RGA explores the complex nature of chronic pain claims. Questions or comments? Contact the author: ReViewANZ@rgare.com
The treatment of patients with chronic pain can be difficult and challenging.
Recent advances in our understanding of the condition have led to viewing chronic pain as a multi-factorial problem with interrelated structural, functional and psycho-physiological factors. Treatment usually requires the integration of a multidisciplinary team of specialists with a bio-psychosocial (BPS) treatment philosophy. The complexities in the medical management usually flow into the claims management process and often become a major hurdle for the claims assessor. A lack of visibility into the treatment regime often leads to poor claims experience.
There is an abundance of evidence clearly demonstrating that being at work is generally beneficial to people’s physical and mental health and well-being, although this is dependent on the nature and quality of the work being undertaken. A best practice philosophy for claims management is to achieve the best outcome for both insurer and customer in the most efficient way. Generally, this means a return to work for the customer.
Due to the complexity of chronic pain, establishing a solid strategy from the very beginning of the claim is imperative. A highly collaborative, multidisciplinary approach engaging all stakeholders from the beginning is important. In conjunction with this, understanding the customer’s return-to-work expectations and vocational options will assist in formulating the most appropriate and effective recovery pathway for the customer.
In acute, recent pain, the unpleasant sensation is nature’s way of alerting one to potential or real tissue damage. The pain is usually proportional to the degree and imminence of that bodily danger, a threat to which one should react promptly so as to mitigate the danger. The experience is both physical and emotional. Once pain has lingered a long time, the pain is not commonly associated with a threat of further physical damage, yet the brain still interprets it that way and reacts as if still under threat, causing emotional distress and enthusiastic avoidance of anything associated with the sense of tissue damage. In such instances, there is no reason to avoid such actions except that one dislikes pain. Of course, while reacting thus, the consequent passivity and inactivity compound the myriad of related issues.
For the majority of disability income claims, ongoing liability depends on the customer’s functional capacity to perform one or more of the major duties of his or her occupation. Claims for chronic pain can be challenging to manage due to the subjective nature of the experience of pain and individually variable responses. However, despite how complex the actual medical management may be, focusing on the customer’s functional capacity and how this relates to his/her ability to perform their previous role is the objective of the claim assessment. It is also the focal point of sound evidence-based treatment.
If a person’s pain is ‘curable,’ someone is likely to have facilitated that within a reasonable time frame, assuming the person is receiving optimal treatment. If not cured, why, then, do patients and their practitioners continue pursuing a cure, when acceptance of chronicity and functional restoration is a more productive and far less destructive route? With this in mind, it’s important to understand the current treatment regime and the initial onset of the condition.
Pain is said to be chronic if it persists for 3-6 months beyond the normal healing time of a particular diagnosis or injury and is considered a condition in its own right, with BPS and vocational factors to be considered. It’s important to identify whether the customer is continuously being treated for perceived complications stemming from the original injury or whether he or she is receiving treatment to manage the chronic pain condition or co-morbid condition, while considering the appropriateness of those interventions. Once determined, this enables a better understanding of the expected claim duration and the identification of medical milestones and potential barriers. It may be beneficial to engage the company Chief Medical Officer (CMO) and/or arrange a specialist Independent Medical Examination (IME) to comment on the treatment regime and expected outcome.
Once the diagnosis of ‘chronic pain’ is made, it is important to obtain as much information as possible in regards to the customer’s current level of function, stage of treatment, return-to-work expectations and illness beliefs. Identifying function can be challenging due to the lack of objective evidence and the psychological overlays of the chronic pain condition.
The scientific literature is unequivocal in the fact that return-to-work potential is greater when incorporating psychosocial assessment and management strategies1,2. An initial needs assessment can be highly beneficial in this regard and can assist in establishing a solid claims strategy. This assessment is completed by an allied health professional experienced in occupational rehabilitation and is usually conducted in the customer’s home, or any other suitable location, and involves such things as:
On completion, a comprehensive report is provided detailing their assessment and recommendations made for the achievement of functional and vocational rehabilitation goals. Generally, following these assessments, all parties have an informed idea regarding the overall recovery pathway.
