Jun 1, 2022 | Insights
When you think about major health conditions affecting society, what comes to mind first? Cancer, diabetes, and heart disease all dominate the collective conversation, and rightfully so. They impact millions of people across the globe and have their own societies, awareness months, cereal sponsorships, celebrity spokespeople, and social media hashtags…the list goes on.
Chronic pain, however, is more prevalent than all three of these conditions combined. Perhaps it’s the pervasiveness or obtuse nature of the diagnosis that makes it a “sleeper pick” in the national conversation. Regardless, it’s a condition many in workers’ compensation know all too well.
Chronic musculoskeletal pain is the leading cause of disability, according to a recent study published in Physical Therapy. And people who try to keep working through pain say it reduces their productivity. Those with chronic joint pain estimate that they lose over two hours a week of productivity, and people with pain in multiple sites say they lose over nine hours a week.
Physical therapy should be part of any chronic pain patient’s regimen. It can relieve pain, increase mobility and flexibility, and guide patients to self-management techniques that work for them.
However, derailing chronic pain is a much better goal.
Preventing acute pain from transitioning into chronic pain has become a top research priority of the Federal Pain Research Strategy (US), prompting physical medicine researchers to analyze “predictors” of this transition.
What characteristics or circumstances indicate that an injured worker could develop chronic pain? Knowing these predictors empowers claims representatives and practitioners to get in front of it and deploy resources to block it.
Published in Pain Reports, the Framework for improving outcome prediction for acute to chronic low back pain transitions analyzed 20 previous studies that examined the transition of acute to chronic pain. Researchers combined the predictors identified in the earlier investigations and divided them into demographic, pain, health status, psychosocial, and individual context domains.
Authors noted some underrepresented predictors in the studies, including the health indicators of physical activity and sleep disturbance, along with alcohol, tobacco, and drug use. They strengthened social determinates of health, adding marital status, household size, and living arrangements to the demographic domain because emerging evidence points to their impact on chronic low back pain. Having Medicaid coverage was a predictor of poorer low back pain outcomes in one study and lower education and income levels decreased the positive effects of psychologically informed stratified care in another.
Since pain itself is a predictor, authors stressed the importance of the clinical history and covering things like the duration of pain, history of previous conditions, and the pain experience (anatomical location, severity, intensity, and impact). One study showed that multiple sites of pain can be predictive of poor low back pain outcomes.
In the psychosocial domain, authors stressed the need to capture negative mood and coping styles along with positive coping skills like self-efficacy and acceptance. They also recommended longitudinal monitoring, i.e., capturing time-varying factors, to track emerging psychosocial impacts.
The individual context domain refers to occupational factors, usually things like job satisfaction and perceived work stress. Framework authors recommended adding measures to capture the patient’s perceptions of receiving care, treatment preferences, and the expectation of having persistent pain.
Takeaways
Practitioners and researchers agree on the predictors of chronic pain, and the Framework research made great strides toward standardizing them. Standardization facilitates research and makes it easier to integrate predictors into electronic medical records.
However, claims representatives do not have to wait for integration to identify injured workers who are at risk of developing chronic pain because many predictive data points already reside in EMR systems. Data on previous conditions, weight, pain duration and location, drug, alcohol and tobacco use, along with anxiety and depression can be mined. Emerging predictors, such as marital and financial status and multiple pain sites could be added to screening tools to improve results.
Early and accurate predictions inform care decisions and drive the best use of healthcare resources early in the claim. For example, less resource-intense methods, such as telerehab and non-pharmacologic care, can be used on the low-risk claims. The high-risk ones need more treatment options and closer monitoring, possibly with nurse case management.
Arranging a consultation with a physical therapist who screens for psychosocial factors is a good starting point. During the consult, the therapist and patient discuss the injury, the pain, and its impact on their lives and ability to work. Consulting therapists also educate the injured worker on their condition, explain the mechanisms of pain and how it transitions to chronic, and help set expectations for physical therapy and relief.
The consultation report should flag barriers to recovery, especially psychosocial factors. Then claims representatives can deploy appropriate resources, such as cognitive behavioral therapy or psychologically informed physical therapy.
