "real or imaginary", or "physical or hysterical". It is also difficult to provide an objective assignment of the relative weight of all the physical, behavioral, psychological, social and cultural factors that are usually involved.
Chronic pain occurs in about 11-54% of the population in various forms, and can develop without any evident cause, or may develop associated with a stress, or injury or specific illness. In fibromyalgia only 29 of 127 patients (23%) could identify a precipitating event (Greenfield, 1992). The ones that present to Workers Compensation Board are those who relate their onset to a work situation or event, but many people have chronic pain with no consideration of compensation or litigation.
A common scenario in the workplace is an injury, strain, or repetitive task that initiates muscle spasm, aching or pain. The person may have an acute low back strain, or a flexion-extension neck injury ("whiplash"), or painful muscle from overuse of the limb in a work task. These are commonplace and usually settle down and clear within a matter of days or weeks, often with no specific therapy. Some others are more severe and may require therapy, but there is still an expectation that it will clear with a specified time period over weeks or months. In a small percentage of people the chronic pain persists long after normal healing should have occurred, and in most instances no pathology or structural changes can be found to explain the persistence of pain (Swanson, 1976). Recent work on plasticity of the nervous system (Wall, 1994), indicates that over time changes can occur in the peripheral and central nervous system mechanisms for sensation and pain, that may result in pain continuing and previously non-painful stimuli to be perceived as painful.
Falling into the group of conditions that may have pain that is chronic are a number of specific pain syndromes (trigeminal neuralgia, bone pain from cancer, reflex sympathetic dystrophy and rheumatoid arthritis, for example), but most people with chronic pain fall into an overlapping group that share many similarities, i.e. fibromyalgia, myofascial pain syndrome, chronic low back pain, tension headache, "whiplash" and tempromandibular joint syndrome. Some forms of chronic pain, as mentioned have a degree of pain chronicity that is compatible with the underlying anatomical disruption or physiological abnormality. This report, however, confines itself to chronic pain that seems disproportionate to the underlying disease process or injury both in terms of the chronicity, the disability and the lifestyle disruption.
In recent years the concept of "chronic pain syndrome" has been defined to understand, study and manage patients with long standing, unexplained pain. The syndrome is defined as persistent pain for more than 6 months after normal healing would have been expected. Although "chronic pain syndrome" is a useful concept to approach the management of chronic pain patients there has been a pendulum swing in its acceptance. Initially it grew in acceptance because it was helpful in recognizing the multiple features of chronic pain, and it de-emphasized the tendency to keep searching for specific causes and specific "cures". The literature in recent years has grown rapidly but recently the influential report of the International Association for the Study of Pain, in the 1994 edition of "Classification of Chronic Pain" decided not to use the term (IASP, 1994). Their rationale was that if there are physical, psychiatric and other aspects they should be specifically assessed and a specific diagnosis applied.
Patients with chronic pain may have localized or widespread pain and tenderness, some with tender points in predictable spots, but with few other physical findings. They often complain of fatigue, sleep disturbance, and limited function. They may have evidence of depressive mood, and exhibit behaviours of chronically ill people. They often search for a single cause of the problem and become frustrated with the medical profession when tests do not reveal a cause and multiple treatment approaches fail to give relief. As time goes on and the symptoms continue, the condition becomes more complex and other factors influence the manifestations, attitudes and symptoms, the chronic pain patient can often be noted to adopt features and behaviours that are referred to as "pain behaviours", and may adopt the sick role and become more limited than one would expect from the physical findings and tests of their function. The approach of medical investigation and treatment, the attitude of family and supporters, and the mechanisms of Workers Compensation Board and social agencies may become important factors by providing "rewards" for remaining unwell, and accentuating the illness behaviour. The person may be quite unconscious of this, but it can be a process that worsens the condition even though the aim of these processes was to help the person.
It is agreed by experts on chronic pain that it is a complex of physical, psychological, emotional, social and cultural factors that interplay to produce and continue this syndrome. This view produces a potential conflict between those attempting to treat this problem and the sufferer, as the patient does not usually like this kind of discussion, and wishes a return to the search for a single pathological cause and an effective treatment. Also, it can be easy to argue against a composite picture as painted above when discussing a patient, as each individual is different, and may disagree with features commonly seen in the chronic pain syndrome. Complicating the picture is the patient's physician, who sees him or herself as the patient's advocate, who may have a concept of pain based on the understanding of acute pain, which is protective, and usually has a specific cause and a logical treatment that often works. If the physician keeps doing more and more tests, and applying more and more treatments with the view to eradicating some unidentified tissue damage, the sick role is accentuated, and the patient becomes more frustrated, downhearted, frightened and insecure.
There is a long experience with chronic pain showing that applying the principles of acute pain is incorrect and unsuccessful. Physicians must be re-educated on this point if these patients are to be managed successfully. The concepts that should be applied recognize that there are complex physical, emotional, psychological, social and motivational issues to be addressed, best done by a multidisclipinary team, and that overuse of analgesics and other medications often lead to dependence, addiction but little pain relief in these patients. An important key is early intervention in the process. This not only means early intervention in the development of chronic pain, but attention to how acute pain is treated so that it does not lead so often to chronic pain. In addition early return to work despite pain is essential, as the likelihood of return to work and a full and active life becomes less likely as the months go by. When it is clear that early intervention is important, the further steps are based on a careful assessment of the problem at that point, coupled with assessment of vocational, psychological and social factors.
Complicating the understanding and management of chronic pain is the confusion and the various schools of thought, often hardened in their positions, that relate to the physical and psychological aspects of the problem, the social and cultural aspects and the approaches to therapy. Such ambiguity results in uncertainty, controversy and suspicion. Suspicion has been increased by the association of chronic pain syndromes with malingering, the increased public scrutiny of social program such as Workers' Compensation, social concerns about worker productivity, and the competing interests of employers and employees in the design of the compensation system (Tarasuk and Eakin, 1993).
