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.
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:
- Early physical therapy and early manual therapy have the best outcomes (Workers Compensation Research Institute 2020,and 2021 studies.)
- An initial consult with physical therapist before therapy can have a positive impact on downstream healthcare utilization and is associated with reduced opioid use.
- Turning to physical therapybefore imaging and medication reduces the use of opioids, imaging, and surgery.
- Psychosocial factors are predictors of chronic pain. It’s important to screen for them and address them early and monitor for new ones as the claim continues.
- Patient education accelerates recovery, addresses many psychosocial factors, and has proven to be helpful in treating chronic low back pain.
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/.