A New Framework for Predicting Chronic Pain

The Centers for Disease Control and Prevention estimates that over 50 million Americans suffer from chronic pain, and other researchers put that number much higher, around 110 million. Additionally, 7.4 percent of people with chronic pain say it interferes with work and daily life activities.

While these stats are for the general population, many workers’ compensation patients suffer from chronic pain. Twenty percent of injured workers in Australia reported having chronic pain. A literature review showed that workers’ compensation patients in the United States were generally more distressed and had poorer outcomes than those not covered by workers’ comp. There is a higher prevalence of chronic pain than diabetes, cardiovascular disease and cancer combined, prompting physical medicine researchers to analyze the predictors of chronic pain with the goal of preventing pain from becoming chronic. The Framework for improving outcome prediction for acute to chronic low back pain transitions, published in Pain Reports, reviewed 20 studies that had investigated the acute-to-chronic low back pain (LBP) transition.

Researchers found that these individual studies rarely had enough data from all the predictor domains to present a full picture. They recommended and developed a standardized structure to guide further research and help practitioners address issues that contribute to the acute-to-chronic transition.

Their structure used the following predictor domains:

• Demographic measures
• Pain measures
• Health status measures
• Psychosocial measures, and
• Individual context measures

The Framework authors added elements to some domains. They incorporated income, marital status, household size, and living arrangements into the demographic domain for example. Emerging evidence points to the impact these social determinates have on chronic pain. Having Medicaid coverage was a predictor of poorer LBP outcomes in one study and lower education and income levels decreased the positive effects of psychologically informed stratified care in another. Authors also advocated for the addition of comorbidities, an emerging area of interest for predicting chronic LBP.

Psychosocial factors consistently show up in LBP research, but researchers could not identify an all-encompassing tool for detecting them. They stressed the need to identify negative mood and coping styles (fear avoidance/catastrophizing), along with positive coping skills, like self-efficacy and acceptance. Recognizing that some psychosocial factors develop as the case progresses, the authors also suggest using longitudinal monitoring, i.e., capturing time-varying factors, to better understand psychosocial impacts.

The Framework authors included the “perceptions of receiving care, patient expectations and treatment preferences” in the individual context domain, which typically refers to occupational factors, such as job satisfaction and perceived work stress. One validated prediction tool asked about the expectation of having persistent pain, but this was not widely explored in other studies.

Finally, they recommended integrating Framework into electronic health records to improve the accuracy of outcome prediction and guide LBP treatment strategies.

Takeaways

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. Here’s what we know:

• Early physical therapy produces better outcomes (The Workers Compensation Research Institute 2020 study.)
• An initial consult with physical therapist before beginning therapy can have a positive impact on downstream healthcare utilization and is associated with a decrease in opioid use. · Turning to physical therapy before imaging and medication reduces the use of opioids, imaging, and surgery.
• Psychosocial factors can delay recovery and return to work and potentially lead to the development of chronic pain. Addressing these through psychologically informed physical therapy and cognitive behavioral therapy can remove barriers to recovery. Early detection and monitoring as claims continue can prevent the acute-to-chronic transition.
• Patient education accelerates recovery, addresses many psychosocial factors, and has proven to be helpful in treating chronic LBP.

Chronic pain is complex, difficult to treat, costly, and it affects many injured workers. Workers’ compensation professionals need to make preventing chronic pain a high priority. 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. 

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Brian Peers, DPT, MBA

Vice President, Clinical Services and Provider Management MedRisk

2701 Renaissance Blvd.

King of Prussia, PA 19406

800-225-9675 x 1011 BPeers@Medrisknet.com

Brian Peers is a licensed physical therapist serving as MedRisk’s Vice President of Clinical Services and Provider Management. He is responsible for overseeing and ensuring the quality of MedRisk’s

centralized telerehabilitation services, as well as MedRisk’s platinum grade clinical review and peer-to peer provider coaching program. He is board certified as an orthopedic clinical specialist and is recognized as an expert in rehabilitation of the injured worker. Prior to joining MedRisk, Dr. Peers was the owner and operator of an interdisciplinary rehab practice and has held faculty appointments at multiple physical therapy education programs. He has also served as an injury prevention consultant for multiple large corporations and the United States Department of Defense. He holds Bachelor of Science and Master of Physical Therapy degrees from St. Francis University in Loretto, Pennsylvania, an MBA from Louisiana State University in Baton Rouge, Louisiana and a Doctorate in Physical Therapy from the University of St. Augustine, in St. Augustine, Florida.

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