Because much thinking is still based on a Cartesian mind-body separation, there is a tendency to feel that chronic pain is either "physical" or "psychological", not recognizing that it is always a combination of the two. As Patrick Wall points out, it is "unwise arrogance" to believe that we can identify all forms of peripheral pathology so our lack of evidence is not necessarily evidence of a lack of pathological change. In addition, a peripheral event may trigger long lasting changes in the nervous system by way of nerve impulses and transported substances that produce a cascade of changes that may persist in the nervous system long after the peripheral pathology has disappeared. Lastly, Wall has pointed out that we are recognizing that the central nervous system is not entirely "hard wired" but kept in the stable state by elaborate, dynamic control mechanisms. These control mechanisms may be altered so they shift into an unstable state, with symptoms such as chronic pain resulting (Wall, 1994).
The management of the patient must be based on an understanding of the complex nature of chronic pain and move away from the acute model. It is imperative that physicians and others recognize that the patients are suffering and are having distress. The patient must be respected, while recognizing the wide range of influences that perpetuate chronic pain. Unfortunately, unless handled sensitively and with good information, the patient perceives that treating them in other than the medical model for acute pain means that the physicians thinks it is "all in my head".
Better outcomes in chronic pain would be achieved if there were a simpler, clear cut compensation mechanism that encouraged early return to work, even if the work is modified or the work changed, assessment by multidisciplinary groups skilled in the management of chronic pain, and lessened antagonism among the various players.
The recommendations for better management of chronic pain patients centre around the education of physicians and other health care professionals; the education of employers and co-workers and modification of the workplace and employment for the prevention of chronic pain and to accommodate the returning chronic pain patient; the use of a rehabilitation approach including early intervention, increased activity and function, and early return to work.
a) Better care of acute pain and trauma
b) Use of normal recovery times for illness and injury
c) Early recognition of chronic pain characteristics and behaviours
d) Early intervention when pain exceeds normal recovery times
e) Use of multidisciplinary teams to manage chronic pain
f) Stressing the goals of increased activity and improved function even in the presence of pain.
g) Acceptance of the goal of early return to work
The author of this report agrees with Spitzer (1993) who made five major points about the management of low back pain that could be generalized to the chronic pain patients discussed in this report:
Spitzer concluded that the hurt of chronic pain was not necessarily harmful, but that chronicity was harmful and could be devastating to the workers and their families. (Also see Melzack, 1989; Liebeskind, 1991; Jareti and Lliebesking, 1994.)
Although the title of this report is related to "Pain", I suspect that we would understand the situation and the patients much better if we concentrated more on the concept and meaning of "suffering". This would help us understand what is occurring to the people, their families, their therapists and all the others who relate to them.
The aim of the medical profession is to relieve suffering. Cassell (1982) reminds us, however, that this may be naive. He states that the public, and patients, feel that the aim of the medical profession is the relief of suffering, but apparently the profession doesn't. Doctors tend to separate the physical and the non-physical aspects of suffering. . Medicine's traditional concern for the body and physical disease, and the widespread belief in the mind-body dichotomy on medical theory and practice, resolves to the paradoxical situation in which physicians may even create suffering in the course of their treatment of the sick.
A football player, injuring their leg, will often accept it without any apparent suffering, and regards it as an annoyance that may impede or end their play in the game. He often gets up, limps a little and then attempts to "run it out". In other circumstances a person may experience leg pain and have associated anxiety and suffering because it is seen as potentially threatening, and with long term consequences. The person may refuse to move, and after periods of rest, when the leg becomes stiff and sore, it increases the feeling that the tissues have not healed, and causes them to rest more, which in turn may aggravate the symptoms and problems and fulfil the prediction that the injury was serious with long term consequences. The person will often express a lot of pain and suffering behaviour which is reinforced by the continuing symptoms, or just the anticipation of movement and pain.
Cassell makes three major points. First, suffering is experienced by persons. Personhood is multifaceted, and includes mind, spiritual, body and the subjective experience. Second, suffering occurs when an impending destruction of the person is perceived, as from any event that threaten the intactness of the person. The third point, and one that I think is often missed, is that suffering can occur in relation to any aspect of the person, whether it is in social role, group identification, the relation with self, body, family, or the relation with a trans-personal transcendant source of meaning. Suffering is ultimately a very personal matter. patients may report suffering when one does not expect it, or do not report suffering when one expects they would.
To try and understand the person, Cassell offers some important points about personhood. A person has a personality and character; a past; a cultural background. A person has roles; exists with other persons and is a political being. A person has a body; has a secret life; has a perceived future; and has a transcendent dimension, and a life of the spirit.
All of these elements of the person are susceptible to damage and loss. What might happen from an injury or illness is not always predictable in the individual. Cassell says that the only way to learn what damage is sufficient to cause suffering, or whether suffering is present, is to ask the sufferer.
Patients suffer when they perceive that there is some threat to their person, they have no control and the pain may not pass. When patients feel that their problem can be managed, and that their pain and distress can be controlled, their suffering is remarkably reduced. A loss of control is an important component of suffering. Cassell concludes that people in pain report suffering when they feel it is out of control, when the pain is overwhelming, when its source is unknown, when the meaning of the pain is dire, or when the pain is chronic. Thus, they perceive pain as a thread to their continued existence, not merely to their lives, but to their integrity as persons. There is some hope in this concept, as we may be able to relieve suffering if we can make the source of the pain known, or change its meaning, or demonstrate that it can be controlled, or than an end is in sight.
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"Pain is difficult to measure as it varies in degree from one to another individual with similar injury, and evokes differing emotional responses and adaptations in injured individuals. Differing perspectives, priorities and biases appear to affect the opinions and behaviours of those involved: the injured worker and family, the employer, fellow workers, insurance carriers, administrative law judges, attorneys, physicians, other health care providers, and rehabilitation counsellors. These influence decision-making and may actually interfere with medical treatment.
Yet the common goals of all involved is to accurately evaluate and diagnose the causes of the worker's pain and disability, to promote a timely relief of symptoms and resumption of optimal function, to minimize the emotional impact on the injured worker, and to control the costs of the injury, its treatment and its administration."
Harrington, 1992
In this section of the report I will attempt to answer the questions put forward by Workers' Compensation Board. (For the detailed list of questions see Appendix A: Terms of Reference).
Everyone understands the nature and significance of acute pain. You burn your finger; you stub your toe; develop a headache; you pull a muscle. There has been extensive physiological study of acute pain, with an understanding that it is protective, accompanied by varying reflex, emotional and behavioral components, and it can be modified by social and cultural factors. When discussing pain, most people, including physicians, think of acute pain and the mechanisms of acute pain. It is not surprising that patients and physicians usually think of pain, even long standing chronic pain, in terms of an underlying cause, and they search for ways to identify and remove it, and use treatments to suppress the pain, and eradicate the cause if possible.