Keep in mind that the physical therapist is usually the provider on a claim who sees the injured worker most frequently and spends the most time with them on each visit. Therapists can be early identifiers of issues that cause pain to transition from acute to chronic.
Alternative medicine, acupuncture, and behavioral management therapy may be useful. In most cases, conservative care should be provided first, but some injured workers need injections, pain pumps, or surgical interventions to stop or reduce the pain. The same solution won’t work for everyone, and a nurse case manager can navigate different treatment options to find what works best for a specific injured worker.
While there’s always more to learn, here is what we already know:
Three Steps to Take to Prevent Acute Pain from Becoming Chronic
- Analyze portfolio for claims at high risk of acute-to-chronic pain transition. Closely monitor high-risk claims and strive to reduce or eliminate pain.
- Review and bolster screening tools to better identify predictors of chronic pain development, including negative mood and coping styles, perceived injustice, multiple pain sites, perception of persistent pain, and comorbidities along with marital and financial status.
- Invest in data analytics/predictive modeling technology and professionals or partner with companies who do.
There are many reasons that pain becomes chronic, including delayed treatment, the use of opioids, the intensity of the pain, provider choice, and psychosocial factors. Stopping acute pain from becoming chronic keeps injured workers from spiraling into a lifetime of pain and disability and saves workers’ compensation payers and the overall healthcare system billions of dollars a year.
“Brian Peers: How Do You Keep Acute Pain from Becoming Chronic? Understand the Predictors.” WorkCompWire, 4 Apr. 2022. https://www.workcompwire.com/2022/04/brian-peers-how-do-you-keep-acute-pain-from-becoming-chronic-understand-the-predictors/.
Apr 26, 2022 | Insights
The mass shift to remote working (and even permanent telecommuting) has interesting implications on workers’ compensation class codes.
Prior to the pandemic, only 6 percent of U.S. workers worked from home – and 75 percent had never worked from home before. This all changed in May 2020 when more than 33 percent of workers started remote working.
Now, the data is in. Two recent reports from the National Council on Compensation Insurance (NCCI) show interesting trends in class codes as a result of this shift to remote work.
Key Findings
- Workers’ compensation class codes with higher telecommuting potential tend to have lower loss costs than others
- The office and clerical group has lower average loss costs
- Loss costs in the office and clerical group account for nearly 60% payroll exposure but just 11% of premium
While there may be a shift among classifications in the months to come, other issues come to light. The move to ergonomically incorrect home offices could cause more repetitive stress injuries and slips and falls.
MedRisk is committed to keeping a pulse on class codes and trends in workers’ compensation to help adjusters, case managers and providers efficiently and effectively care for workers.
Read more about the shift in class codes from NCCI here.
Apr 26, 2022 | Insights
Acute pain has a purpose, chronic pain, not so much.
People feel pain when the brain receives a signal that a disease or injury threatens their well-being. The brain signals a worker that they’ve hurt their back, so they quit doing what caused it and seek relief. With chronic pain, the brain interprets a signal as a threat when there is none.
Physical therapy is the go-to for musculoskeletal injuries and the acute pain they bring. The sooner therapy starts, the better. But what about pain that has gone on for three months or three years? Can physical therapy still help?
Pain is one of the most common reasons that people seek medical care. Severe chronic pain negatively affects physical and mental functioning and diminishes quality of life. It also creates a financial burden for individuals and employers. “Relieving Pain in America,” published by the Institute of Medicine of the National Academies, puts the cost of chronic pain between $560-630 billion a year.
More than 116 million adults in the US suffer from chronic pain, and it seems to affect workers’ comp patients even more than the general population. This is according to a study published in Relational Behavioral Medicine that found that workers’ compensation patients were “generally more distressed and had poorer outcomes than those not covered by workers’ comp.”
Pain is typically considered chronic when it has continued for three to six months. Chronic pain can become a condition unto itself, posing a major barrier to return to work. It can cause anxiety, irritability, and depression, and it is complex and difficult to treat.
Yet injured workers who have chronic pain–even those who have been in pain for years–can benefit from physical therapy.
The main difference in the therapeutic approach for acute versus chronic pain is the balance between education and exercise. When there is a recent injury, therapists focus more on exercise and manual therapy to restore strength and mobility and get the patient out of pain.
