I had the pleasure over the last 3 days to attend the national conference of the Australian Pain Society. Luckily for me it was held in Hobart, just a stone’s throw from my practice on the outskirts of the Hobart CBD – everything is close in Hobart.
I thought it might be useful to provide a summary of what was relevant to my practice as an occupational physician, in particular what information might be helpful to doctors and workers stuck within the worker’s compensation system.
The theme of the conference was ‘Personalised Pain Management – Quest for the Holy Grail’ i.e. what progress has been made in developing strategies that work for individuals to manage persistent/chronic pain. There were keynote speakers from the UK, Canada and USA as well as a variety of renowned Australian experts.
Professor Mogil from Canada presented the Sunderland Lecture on ‘The nature and nurture of pain’ i.e. the influence from both an individual’s genetic makeup and their environment on the genesis of persistent pain. He emphasised the genetic basis for the variability i.e. different genes affect our susceptibility to the development of persistent pain. Understanding how genes influence pain can help elucidate mechanisms of chronic pain and identify targets to develop new medications and other treatments to control pain. While this holds promise for the future it is a difficult and complex area that at present doesn’t help a clinician, except to the extent that is provides an explanation as to why there are differing responses to injury in individuals.
What is clear is that the phenomenon of persistent pain has its genesis in ‘neuroplasticity’ i.e. changes at a neuronal and molecular level within the nervous system that result in persisting pain that continues after the original injury has resolved. These changes can occur at the periphery or centrally within the nervous system, at the level of the spinal cord and within the brain itself. The environment of the individual affects these processes and this is where psychological factors and stress are so important.
As a practicing physician my interest is focused on what can be done for an individual patient to assist with recovery and regaining of function following injury and how that translates into action to improve processes at a system level. I was particularly interested in the conference sessions that related to the subgroup of people within the workers compensation system.
The session on the afternoon of the first day entitled ‘Personalised pain management within a multidisciplinary persistent pain program’ was of particular interest. The session included presentations by Professor Michael Nicholas from NSW and Ms Sara Brentnall and Mr Paul Beaton, both from Victoria.
Professor Nicholas emphasised the importance of the patient having their own achievable goals and understanding of the treatment to improve the outcomes. Personalised treatment for chronic pain is vital. His programs include injured workers within compensation systems.
Sara Brentnall presented a perspective from Austin Health in Victoria. Again in that programme there was emphasis on ‘One Size Doesn’t Fit All’ i.e. individualised programmes. The presentation by Paul Beaton from Eastern Health was the most interesting. Not only was the presentation innovative with amazing graphics, but the programme itself was based on the bio-psycho-social model emphasising the need for multidisciplinary input ‘in collaborative partnerships with those in pain’. The emphasis was on ‘active’ self management with personalised care. ‘The Pain Storm’ concept was presented providing a basis for individuals to understand the factors contributing to their own ‘Pain Storm’ with an integrated array of physical, psychological, medical and social strategies to put the person with pain in control with the prospect of lasting change in understanding, attitude, skills and environment and more engagement in meaningful life activities.
Interestingly the Victorian programmes referred to above do not include workers compensation patients on the basis that WorkSafe Victoria has a network of practitioners that provide a similar service.
Unfortunately the workers compensation system is a potent factor in taking away an individual’s sense of control and imposing a ‘one size fits all’ approach to the management of persistent pain. It is unsurprising that workers compensation patients have a higher incidence of chronic pain and overall do worse than other types of patients.
The session on ‘Entrapment Neuropathies’ e.g. carpal tunnel syndrome by Professor Michel Coppieters provided some insights. There is increasing understanding of the changes both at the level of entrapment and centrally within the nervous system from animal models. These changes can explain the variable clinical presentation of these disorders and why they do always present as described in textbooks nor always respond to traditional treatments like decompression surgery. Again this provided insight and understanding about why some conditions are difficult to manage, but little practical guidance on how to achieve better results, except that nerve mobilisation may have a greater role to play.