In recent years it has become evident that there are many patients with long standing chronic pain that cannot be understood in terms of acute pain mechanisms. Chronic pain often has no obvious specific underlying local pathological cause that can be identified or eradicated, does not respond to the usual treatments for acute pain, and is associated with complex psychological, behavioral and social factors.
Experience has shown that approaching chronic pain as if it were acute pain is almost always unsuccessful. Rarely is a specific and definable pathological process identified that can be removed with relief of the pain, so repeated CT scans and other tests lead to frustration, increased concern but no useful information, or worse, confusing and misinterpreted information. The usual pain medications are unsuccessful and often create more problems than they relieve. Also, thinking in terms of tissue damage, or an undiscovered pathological process causes one to ignore very important psychological, behavioral, social and cultural factors that are an integral part of this syndrome.
The concept of a "chronic pain syndrome" has recently been argued. The chronic pain syndrome has been defined as pain persisting 6 months after healing and recovery would be expected, if there is a definable trauma, or 6 months after the onset, in the absence of any definable ongoing pathological process. Recently it has been suggested the label "chronic pain syndrome" not be used (IASP, 1994).
After a period of general acceptance of the term, particularly in the medical literature from the United States and Canada, the task force on "Classification of Chronic Pain" of the International Association for the Study of Pain (IASP, 1994), decided to back away from the term. Their argument was that the syndrome recognizes the presence of the many factors, but might evade the requirement for accurate physical and psychiatric diagnoses. Although the IASP agreed that chronic pain was quite separate from acute pain, and was a unitary phenomenon experientially, they still argued there may be more than one cause and the causes may vary in importance. The IASP also felt the term was used pejoratively.
The IASP discussed their decision to move away from the term under "Some Controversial Issues" but this may create more problems than it solves. For instance, it tends to emphasize the requirement to continue to search for specific diagnosis in patients with chronic pain when the pressure should be to get on with its management. The use of the term chronic pain syndrome does not preclude making specific diagnoses of the physical, psychiatric, behavioral and other factors present, but does emphasize that overconcentration on the specific aspects may sideline and obscure the major goals of management. However, in this report the concept of chronic pain will be used generally and reference to chronic pain syndrome will only be to writers who used this term in the past or to the specific questions WCB asked about the syndrome.
To understand the condition of chronic pain better, it is helpful to think in terms of "suffering". I say this because the word "pain" evokes the concept of acute pain, when it is clear that these patients are suffering, and that the suffering is often painful, but that there are other components of suffering as well. They are suffering with disturbed sleep, negative mood and sometimes depression, feelings of insecurity and lowered self worth, and feelings that they are severely impaired, even more impaired than they obviously are. They have behaviours that are in keeping with the "sick role", often manifesting behaviours and appearances that communicate how ill and pained they are. These patients have complex suffering, often with pain, and sometimes suffer from the anticipation or fear that actions or activities will precipitate or worsen the pain (Cassell, 1984).
It is to be expected that pain would be an important variable in the recovery process following an injury. An acute injury is usually associated with tissue damage, tissue repair and ultimately healing. There is a "normal" time course for tissue repair and healing which will vary with the site of damage, the degree of damage, whether incomplete or irreversible, and the type of tissue involved. One aspect of pain recovery is the personal response to pain. This has features that relate to the kind of injury, the circumstances surrounding the injury and its significance to the person, cultural differences in response, and various extraneous factors such as secondary gain.
Other factors include the anatomical location, and the emotional response to the kind of injury. For instance, individuals are much more sensitive and aware and threatened by injuries around the face, and may be impaired longer if the injury occurs to a weight-bearing joint, an eye or hand, than if a similar degree of trauma and tissue damage occurred in another anatomical site. It goes without saying that injury that results in pain will tend to have a slower return to normal function and activity.
Tissue damage and pain are often associated, but not always proportional. For instance, some severe injuries with a lot of tissue damage may be accompanied by moderate and well tolerated pain and discomfort in some individuals, whereas minor trauma which may not even be visible, may cause another person distressing discomfort and pain (Arinoff, 1991). There are legendary stories of soldiers charging ahead despite severe multiple wounds, later indicating they felt no pain at the time. Football players, pilots and most professionals often minimize trauma that would be expected to be painful, and wish to return to work early, arguing that they are recovering rapidly.
Pain is categorized as acute and chronic, and this has direct relevance to the relationship to the recovery process. In an acute injury, acute pain is normal and expected, particularly in the early stages of trauma and tissue repair. Chronic pain may persist when recovery has not occurred and the pathological process continues, or when a series of factors create a situation in which pain and suffering continue in the absence of any evidence pathological process or tissue damage. In that situation it is felt that recovery has not occurred, not because there is evidence that tissue damage has not repaired, but because the symptom of pain persists.
Chronic pain patients who relate their problem to the workplace fall into three categories:
The chronic pain developing after a workplace injury is defined as persistence of the pain without any identifiable pathological change to explain the persistence of pain, continuing 6 months after recovery would have been expected. Those that develop chronic pain at work but unrelated to an event, are defined as having the chronic pain for more than 6 months. The last group are those who develop chronic pain, often over a very long period, but they begin to notice that work activity is aggravating their problem.
In some instances an accident, repeated trauma or "repetitive strain", associated with a task, is related to the onset of the pain. As time goes on, however, the pain becomes more chronic and widespread, and persists even when the person is not involved in the task. Many of the chronic pain syndrome patients do not have an accident, or injury event that they can distinctly relate the onset of their problem, but instead, have gradual onset of chronic pain that is inferred to be due to work. This seems to be confirmed by the increasing pain associated with continuation of physical effort and work. The relationship of pain aggravation to the effort of continuing employment leads to the logical conclusion that work should be reduced or stopped, and the chronicity increases because any attempt to return to work aggravates the pain. This is a cycle that has to be altered.
The relationship to the workplace is confounded further by the recognition that many people with do not make an association of this with the workplace, and have no claim for compensation. In the practice of most physicians, many cases of chronic pain they see are not related to compensation or litigation. The association of pain aggravation and persistence associated with compensation has been over-emphasized in the past.
