Workers' Compensation

Alternative Approaches to Treating Chronic Back Pain

Drugs aren’t the only solution

This is a hard pill to swallow for “pill mill” doctors and pharmaceutical companies that provide their supply, but alternative workers’ compensation approaches to managing chronic pain are increasingly popular. A November 17, 2011 session at the Workers Compensation Research Institute’s (WCRI) 2011 Annual Conference demonstrated that a back injury does not always buy a ticket for a magical mystery tour.

Concerns regarding pain medication extend beyond their costs. Long-term use of these highly addictive drugs can be fatal.

Shelley Boyce of MedRisk, Inc., moderated the discussion. The speakers were Alexander Garschagen of Ciran Rehabilitation Activation (Ciran) in the Netherlands and Dr. James Rainville of the New England Baptist Hospital in Boston.

Boyce’s Overview

Boyce identified long-term musculoskeletal pain generally, and chronic back pain specifically, as the most “prevalent and costly workers’ compensation claims.”

She noted that traditional methods for treating chronic pain have not always been effective.

This presentation stated as well that one challenge has been that claimants tend to move from provider to provider without significantly reducing their pain. Boyce observed as well that providers with a traditional approach tend to focus on their own area, rather than offer a range of services.

Successful Dutch Chronic Pain Reforms

Garschagen reported that the Netherlands spends less than the U.S. on healthcare. The supporting statistics indicated further that the care in the Netherlands has been more effective than the treatments in the U.S.

Two big healthcare problems that Garschagen identified that both the U.S. and the Netherlands have faced are that “annual pace of healthcare expenditures outpaces income growth” and that chronic problems related to musculoskeletal pain and related mental health issues were expensive.

Standards that applied to healthcare providers in the Netherlands included the traditional elements of “price and quality of care.” These companies additionally competed based on the “health outcomes” that they produced.

Of particular relevance to workers’ compensation providers, Garschagen shared that insurers competed for “customers [based] on premium[s], quality and service.” These insurers were also legally required to have a “’healthy’ balance sheet, achieved by managing the health care spending by policyholders and providers.”

Garschagen specified that “employers are the drivers of the competition” in the Netherlands’ disability insurance system. He identified an employer’s specific obligations as providing “the legally warranted wage payments for disability” for the first two years after a compensable incident.

Most patients that Ciran treated had a combination of musculoskeletal, pain, and mental health problems. Further, a typical patient’s condition worsened before that person sought treatment from Ciran.

Garschagen made it abundantly clear regarding that care that “we don’t do drugs in our facilities.”

Objectives for in-patient rehabilitative care included restoring a patient’s autonomy and ability to lead a “normal daily life.” Out-patient rehabilitative care focused on “increased participation in [the patient’s] private, social and working life.”

As shown below, the Netherlands’ approach to treating chronic pain was also more holistic than the traditional U.S. model that Boyce described.

The multi-dimensional description of “health” that Garschagen discussed defined that term as “the person’s capability of continuously attaining a personal, physical, mental and societal balance in anticipating and interacting with events in her or his immediate environment.”

Statistics that Garschagen provided regarding the success of a 16-week drug-free holistic approach to treating chronic pain included “significant improvement in 5 dimensions of physical functioning.” These patients also experienced “significant reduced levels of anxiety and depression” during their 16-week treatment.

Garschagen described this more generally by stating that the rehabilitative approach to managing chronic pain resulted in “lower impairments, lower health complaints.”

Root of Back Pain

Rainville’s presentation was arguably the most controversial one at the entire conference. His overall theme was that aging and genetics, rather than compensable incidents, were the true causes of chronic back pain. He added that people with that pain should not give in to that discomfort.

Rainville stated specifically that “we have to rethink the problem of back pain;” he asserted as well that “it is a choice to be disabled by back pain.”

Rainville noted further there has been “no change in the amount of back pain after treatment” despite health-care expenditures increasing 82-percent between 1997 and 2006. 

Regarding workers’ compensation, Rainville stated that “in order to be eligible for workers’ compensation, you must say that you were injured at work or [while] engaged in work activities.” He indicated that this requirement provided an incentive to assert that low back pain was work-related.

Statistics that Rainville provided to show that work-related injuries did not play a significant role in causing back pain included that “70-percent of people cannot identify anything associated with onset of [back pain] symptoms” and that “work accounts for only one-percent of disc degeneration.”

Referring again to the roles of aging and genetics regarding disc degeneration that caused back pain, Rainville stated that people who experienced that pain would have had that condition regardless of their work activity.

Other studies to which Rainville referred found that “ergonomic interventions have not produced substantial reduction of back/neck injuries” and that “activity avoidance offers no advantage over continued activities.”

Additionally, Rainville described “pain inducing activities” as “harmless” and stated that “we can choose to continue activities in the presence of pain without doing harm.” Specific advice regarding claimants with back problems is that they should return to work and “make some money while you are in pain,” rather than remain idle.

Rainville reported further that “spine degeneration does not go away.” He then prescribed sustaining a sensible level of activity despite back pain to increase tolerance of that discomfort.

Back Talk

The overall lesson from the presentations was that the workers’ compensation system should “Just say no to drugs” regarding treating musculoskeletal pain generally and chronic back pain specifically. 

Garschagen provided proof both that the Netherlands’ healthcare system is more efficient than ours and that a holistic approach can help chronic pain patients. He showed as well that rehabilitation can be preferable to drugs.

Much of the negative response to Rainville’s conclusions likely related to a misperception regarding his stance. He did not claim that low back pain was a myth but asserted that the relationship between employment-related activity and that discomfort was much less significant than the workers’ compensation system generally considered it.

Rainville additionally merely presented evidence that drugs have had little lasting effect on back pain and that, for the most part, people should simply walk it off.

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