In conjunction with the above-mentioned key considerations, having a complete understanding of the customer’s employment status, the employer’s willingness to accommodate suitable duties and/or reduced hours, and the functional demands of the pre-disability duties will assist in managing the claim. Any improvement in the customer’s functional capacity can be measured against the functional demands of his or her pre-disability role to determine readiness for work. Depending on the customer’s employment status, this information can then be used to initiate return-to-work discussions. A worksite assessment is a useful method for obtaining an overview of the workplace and determine the availability of suitable duties.
Educating the customer about managing the ongoing symptoms of chronic pain is the key factor for successful management of vocational recovery. An inability to make sense of the often worrying and persisting uncertainties of pain may force the customer to avoid undertaking some of the normal activities of daily living, including work. When talking to the customer, it’s important for the claims assessor to understand what the person hopes to achieve and their level of expectations post-treatment. Are they hoping to be 100% symptom-free? Or are they seeking some pain relief and enough functional improvement to be able to return to their normal daily routine, and perhaps to some form of work? What will happen if the customer can’t ever be 100% pain-free; what will this mean to them? This is an important consideration when managing the claim, as the assessor needs to consider the customer’s readiness to undertake some of the activities the assessor suggests, such as rehabilitation provider assistance or pain management programs.
Having the customer talk to their physicians can help them take an active role in managing the pain and regain control of their life despite ongoing symptoms, which may assist in regaining enough functional capacity to return to some form of work. The overarching strategy is to accept that the pain is not readily curable, but that the secondary losses can be mitigated through conscientious and careful integration of those normal activities that should be considered harmless, or non-damaging.
Reaching a definitive pain diagnosis can be challenging for health providers as pain cannot be objectively measured. It may take many months to accurately rule out treatable causes. If there are no specialists involved in the customer’s treatment to date and the condition is solely being managed by the general practitioner, the claims assessor should question whether or not the customer is receiving optimal treatment for his/her condition.
Similarly, if only one type of specialist is involved (e.g., an orthopaedic surgeon), the claims assessor should consider whether obtaining an opinion from an alternative specialist is indicated. A psychological and/or psychiatric assessment may also prove beneficial, as up to 70% of chronic pain patients have a comorbid mental disorder. If the customer is not undergoing appropriate treatment, this would most likely impact the overall duration of the claim. In the ideal situation, such patients should be assessed by a reputable multidisciplinary pain management centre.
Once a practitioner is satisfied that there are no medical issues still to be explored, and that there are no physical treatments obviously outstanding, the important therapeutic intervention is to encourage a rehabilitative/reconditioning approach, with focus on both the physical and psycho-behavioural losses that have developed.
Understanding the customer’s day-to-day activities (such as cleaning, cooking, watching TV, going to the gym, playing sports and taking children to school) is an effective way of understanding their functional capacity. If the daily activities appear to be inconsistent with the reported symptoms of the chronic pain condition, then this should be addressed immediately with the treating physicians. Similarly, if the pain described is chronic in nature, yet the customer continues to be able to perform functional tasks and roles, this, too, should be addressed with the treating physicians as an indicator of vocational capacity despite pain.
Signs of avoidance behavior is another area of concern. A customer’s fear of pain aggravation or exacerbation may lead to inactivity, which in many cases is more harmful than the pain itself. As previously mentioned, educating the customer about pain management strategies and coming to terms with the fact that the pain is not readily curable can help mitigate this behavior. However, gaining a patient’s cooperation can prove difficult, despite the overwhelming evidence supporting the value of these strategies. Factors impeding such commitment include a belief that a cure must exist, the attitudes of involved practitioners, and the patient’s (and their relatives’) beliefs, mood state, personality style and resilience.