A more complicated concept is related to pain proneness. It has been argued that some people are prone to chronic pain and that it might occur in the individual whether or not they were in their employment, and therefore the development of chronic pain could be said to be incidental to employment. This idea has also been over-emphasized in the past (Lynch, 1993) and has been unhelpful as a concept when addressing the important decision surrounding chronic pain. At the very least, this might constitute the psychological variant of the "thin skull principle".
Many conditions can produce pain, and develop into chronic pain, but for simplicity purposes they can be grouped into two large groups. The first is that of specific syndromes, a large group of specific conditions that may become chronic such as herpes zoster, reflex sympathetic dystrophy, trigeminal neuralgia, migraine, phantom pain, etc.
The second is chronic pain resulting from a group of musculoskeletal pain disorders. This group tends to be the most challenging and perplexing for the patients, physicians, Workers' Compensation Board and the legal system. This group includes conditions often referred to as fibromyalgia, fibrositis, myofascial syndrome, cervical strain, chronic low back pain, whiplash, repetitive strain syndrome and chronic tension headache. These are common in the population, and are as more often unassociated with the workplace or compensation.
Attempting to classify and designate specificity in these musculoskeletal syndromes has been difficult, and there is so much overlap that one might consider them all as variants of the same process, whether developing chronically, or related to an acute event. Although there is still a tendency to separate syndromes such as fibromyalgia, myofascial syndrome, cervical strain, chronic low back pain, repetitive strain injury and chronic tension headaches, they may be variants of the same process. Jeffrey Thompson of the Mayo Clinic in 1990 argued for unifying conditions with separate diagnoses under one conceptual framework called "tension myalgia". So far, this has not had wide acceptance (Thompson, 1990).
Nachemson (1994) argued that predictors of chronic pain include dissatisfaction in the workplace, and lack of a sense of control. He indicated a strong predictor of chronic pain was positive responses to questions that assessed how the person felt about and communicated with bosses, fellow workers, and the job. This may apply to some but there are other studies that show the vast majority of disabled workers want to return to work.
Karasek and Theorell (1990) postulated a "job strain" model to assess the psychosocial characteristics of workers and the workplace. The job strain model proposes that workers at greatest risk are those whose jobs place high demands on them but give them little control, and little personal support. They include assembly line workers, nurses aids, key punch operators, garment stitchers and others. Workers with high demands and low control also have more illness related absenteeism and a greater risk of other disorders such as coronary heart disease. In contrast, "healthy work" is that which allows people to use and develop their skills, to participate in decisions surrounding their work and their workplace. This has important implications to management in other ways, as it also appears to increase productivity.
Uncertainty and suspicion were two factors that shaped worker responses to their injuries, and some of this was centred around the workplace and the attitude of fellow workers and employers. Because there is a lot of uncertainty surrounding low back pain, fibromyalgia, and other causes of chronic pain syndrome, there tends to be a sense of suspicion by all who relate to the person with chronic pain, and whether it is real or serious. The lack of objective evidence and the uncertainty increase the potential for resentment by workers and employers, and accentuate the problem for the patient. The likelihood of long term pain can be reduced by early intervention or by a health professional who early indicates the job is waiting, shows compassion, and reduces fear and concern.
Robins and co-workers (1990) studied whether increased body awareness and illness worry might explain the distress and disability expressed by patients with chronic pain. They examined 20 patients with fibromyalgia and compared them to 23 with rheumatoid arthritis and looked at measures of depressive and somatic symptomatology, pain, disability and amplifying somatic style. The fibromyalgia patient has greater somatic symptomatology, equivalent levels of pain and less physical disability than those with rheumatoid arthritis. There was no difference between the two groups on body awareness or illness worry. Illness worry correlated highly with symptomatology for both groups, but with physical disability only among the fibromyalgia patients. Their results suggest that disability in functional somatic syndromes may be determined by patients worry about having a serious disease. Feelings of vulnerability and apprehension about having an illness of unknown origin can contribute to activity limitations in fibromyalgia patients, and to their degree of somatic distress.
There are few if any common definable medical conditions that would predispose one to workplace injury induced chronic pain. However many have argued that psychological and situational features (job dissatisfaction, marital problems, alcoholism, job insecurity, etc) may make one prone to continuing symptoms if an injury occurred.
Although the worker with chronic pain is usually only interested in what damage occurred to cause the pain, and what can be done to relieve it, researchers have noted that they have other features that may be helpful in understanding why this small group of people don't "heal", and continue to have pain and suffering. They have more complaints about body symptoms in general, and are apt to be more concerned about symptoms generally. They have more migraine and tension headaches, colitis and other problems. They are noted often to romanticize how good things were before the problem occurred, but it has been noticed that many have been dissatisfied in their jobs and had problems in their personal lives. They may have symptoms of mild depression to some degree, and a history of depression more often in their past. Conversely, it has been noted how infrequently this syndrome occurs in people who get a great deal of satisfaction and pride from their family and jobs. Of course, these are generalizations from studies of groups, and may not apply to individuals, who are, after all individuals.
Secondary gain is often raised in relation to persistent symptoms and chronic pain. It is evident that individuals minimize pain and return to work sooner when they feel there are only negative results from continuing illness and debility. If they are enthusiastic about their job, and see a lot of negative aspects, with no rewards for being off work, they wish to return. If, however, there are a lot of rewards, often subtle and unconscious, for being off work and having continuing symptoms, recovery may be slower and return to work delayed. Unfortunately, the current process of our medical system often provides rewards for being ill with fewer for getting better. We give greater attention to those who complain most, we give medications to those with more symptoms, we give them more care and tests, show them more concern and provide more support. They are given a reason for not working or carrying out their responsibilities. Fordyce (1988) developed the operant conditioning approach to treating chronic pain which attempts to remove the rewards for being ill and complaining, and substitutes rewards for getting better, complaining less and improving function.
Secondary gain is a difficult area of discussion with patients, because they see their problem in terms of injury and pain, and secondary gain if present is unconscious, and tends to be unrecognized and denied. It is a difficult topic because secondary gain is a part of virtually every pain situation but we don't like to recognize these features in a pain experience. We all have elements of secondary gain in any pain situations and the question is the type and degree of secondary gain manifestations. It tends to be recognized only when it is excessive or exaggerated and the actions or behaviour seem out of keeping with the underlying problem, or when the goal of the behaviour seems evident. It can be argued that secondary gain is an element of the environment in which the pain problem occurs, rather than being an element of the person.
