Contextual factors play a critical role in musculoskeletal pain[1] and consequently also pain related disability[2]. This is demonstrated powerfully in the compensation arena. The compensable context is associated with comparatively inferior outcomes, including poorer responses to interventions[3-5].
In a circular argument, the context itself is commonly blamed for the inconsistent results in this group. In the clinical setting the complexity of context in the compensation arena adds to a widely held belief that “my regular patients do so much better than compo patients” and “it’s the fault of the system that my expert management is obstructed, and the patient is in so much pain because of delays in approvals, disputes, legal action …” Such beliefs stem from the prevailing linear model of care that prioritises the diagnosis and management of structural causes of pain. Adhering to this model of care means that contextually disadvantaged patients may be included in this circular argument for being ‘at fault’ for their own outcomes. Terminology expressing such views may include the use of phrases such as ‘non-organic pain’, ‘abnormal illness behaviour’ and ‘the pain is due to a psychiatric disorder’ or is ‘for secondary gain’.
A fundamental flaw in the linear biomedical model of care is that pain and injury are rarely proportional. Indeed, many of the findings that underpin treatment decisions in this model, such as the degenerative changes seen on investigations in regions of pain, are problematic because these are also commonly present in asymptomatic individuals as well adapted changes. Outcomes cannot be measured in terms of tissue improvements in regions of pain, but rely on subjective pain reports, which can be limited to a one-dimensional measure of a complex phenomenon (e.g Numerical Pain Rating Scale).
Furthermore, severe traumatic injuries may result in excellent outcomes in an optimal contextual environment such as a sports context. At the other end of the spectrum the complex compensable context may see extraordinarily minor injuries result in tragic, long lasting pain conditions.
It is generally considered that better outcomes will be achieved with better technology, better patient selection, better pharmaceuticals and more proficient operators. Unfortunately, excellent advances in these areas in recent decades have coincided uncomfortably with significant increases in persistent pain numbers and related expenses[6]. This is not limited to a burgeoning of cases in the compensation arena, but also an increase in the number of non-compensable patients who do poorly, despite standard model of care management[5,7].
The role of contextual factors in pain and overall management outcomes is arguably best explained by contemporary pain science. This science forms the foundation of the poorly prioritised biopsychosocial management model of care and includes placebo and nocebo psychobiological responses, and adaptive / maladaptive neuroplasticity processes. Indeed, simple improvement in patients’ pain literacy (i.e. knowledge and understanding of the neurobiology and contributing factors that underpin a pain experience) has been demonstrated to reduce pain and pain related disability significantly, and importantly – safely[8,9]. The evidence for this is developing but the early observations that this safe, non-interventional approach can alter outcomes meaningfully in a positive direction is tempting. The combination of improving pain literacy together with re-adaptive exercise rehabilitation is also attracting attention[10,11]. This too is a relatively simple approach that aims to wind down over-protective processes and seems sensible as it reassures that the pain that can be felt with standard exercise and normalisation of activity is not associated with harm.
With specific reference to the compensation context I spent a large amount of time several years ago co-authoring a publication that explores the compensable context by prioritising a neurobiological perspective in great detail and offers practical implementation guidelines.[12]
This publication presents the view that a comprehensive understanding of pain science, and a firm commitment to prioritisation of the neurobiology based biopsychosocial management model, is crucial if we seek to alter the paradoxical trajectory of persistent pain in developed nations. This consideration is required at all levels and this is especially relevant in the compensable environment – the patient / treater level, the insurer incentivised level and the legislative level. This is vital if optimal outcomes and meaningful change in persistent pain is to be achieved.
In more recent times we are learning from sham controlled trials of surgical intervention forey targeting pain[13] that a ‘gold standard’ by which we validate the existing model of care, ie: outcomes of management, is up for question. The compensable environment reinforces the critical role of context in musculoskeletal pain conditions because there is a statistically diminished likelihood of such contextually sensitive responses.