Education plays a role in treating acute pain, but it takes center stage when treating chronic pain. Understanding the mechanisms of pain, especially how chronic pain develops, helps patients identify ways to derail it.
When pain goes on a long time, the body develops workarounds for coping. The person’s posture changes, and they may slump or limp. Muscles tighten, trigger points develop, and stiffness deconditioning can occur. Some patients do not feel like moving around, and their lack of activity decreases circulation, weakens muscles, and can affect joint mobility.
These injured workers need more education about the mechanisms of pain, how to relieve it, how move more efficiently, and ideally, how to self-manage it. It’s good to have patients start with a consultation with a physical therapist to discuss the injury, their pain experience, and how it has affected their lives and ability to work. Patients should understand that this course of physical therapy will differ from treatment they had immediately post injury.
This session should include a psychosocial screening even if the worker was screened earlier. Psychosocial factors often develop as pain continues. Some patients come to believe that they’ll always be in pain, never be able to do what they once did, and they lose hope.
Treatment needs to be patient-centric and customized. Combining aerobic conditioning with strength training helps some people, while relaxation and mindfulness work better for others.
Shared decision-making is important. According to an article in the Journal of Manual and Manipulative Therapy, the traditional decision-making process where the provider is the authority and the patient does what they’re told, doesn’t cut it. Collaboration is key.
The therapist will demonstrate strength, mobility and flexibility exercises and apply manual therapy, such as trigger point and myofascial release, spinal manipulation, and dry needling, and explain how they work and their benefits. The patient gives feedback on which techniques help. Together, the patient and therapist decide on the treatment program and set realistic expectations for eliminating or managing pain.
Chronic pain patients learn how their bodies have created workarounds to accommodate injuries and how they led to pain. They see that adjusting their posture or doing a particular set of stretches brings relief. As patients learn the reasons that certain exercises and stretches help them feel better, they become more likely to comply with the exercise program.
There are encouraging success stories of chronic pain patients who have tapered off high doses of opioids and overcome chronic pain through physical therapy. Others learn to accept a level of pain and how to reduce its frequency and intensity. Unfortunately, not every injured worker attains 100-percent freedom from pain.
Consider examining your portfolio of claims for workers in chronic pain and suggest a course of physical therapy. Things change as time goes on, and injured workers who couldn’t accept that they might always have pain may be ready to learn how to manage it.
Ideally workers’ compensation professionals and practitioners will learn to intercept pain before it becomes chronic. Stay tuned for more on this in part 2 of the series!
Mar 29, 2022 | Insights
It has become well understood that a broad range of biological, psychological and social factors impact an injured worker’s recovery. Recent shifts in the industry – especially in light of the pandemic – have heightened focus on how we can better identify and address psychosocial issues in particular.
Unlike physical ailments like bruises, psychosocial setbacks are usually invisible, but their impact on an injured worker’s recovery as well as healthcare utilization costs are prominent. That’s why claims organizations are working to adapt to help practitioners identify these factors – the earlier the better. Unless someone asks questions and makes observation as a part of the intake process of a claim, these factors will continue to go unnoticed and workers’ time to recovery will continue to suffer.
In this white paper – in partnership with Risk & Insurance – Brian Peers, VP of Clinical Services & Provider Management, MedRisk, and Jean Feldman, RN, BSN, Director of Managed Care, Workers’ Compensation Claims for Sentry Insurance, discuss the critical role physical therapists play in not only treating physical injuries but also identifying biopsychosocial factors that could impact recovery.
PTs are well-equipped to make a difference in this area for two key reasons:
- Physicians do not spend enough time with injured workers to develop a close enough connection with them to identify and address psychosocial issues.
- PTs do – they have the opportunity to build trust and engage in meaningful conversations about how the injured worker is doing, not just as a patient, but as a person, during appointments.
“If someone’s feeling like, ‘I don’t want to move because I think it’s going to hurt,’ who better to help them through that than someone who’s an expert in recovery?” explained Peers. “So not a psychologist, not an orthopedic surgeon, but someone whose specialty is recovery.”