Unfortunately, the recognition of secondary gain raises in some people's mind the question of "faking", malingering, or outright fraud. The assignment of percentages of physical versus psychological including aspects of secondary gain, is so clouded with subjective inconsistency that it raises many questions about the attitudes of the examiner as it does about the patient. Because malingering is unusual in this setting, the patients are generally unaware of the nature of their responses and behaviours, and greatly resent discussions and declarations on the level of their secondary gain. This increases the resentment and antagonism in a situation which should be nonadversarial.
It should also be recognized that there is a "psychological thin skull" as well as the physical one. The principle of acceptance of the physical thin skull syndrome in patients who are more liable to injury because of underlying physical change should also apply to people with varying psychological and psychosocial background. There are individuals who will become more distressed by an injury or by pain, and who may cope less well.
Like most physiological phenomenon, one can find a range of function or response into which most people would fit. This would then be defined as a "normal" response because the vast majority of people respond in that fashion. It may seem odd to refer to people who can see much better, run much faster, hear more acutely and remember more complex material as being "abnormal", but they may fall out of the "normal" range.
In speaking of "usual" sensitivity to pain, the concept is usually about acute pain and derived from acute pain experiments. One can show some variation between individuals, and this sensitivity to pain, the threshold to pain and the tolerance of maximal pain, can be varied by a number of factors including medication, suggestion, and emotional factors. There are some aspects of pain that are innate and there is the unusual situation of congenital insensitivity to pain and sensory syndromes associated with remarkable reduction in sensitivity to pain including congenital sensory neuropathy and leprosy. On the other hand, there are individuals who may have normal sensitivity to pain on acute experiments, but who emotionally tolerate pain very poorly. Even minor painful conditions, or the threat or anticipation of pain may cause great distress and anguish in these people.
It was a mistake to think that there is a "correct" amount of pain. The error occurs if we believe that there is a uniform response to a given injury or pain stimulus (McGrath, 1987, 1989).
Usual recovery times are helpful because they allow us to recognize that recovery is occurring as expected and without evident complicating factors. An additional reason for using a concept of "usual recovery time" is the recognition of a patient who is developing the features and characteristics of chronic pain early as possible. This early signal would allow early intervention to prevent that disabling process from developing. Unfortunately, appropriate steps are often taken only when the chronic pain has been present for a very prolonged period, when it is difficult to manage and reverse, and when the likelihood of return to work is poorer.
Guidelines developed for "usual recovery times" or "duration times" (the term used by the Alberta Workers' Compensation Board) give an estimate of the average time required for workers to return to work after various work related injuries and treatment. They list a number of conditions and give the minimum and maximum time for return to work. The maximum time is not necessarily a definite return to work date, but rather the time when questions should be asked as to why the worker has not returned to work (RTW). The questions can be answered by medical reporting or by independent examination. An example is as follows:
Cervical Sprain or Strain
(Whiplash or Non-Whiplash Soft Tissue Injury Without Nerve Root Involvement)
| ICD-9 CODE | JOB CLASSIFICATION | RTW MIN/MAX |
| 723.1 | Sedentary Work | 0 - 4 weeks |
| Light Work | 0 - 5 weeks | |
| Medium Work | 0 - 6 weeks | |
| Heavy/Very Heavy Work | MA opinion based on | |
| medical reporting if layoff | ||
| exceeds 6 weeks |
Alberta Workers' Compensation Board, Duration Guidelines
Such a guideline for return to work for chronic pain could be developed but it would actually be two different groupings of return to work guidelines. The first would be the return to work guidelines for a series of acute injuries, and the second would be an expected recovery time and return to work guideline for those that had continuing pain.
One recent classification of disability for low back pain could be applied more generally to musculoskeletal injuries in the workplace (Krause and Ragland, 1994). They proposed an 8-phase classification system primarily based on the duration of work disability, and which takes into account other biomedical, developmental and social characteristics of work disability resulting from low back pain. The classification shown in a figure (see below) and outlines the various timing for each phase. This is a useful concept because it indicates the appropriate approach to be taken at each stage, and triggers early movement into a rehabilitation mode if the process is continuing. In their paper they outline the definition of each phase and review the background evidence for the condition at each phase.
Unfortunately, there are few features of chronic pain syndrome that can be termed "objective" in the usual sense. There have been attempts to objectify elements such as the identification of trigger or tender points and behavioral responses (Waddell Scale, 1988), assessment of function; severity of pain (Pain Scales) and the depression-anxiety features (Beck Inventory, etc), but they are coloured by subjective aspects and motivational influences. Thus the answers to this vexing and problematic condition that affects so many people and challenges all associated with these patients cannot be found in simple, reproducible tests or assessments.
It is possible to diagnose the condition when patients have widespread musculoskeletal pain for 6 months beyond normal healing times, and have characteristic point tenderness in cases of fibromyalgia and the other musculoskeletal pain syndromes, but specific determination of the degree that any associated or predisposing factor may have in the development or aggravation of the chronic pain is too unreliable and subject to bias to be helpful or fair in the determination of compensation scales and percentages.
As mentioned earlier, chronic pain syndrome compromises many clinical conditions and causes and it is recommended that these be addressed individually.
The development of no fault compensation to provide support for injured workers in return for giving up the right to sue employers developed early in this century, was an important social advance and was, as Ron Ellis (1994) stated, "not just financially smart for workers, employers and the state, but it was also morally right and just".
Although a right and just system, it may be a factor in the duration and outcome of injuries, and of chronic pain. It has been noted that increasing compensation rates increased the number of claims. It has also been noted that in various conditions, those with compensation have more serious complaints despite not having greater disease, but have more prolonged periods of recovery, use many more services, and have a lower rate of return to work. It is a difficult issue, particularly in the individual case, but the compensation system can be one aspect that complicates the rehabilitation and return to work of people with chronic pain. (See section on Compensation/Litigation.)