All persistent musculoskeletal pain cases are set in play somewhere. Indeed, the beginnings may well pre-date the initiating event. An important question is what is the bigger influence in this process? Is it the strain in the back while lifting at work, or is it being told in a vulnerable context to be protective and careful because the pain is due to ‘bulging discs’ and ‘may need surgery one day’?
About Kal Fried
Kal attained Fellowship of the Australasian College of Sports & Exercise Physicians in 1995. He has had appointments with a variety of sporting teams over many years in addition to general sports medicine consulting. Kal has consulted with the TAC and WorkSafe in Victoria as a medical advisor on the Clinical Panels and on various projects and is an Independent Medicolegal Examiner. Kal is proudly involved with the Pain Revolution https://www.painrevolution.org/ and wrote a recent blog on this involvement[14]. Recent years have been focussed on pain management by combining neurobiology and exercise medicine principles. To this end he is part of a tight, inter-disciplinary team – http://www.thermg.com.au
References
[1] Moseley and Butler, Butler D. Explain Pain.; 2013. doi:10.3138/ptc.58.3.243
[2] Bartys S, Frederiksen P, Bendix T, Burton K. System influences on work disability due to low back pain: An international evidence synthesis. Health Policy (New York). 2017;121(8):903-912. doi:10.1016/j.healthpol.2017.05.011
[3] Murgatroyd DF, Casey PP, Cameron ID, Harris IA. The effect of financial compensation on health outcomes following musculoskeletal injury: Systematic review. PLoS One. 2015;10(2):1-33. doi:10.1371/journal.pone.0117597
[4] Harris I, Mulford J, Solomon M, van Gelder JM, Young J. Association between compensation status and outcome after surgery: a meta-analysis. JAMA. 2005;293(13):1644-1652. doi:10.1001/jama.293.13.1644
[5] Gabbe BJ, Cameron P a., Williamson OD, Edwards ER, Graves SE, Richardson MD. The relationship between compensable status and long-term patient outcomes following orthopaedic trauma. Med J Aust. 2007;187(1):14-17.
[6] The MBF Foundation. The high price of pain: the economic impact of persistent pain in Australia. 2007;(November).
[7] Croft P, Blyth FM, van der Windt D, Proof OUPU. Chronic Pain Epidemiology. Chronic Pain Epidemiol From Aetiol to Public Heal. September 2010. doi:10.1093/acprof:oso/9780199235766.001.0001
[8] Louw A, Diener I, Butler DS, Puentedura EJ. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Arch Phys Med Rehabil. 2011;92(12):2041-2056. doi:10.1016/j.apmr.2011.07.198
[9] Lee H, McAuley JH, Hübscher M, Kamper SJ, Traeger AC, Moseley GL. Does changing pain-related knowledge reduce pain and improve function through changes in catastrophizing? Pain. 2016;157(4). doi:10.1097/j.pain.0000000000000472
[10] Booth J, Moseley GL, Schiltenwolf M, Cashin A, Davies M, Hübscher M. Exercise for chronic musculoskeletal pain: A biopsychosocial approach. Musculoskeletal Care. January 2017. doi:10.1002/msc.1191
[11] Clarke CL, Ryan CG, Martin DJ. Pain neurophysiology education for the management of individuals with chronic low back pain: A systematic review and meta-analysis. Man Ther. 2011;16(6):544-549. doi:10.1016/j.math.2011.05.003
[12] Beales D, Fried K, Nicholas M, Blyth F, Finniss D, Moseley GL. Management of musculoskeletal pain in a compensable environment: Implementation of helpful and unhelpful Models of Care in supporting recovery and return to work. Best Pract Res Clin Rheumatol. 2016;30(3):445-467. doi:10.1016/j.berh.2016.08.011
[13] Louw A, Diener I, Fernández-de-las-Peñas C, Puentedura EJ. Sham Surgery in Orthopedics: A Systematic Review of the Literature. Pain Med. 2017;1(18 (4)):736-750. doi:10.1093/pm/pnw164
[14] Fried K. ACSEP @ THE PAIN REVOLUTION 2018. Australasian College of Sports & Exercise Physicians Website. https://www.acsep.org.au/page/news/blog/acsep-the-pain-revolution-2018. Published 2018.