Finally, consideration must be given to the nature of the customer’s previous occupation. If the customer’s previous occupation is classified as manual or heavy manual and requires a large amount of physical exertion, is it unrealistic to expect the customer to return to work in the same occupation despite signs of functional improvement? Conversely, for sedentary or safety-critical roles, how much does pain impede the individual’s ability to concentrate, and what are the potential ramifications as a result of this? Where it is found that the pain will permanently impact an individual’s capacity to return to his or her pre-disability occupation, a vocational assessment may be appropriate to explore more suitable alternatives.
The case study below highlights some of the challenges of assessing claims with chronic pain conditions. John is a 46-year-old partner in an accountancy firm. Three years ago he developed the sudden onset of lower back and right leg pain during a game of social tennis. Previously a regular exerciser, he has neither worked nor exercised since.
He initially rested in bed for three days before attending his GP, who recorded: “Tennis Saturday. Sudden onset LBP (lower back pain) + R leg when twisted. L5 distribution ache/burn. Neurologically intact. SLR (straight leg raising) 60.” The GP arranged a CT scan of the back and prescribed paracetamol, anti-inflammatory medication and physiotherapy.
John returned to his GP a week later. The CT scan had revealed some mild degenerative change in the lower lumbar facet joints and a subtle narrowing of disc spaces at L4/5 and L5/S1. In view of the continuation of symptoms, the GP arranged a referral to an orthopedic surgeon and an MRI scan. The MRI was consistent with the CT, also showing a degree of disc bulge toward and possibly contacting the L5 nerve root. The analgesic tramadol was added.
The orthopedic surgeon declared that surgery was not indicated and recommended hydrotherapy. John took himself to a chiropractor and an acupuncturist. After 7 weeks, John remained essentially at rest, and the GP sent him to a radiologist for “facet joint blocks.” This procedure gave the insured about 3 days of significant (but sub-total) relief of his pain.
Since then John has tried many medications and passive treatments: ongoing hands-on physiotherapy and chiropractic therapy, injections, TENS machines, alternative medicines, and more scans and surgical opinions. John remains essentially sedentary, and, not surprisingly, he has developed an associated mood disorder, is self-medicating with excessive alcohol, and has gained 17 kg. His family laments the loss of the man they knew. He now takes regular opioid analgesics.
In this instance, a good starting point might be having John’s treating physicians educate him about “avoidance behaviour” and initially encouraging him to undertake some structured activities around the house. Following that, a sensibly limited daily walk, which may cause a degree of greater pain, but could not cause any harm. Provided he understands this, a daily walk (or other sensible exercise regime) would improve his mood, his sleep, his anxiety and his weight issues. With the introduction of rehabilitation support, or involvement of an occupational therapist, a clear and safe plan would be developed to build up his tolerances and thus would reduce the physical deconditioning, and which (through his own illness behaviour) promotes his deterioration.
With the ongoing assistance of his treating physicians, continuous rehabilitation support, and possibly guidance from the company CMO, a gradual reintroduction to other aspects of daily life would also take place. When ready, considerations for return-to work planning can be initiated taking into account safe return to work principles, such as regular rest breaks, adaptations, employer education, pacing and assisting him to adjust to any ongoing functional limitations.
The treatment of chronic pain requires a multidisciplinary approach engaging all key stakeholders in the patient’s medical management. The same can be said from a claims management perspective. The chronicity of pain does not inevitably equate to long-term disablement if the correct approaches to rehabilitation, both physical and psychological, are implemented.
It’s important for the claims assessor to establish a thorough understanding of the optimal treatment regime, and the identification of both medical and functional milestones are imperative. With the support of the treating physicians, customer education is the driving factor to slowly reintroduce the customer back to normal daily activities. The aim is to continuously assist in building the customer’s functional tolerances upon each milestone to the point where a return to work is achieved. Questions or comments? Contact the author: ReViewANZ@rgare.com.
Consultant Psychiatrist and Chief Medical Officer, RGA Australia (ret.)
Associate Professor, Griffith University School of Medicine, Senior Visiting Medical Officer, Pain Management and Research Institute of the University of Sydney and Royal North Shore Hospital,
Senior Staff Specialist in Pain Management, Gold Coast University Hospital