As noted by Tate (1992) several factors influence the rate of return to work by workers who receive disability benefits. These include the disability benefit system per se, labour market conditions, the employing company and type of work, the timely provision of vocational rehabilitation services and workers disability and demographic characteristics. Variables such as age, sex, education, occupation, amount of wage replacement and type of disability are predictors of the return to work outcomes. A worker is more likely to return to work if they are younger, single, with higher education and in a professional or managerial type of job. Also, studies have shown that where a person's wage replacement exceeds 75% of their former wage, return to work becomes less likely (Tate, 1992).
The issue of compensation and chronic pain has serious long term implications. It has been noted that the number of claims for low back pain and chronic pain are increasing in many countries, far beyond the increase in the work force. Indeed, Nachemson (1994) suggested that the rising claims for low back pain may signal the end of the welfare state in Sweden, and Aronoff of the Boston Pain Center strongly warns of the "chronic pain and the disability epidemic" in the United States which is threatening their system. (Aronoff, 1991)
The influence of compensation on claims and outcome in chronic pain are not agreed by all. Terence G. Ison in his book, "Compensation Systems for Injury and Disease: The Policy Choices" disagrees with those who argue there is a strong influence of compensation and claims processing on the course of disability (Ison, 1994). Ison, a professor of law at Osgoode Hall in Toronto argues that more significant variables include the nature of the disability, vocational opportunities, the capacity of the medical profession in diagnosis and treatment, premorbid job satisfaction, family support, and other cultural, personal, environmental and economic factors. He would agree, however, that there are some instances in which compensation claims may be a factor of importance, and a few where it may be a major influence. He says that most injured workers want to overcome their problem and return to work. There are two small subgroups who may cling to their disabilities as a source of income:
He points out that the last group may find that a compensation claim is their only prospect of avoiding welfare, as an injury may prevent them from carrying out their normal work, it is too early for retirement, and they are not suited for other lighter work. Ison says that to apply a label of "monetary gain" or obvious "secondary gain" to the people in these groups serves no curative purpose, and may even increase their problems and stress. One could argue that the real problem is a system that cannot adapt to allow these individuals to be productive.
Ison cautions that much of the anecdotal evidence for a wide spread incidence of monetary gain comes from specialists who see a small preselected sample of hard cases. He states that physicians who see a more representative sample of Workers' Compensation claimants state that the majority want to recover and return to work and a minority (probably about 10%) do not.
Another controversial view relates to the belief that if monetary gain is widespread, settlement of claims should relieve the symptoms. There is a lot of evidence that problems continue even following settlement, but others argue that perhaps the symptoms have become entrenched. The weight of evidence would suggest that the symptoms generally continue (Trimble, 1981) (Mendelson, 1982).
This report does not put forward policy suggestions for how WCB should address the problem of chronic pain but advocates that whatever policies are developed recognize the complex, interrelated nature of the problem and develop a system that is efficient and nonadversarial, so the rehabilitation program can get on with the important goal of assisting the person to improve function and return to work. A complex, prolonged and adversarial process will aggravate and prolong the distress and encourage behaviours and induce anxieties that worsen chronic pain.
It is not practical or reasonable to apportion cause between injury and other causes of chronic pain syndrome in a specific case. Only a third of patients with chronic pain relate the onset to trauma or injury and the differences between those with and without compensation or litigation may be due to those processes rather than trauma or other contributing causes.
Patients with chronic pain related to injury may have associated factors (job dissatisfaction, high pressure -low control jobs, marital problems, increased concern about body symptoms, etc) that may be regarded as "causes" in others who do not relate trauma to the onset of their syndrome. But to assign percentages of cause to these complex inconsistent variables, some of which may result from the chronic pain syndrome, is not practical or reliable.
It is reasonable to accept that chronic pain, even if initiated by injury, is a complex of physical, emotional, behavioral, social, cultural and motivational features. If apportionment used a general approach it could be applied, but to tease out percentages in the individual cases is impractical.
In the past it was tempting to try and categorize conditions, particularly complex conditions, as either organic or psychological, but that is simplistic and naive. Depression, regarded as a psychiatric disorder, has biochemical, neurological and physical features. A broken leg on the ski slopes has important psychological, behavioral, social and cultural features. It is hard to think of a condition that is not a composite of organic and psychological features.
Unfortunately, any attempt to arbitrarily assign percentages to each type of injury or condition would engender some argument, and likely no one would be happy with the conclusions. Is chronic low back pain, or migraine, or "whiplash", primarily psychological, primarily organic, or a mixture? I suspect we would find some who believe in each categorization.
Fibromyalgia is a good example of a chronic pain disorder that has complex and poorly understood physical, neurochemical and psychological components that we could not easily separate out. Fibromyalgia patients have multiple body symptoms in multiple functional systems with no clear organic cause (Yunus, 1981). People who have increased body awareness more often perceive that these are threatening. Those that are attentive to their body symptoms report many more physical complaints and psychological symptoms. Fibromyalgia patients experience musculoskeletal sensations as more noxious intense and disabling because of unusually heightened awareness of body functioning, Robins (1990) speculates, "exaggerated worry about having a serious illness may also lead fibromyalgia patients to restrict activities and mislabel new bodily sensations to confirm feelings of vulnerability to illness." People who worry about being ill tend to think they are particularly vulnerable to diseases, and remain convinced of illness even after being reassured by their physician, and continue to report more symptoms and greater levels of pain that have no physical explanation. These patients also report more impairment when they have an illness. They found that fibromyalgia patients were more likely than rheumatoid patients to consider themselves sickly all their lives and to have given up work or usual activities at some time because they were not well. These features don't however, indicate anything about the underlying pathology of the disorder, only aspects that may color the response.
Can we then decide if chronic pain is "primarily", or "mostly" one or the other? It is possible to do so only in a general way, but that may be more practical and reasonable than to try and make a percentage determination of how much is organic and how much is psychological in an individual case. Thus one could categorize in a general way, but it might not apply to individuals, who come with their own complex of family and experiential background, emotions, psychology, motivations, hopes and relationships, and who may have physical illness that varies in severity and symptoms. One person with an injury may ignore the discomfort and return to work, while another with a similar injury may complain bitterly to everyone in sight, and stay off work, attending physicians offices and requesting treatments and investigations. Both have a mixture of organic and psychological components, and it is only possible to suggest what would be a reasonable response and outcome, with an expected prognosis in usual circumstances.