Peers and Feldman also provide insights on bridging the mind-body connection and the importance of compassion for an injured worker’s circumstances – and, simply put, doing the right thing.
As Feldman said: “If we do the right things, it will help that individual get back to work, recover faster, recover safely. It’ll help our employers decrease their costs. We’re all in this together.”
To read the full white paper, click here
Mar 10, 2022 | Insights
Chronic pain is complex, costly and widespread – especially for injured workers. In fact, workers’ compensation patients in the U.S. generally experience poorer outcomes compared to those not covered by workers’ comp.
Not to mention the economic impact of chronic pain: direct and indirect costs total about $650 billion. This has prompted clinical practice guidelines and the U.S. Federal Pain Research Strategy to prioritize research on reducing the public health impact of low back pain (LBP) – and physical medicine researchers have begun to analyze the predictors of chronic pain in response. The goal: prevent acute pain from becoming chronic.
In this WorkersCompensation.com article, MedRisk’s VP of Clinical Services & Provider Management Brian Peers discusses key takeaways from a mapping review of 20 studies that have investigated the acute-to-chronic LBP transition. From this review, the authors described a standardized predictive framework to improve prediction of chronic LBP.
The structure used five predictor domains, adding elements in some areas that emerging evidence has revealed impactful on chronic pain:
- Demographics: income, marital status, household size and living arrangements
- Pain
- Health status
- Psychosocial: negative mood and copying styles, and positive coping skills like self-efficacy
- Individual context: perceptions of receiving care, expectations and treatment preferences
“There’s a lot to unpack in this research and much work left to be done. However, this analysis and previous studies have told us a lot,” said Peers. “Early and accurate prediction of the development of chronic pain can guide claims representatives in securing the appropriate physical and behavioral healthcare services in the beginning of the claim.”
Among other key takeaways, Peers pinpointed the importance of patient education in accelerating recovery, addressing psychosocial factors and treating chronic LBP. This is pertinent as psychosocial factors can delay recovery and return to work – and potentially lead to the development of chronic pain. Ultimately, this research supports a rising theme from the past couple of years: early physical therapy (including initial consult and education) produces better outcomes for all patients – but especially workers’ compensation patients.
To read more about the framework for predicting chronic pain, click here – or review the full study here.
Dec 7, 2021 | Insights
Assessing injured workers quickly, starting physical therapy (PT) early and when appropriate, getting them manual therapy (MT) quickly will lead to better outcomes for injured workers.
Researchers have found that there are big benefits to starting PT early. In fact, fewer diagnostic tests, opioid prescriptions, pain management injections and lumbar surgeries ultimately lead to faster return to work and lower total medical costs of claims. This begs the question: Is there a specific PT treatment that further influences the utilization and costs of medical resources and outcomes?
All eyes are on MT, a hands-on therapy that improves range of motion and reduces pain. Many practitioners and managed care professionals have long believed that early MT could improve outcomes.
To help fill information gaps in medical and healthcare policy research regarding MT, the Workers Compensation Research Institute (WCRI) analyzed low back pain (LBP) claims in 28 states that did not have surgery and received MT. WCRI compared costs and outcomes between claims with early MT (within 14 days of the worker starting PT) and late MT, as well as claims with and without MT.
Researchers including a member of MedRisk’s International Scientific Advisory Board, Kathryn Mueller, MD, found that early MT was associated with lower utilization of medical services, lower medical and indemnity payments, and shorter temporary disability duration. In fact, the average medical cost per claim was 27 percent lower, the average indemnity payment was 28 percent lower and temporary disability duration was 22 percent shorter when workers received early MT compared with those receiving it later.
While this is the first of many investigations needed to assess the overall cost-effectiveness of MT, the study is a positive step towards more effective WC outcomes.
This also supports MedRisk’s PTConsult program, where a consulting therapist can help identify people who need MT and recommend they get it quickly. Through our extensive network, electronic data interfaces (EDI) and clinical expertise, we partner with clients to facilitate early PT and ensure optimal outcomes for workers.
To read the full study, click here.
Outcomes Associated with Manual Therapy for Workers with Non-Chronic Low Back Pain. Dongchun Wang, Kathryn Mueller, and Randy Lea. September 2021. WC-21-23.