There has been discussion and controversy about whether fibromyalgia exists as primary and secondary types. In the primary type stress and emotional factors, coupled with behavioral and social factors can produce a syndrome of muscle pain and tenderness, depressive mood and sleep disturbance. In secondary fibromyalgia some underlying pathology such as rheumatic disease, thyroid malfunction, serious psychological disturbance, trauma, repetitive work or migraine may combine with psychological and social factors to produce the same constellation of symptoms (muscle pain and tenderness, depressive symptoms and sleep disturbance). Many now believe that there is usually some identifiable psychological, medical, occupational or traumatic process that explains why the person has the syndrome, indicating that all cases are essentially secondary, and related to a host of factors. Recently the designations "primary" and "secondary" for fibromyalgia have been dropped.
Robins comments "The finding that fibromyalgia patients, while not severely disabled on objective measures, none the less continue to report pain, inability to work, and varied somatic distress inconsistent with clinical observations. Claims of pain, fatigue and the inability to sustain a work effort among fibromyalgia patients who are fully functional on conventional tests contribute to the conflict and indecision rheumatologists experience when asked to judge the compensable disability of these patients. Questions of compensation for fibromyalgia sufferers may never be adequately answered until unambiguous methods of measuring pain and/or work capacity are developed. In the absence of such tests, our results suggest that illness worry may account for some of the observed disability in fibromyalgia".
A Concept of Prevention
We are always going to be late in dealing with the problem of chronic pain until we accept that there must be changes in society, in the workplace, in the approach to treatment and compensation that emphasizes a preventive approach. Most approaches to date have been related to the person with chronic pain, but the opportunity is in the prevention of the problem. Preventing problems that have not happened never gets our attention as compellingly as the presence of the problem but I implore employers, unions, physicians and the Workers' Compensation Board to step back from this problem, take a more visionary (and less confrontational) view and see how we can constructively approach the prevention of chronic pain. Current knowledge is incomplete, but it is adequate to begin to take initial steps.
A preventive approach is more humane, and ultimately more cost-effective than the current process of dealing with problems after they have occurred.
A Rehabilitative Philosophy
A rehabilitative philosophy must be brought to the assessment and management of chronic pain when it develops. Commonly an acute pain concept and medical approach is used. This approach attempts to identify a pathological process producing tissue damage, and to find a treatment to repair the damage and cure the problem. Such strategies for acute pain, such as the heavy use of investigation and consultations and treatments with medication are often counterproductive and encourage the chronicity of the problem. Rather than promoting improvement, the acute model leads to overtreatment, and over investigation. It tends to accentuate the anxiety and fear about missed underlying pathology, encourages sick behaviour, and drug side effects of lethargy, physical dependence and depression.
The new goal becomes improved function despite continuing pain. Another goal is return to work, perhaps in the presence of continuing symptoms. Another goal is improvement in the symptoms, but recognizing that cure may not occur.
Adoption of Expected Recovery Times
A number of jurisdictions have developed and utilized expected recovery times. Although these are sometimes difficult to develop and difficult to apply, they are important as they serve as early signals when a worker is having more difficulty than expected, or not recovering well. In chronic pain it is crucial to intervene early and expected recovery times would trigger early intervention.
Education of Physicians
Physicians are not as well educated about the appropriate management of acute and chronic pain, and better understanding by physicians would undoubtedly lead to improved outcomes. Physicians are also sometimes confused about their appropriate role, as they act as the patient's personal physician, their advocate, evaluator of their disability, and provider of medical information to compensation, insurance and other agencies. The Ontario Medical Association is taking a new approach by having the physician provide objective medical input to the employer, who creates opportunities for the disabled employee to return to the workplace.
McBride and Devlon commented that physicians currently are placed in a policing role for which they are ill equipped and uncomfortable. They do not have sufficient information about the workplace or the options for modified work. They may not understand how medical restrictions relate to the ability to do work. The physician cannot objectively assess the psychosocial components of the ability to work, and has difficulty objectively evaluating conditions for which there are few confirmatory diagnostic signs. In this current setting McBride and Devlon point out that physicians tend to approve absences until patients are fully recovered which increases the cost to employers. Perhaps the OMA Program will develop a more collaborative arrangement between the worker, the physician and the employer, and encourage a responsive workplace program that encouraged workers to return, even if in a modified employment.
Consideration should be given to further separating the roles of the patient's physician as director of the patient's care and as advocate for the patient, from the evaluation. The physician is often put in a difficult situation between the patient and the Workers' Compensation Board. This similar awkward position may occur with insurance companies and the legal system in other situations. The physician's role is to care for the patient, but these agencies require the physician to act on behalf of the agencies in a way that may bring him or her into conflict with their own patient. It is of interest that the physician staff of the University of Washington Pain Clinic refused to do such evaluations, seeing it as an interference with their care of patients. They also argued that disability ratings, and decisions about compensability and non-compensability were not medical issues. Although this could be debated, there is no question that the physician feels pulled in two directions.
Harrington (1992), in outlining the methods of accurate examination for pain disorders in the injured worker, noted that most physicians have not been given much information about chronic pain in their training and postgraduate education. This contributes to delays in diagnosis and treatment, prolongation of worker incapacity and often avoidable controversies in the determination of temporary and permanent disability. He encourages the education of physicians in the diagnosis of pain disorders, so as to promote proper management, the avoidance of expensive, sophisticated diagnostic tools, such as MRI and CAT scans, and an early return to a productive life.
"For the family physician and, indeed, most specialists, the prospect of managing the patient with chronic pain syndrome does not usually evoke feelings of enthusiasm, competence, or success. More likely are feelings of inadequacy, cynicism, or outright hostility".
John C. Clifford (1993)
The Workers' Compensation Board should be more actively involved in the education of physicians about these important medical and social problems by sponsoring, encouraging and designing conferences, workshops, written materials and interactive computer programs to assist in the continuing education of physicians about chronic pain and its management.
"Most physicians are accustomed to treating acute injuries that rapidly improve. And most don't know what to do with the chronic pain patient who has no evidence of residual structural deformity or disease. Patients with no measurable anatomical, physiological, or biochemical evidence of functional impairment who continue to feel pain despite rational treatment regimes are a major cause of frustration, burn-out and cynicism in today's health care professionals. This is particularly true of the health care professional who continues to look for a rational, mechanistic solution to the problem. To most of us, our inability to resolve the problem is merely a function of the lack of appropriate knowledge. Traditional medical thinking assumes that when our knowledge is more complete, we will be able to pinpoint the molecular problem, apply the appropriate therapy, and correct it. Part of the dilemma we face, however, in "understanding" chronic pain and suffering is understanding "ourselves".
Edward R. Chaplin
Education of Employers and Supervisors and Workers
A great deal could be done to improve the return to work of injured workers with chronic pain if there were improvements in the workplace. This would include security for the person's employment, there was an ability to modify employment during the recovery phase, and a positive attitude towards the injured worker by the employer and the fellow employees.
The OMA position paper has outlined a fundamental change for the role of the physician and for the attitude of the employer and the workplace. The injured worker and management would have responsibility for developing a timely return to work program using input from the physician. The employer offers the employee a plan to return to suitable work in a timely fashion. The worker brings this to the physician. The physician provides information of functional limitations, restrictions and abilities and other advice for the worker. Information to the employer is provided through the worker. As McBride and Devlon point out, for the OMA model to be successful, a credible workplace program founded on good will and trust and offering productive work options must be in place.
More effort must be made in the workplace to make reasonable alterations and concessions to allow the worker to return. The worker may need modification of time, or modification of the task, or on some instances even a change of job to allow them to return to a productive work life.
Rehabilitation of chronic pain patients is worsened by insecurity about their job, by a inability or resistance of the employers, foremen, or fellow workers to modify the person's work, or if those in the workplace have a negative, disdainful or cynical view of the injured worker (Linton, 1991).
Much can be done by the development of educational materials, workshops and conferences on this concept, and particularly by the personal liaison of field workers.
Development of Practice Guidelines
In recent years the development of standardized protocols and guidelines has become common and the mechanism for their development very sophisticated. Although initially for medical and surgical conditions there was some concern that standardized protocols and guidelines would become "cookbooks" and possibly used to limit and penalize physicians, this has not happened. They have been helpful and beneficial and will continue increase in the practice of medicine.
It would be strongly advised that a practice guideline be developed for the management of patients with chronic pain.
Clinical practice guidelines, although they were initially controversial and made many physicians nervous because of a concern that they would limit their decision making or provide "cook book medicine" have become increasingly important and accepted. Guidelines are now being developed by most major medical organizations in North America, lead by the American College of Physicians, and more recently by the Canadian Medical Association. The Canadian Medical Association document "Guidelines for Canadian Clinical Practice Guidelines", (1994) outlines the philosophy and the methodology, and should be used, along with other documents from the American College of Physicians in the development of a guideline for the management of acute pain, and for the treatment of chronic pain. It is important that such guidelines be developed by physicians who are experienced in these areas and who will be affected by the recommended interventions and guidelines. It is also recommended that representation include not only the relevant expert groups, but also patients and other health care providers that are appropriate. Recently the Nova Scotia Medical Society has indicated their support for the development of such clinical practice guidelines (Zitner, 1994).
Handbook of Management of Chronic Pain Patients
As part of the work on a protocol, a handbook of management of chronic pain for physicians would be useful. This would be a well written, illustrated monograph of about 50-60 pages, outlining the current understanding of chronic pain and suggested guidelines for investigation and management. This would be based on the previously mentioned practice guidelines.
A Multidisciplinary Approach
There are many studies indicating that the best results in chronic pain come from multidisciplinary approaches. One approach, the Rochester Model, is a conceptual model of work disability. The Rochester Model proposes that work disability is a function of a complex interaction among medical status, physical capabilities, and work tolerances in relation to work demands (biomedical, metabolic, psychologic) in addition to psychosocial factors such as worker traits, work style, psychological readiness to return to work, and ability to manage pain or symptoms. This conceptual framework proposes that the injured worker's perception of functional capabilities and the environment in which he or she works can significantly affect return to work outcome. Multidisciplinary approaches use various heath professionals for the expertise they bring to the problem, and a varied approach to manage the complex issues involved in chronic pain. Fewerstein et al (1993) in a multidisciplinary unit using the Rochester Model had 74% of the patients with upper extremity pain disorders returning to work or in vocational training in contrast to 40% of a control group. For those who returned to work, 91% of the treatment group were working full time in contrast to 50% of the control group.
The importance of a multidisciplinary approach is that it addresses many of the complex aspects of chronic pain. Approaching chronic pain with only one focus has a long history of failure. However, it is simplistic to believe that any approach, if it is multidisciplinary, is likely to succeed. There is still a great deal of research required on the various aspects of the multidisciplinary approach, and determination of which components are successful and necessary for the overall success. It is certainly possible to include within a multidisciplinary concept many expensive and needless therapies and therapists, and the requirement for research on these aspects is greater than ever. A review of the diversity among chronic pain centres showing the varied array of approaches and services is reviewed by Csordas and Clark (1992).
Part of the approach must be careful research and evaluation of all of the above. This would be an integral component of all the above recommendations. Evaluation would indicate we are reaching the goals we set out and direct the process of improvement in reaching these goals.
Workers' Compensation Process Simplified
As mentioned earlier, we specifically resist indicating what the WCB should develop as policies as that is the role and expertise of others. However, whatever process is developed should be clear, simplified, and widely understood.
The process should emphasize the importance and therapeutic benefits of increasing activity and early return to work. The process should de-emphasize a continuing acute medical model for ongoing chronic pain, and early institute a rehabilitative approach, with clear milestones in the management and assistance in returning to work.
Lastly, the process should emphasize the important goal of returning the worker to the workplace in an atmosphere of trust and respect. The current atmosphere in the system has an air of negativity and cynicism that only increases the distress of workers.
TJ Murray, OC, MD, FRCPC, FACP
Professor of Medicine Department of Medicine (Division of Neurology) Dalhousie University
5849 University Avenue
Halifax, Nova Scotia
B3H 4H7
Phone: (902) 494-2514
FAX: (902) 494-2074
E-MAIL: Jock.Murray@Dal.Ca
Prepared for the Workers' Compensation Board of Nova Scotia
Back to Know Your Enemy - Personal observations on the rehabilitation model of chronic pain
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