I did have difficulty accepting some of the conclusions of Professor Chris Maher in his presentation ‘Diagnosis and treatment based classification of back pain’ . I accept that his analysis that the traditional ‘Red Flags’ used to distinguish serious spine disorders, need revisiting, but I have some difficulty with his conclusion that we are stuck with labelling back pain as ‘non-specific’ on the basis that discal, sacro-iliac and facet joint pain cannot be distinguished clinically or with investigations, including MRI scanning. While it might not be so important to distinguish differing diagnostic entities in a primary care setting in the early stages following injury, I still believe in the specialist management of persistent back pain that it is useful to distinguish these entities while not neglecting management of psycho-social risk factors.
I found a subsequent presentation by Professor Maher very interesting and useful. The presentation ‘What triggers an episode of back pain’ presented new evidence from a study that indicates that not only are the traditional factors in back injury relevant (heavy loads, awkward posture etc) but that being distracted during an activity/task and being fatigued markedly increases the risk of triggering back pain. This makes a great deal of sense to me.
Another matter of interest to patients with CRPS/causalgia/RSD is that the University of NSW is seeking volunteers with this condition affecting their shoulder/neck/wrist/hand mainly on one side, aged from 18-89 years for MRI studies in Sydney to investigate the role of the brain in CRPS. Interested people could contact Ms Audrey Wang  93991806 or email@example.com.
In summary, attending the conference reinforces in my mind, that persistent pain is a difficult ‘beast’. The increasing knowledge about neuroplasticity, particularly the process of ‘central sensitisation’ and the interplay of genetics, a stressful environment and psychological factors can explain the spectrum of disability seen after work-related injury, but at this stage doesn’t provide a solution for everyone. Injured workers with persistent pain need equitable access to effective multidisciplinary programmes for persistent pain.
It becomes less and less surprising to me that workers compensation systems that take away control, impose additional stresses and fail to recognise the need for individualised treatment programmes contribute to poor outcomes for those with the misfortune to be injured at work. Workers compensation systems need to incorporate processes to stratify people with greater needs into care systems that can adequately deal with those needs without imposing unnecessary additional stressors on them.
i attended the royal North Shore hospital adapt program, i didn’t find desensitization very helpful unfortunately, rest lyrica, distraction and so on have some assistance, I thought it a shame that for being there 3 weeks it would have been good to have some questions answered on pain I had had for some years would have been good, Dr Brooker did explain my headaches were from my neck injuries, but I have nerve impingement from multiple disc protrusions currently foraminal compression to c5/6 giving me some of the worst problems that suggests to me not only cprs but actual mechanical problems undealt with. why else would people need operations for such things. I was suggested to me that early treatment may have helped reduce some of the chronic pain traction for example as one physio said during my mva my head was basically knocked down towards my shoulders during the parts of the accident whereupon my head kept hitting the car ceiling, I do understand the concept of the brain continuing to give out pain signals where something is healed after injury but the mechanical aspects I did not receive answers on and I needed that. The fact that insurers concede to cprs yet then fight you as if it is not a physical complaint is puzzling to be sure. had the insurer chose to treat me or let me get operations on mechanical problems to the spine early, I may not be in such a nasty pain cycle todayI believe.
Thanks Kerrie, certainly medicine doesn’t have all the answers to chronic pain. You need to be guided by the doctors you have faith in as to whether local mechanical causes can be corrected surgically or not at this stage. I agree delays in treatment can significantly affect outcomes, through continuing physical effects from the injury and the psychological effects effects as well – frustration and anger contribute to chronic pain.
Of course continuously being fought by the system, each suggestion for treatment by decent treating doctors cortisone for example as I was never allowed that by the insurer, just the decisions to abide by hired guns that prevent treatment and act to prevent your claim, the continual appointments on behalf of the insurer’s solicitors instead of your interests and so on only cause extra stress, severe additional depression and tightening of your muscles leading to yet more pain, a cycle that human rights wise should not be allowed to continue. How does one who is on a low income with no legal help and not sufficient money to pay out of pocket for reports by respected doctors have a chance to recover sufficiently to cope?
i do applaud you as a doctor for standing up and bringing this conversation forth it is long overdue and I hope others will follow in your footsteps,thanks again.
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I wonder if our Workers compensation system (I’m in Victoria) is just caught up in ‘unsexy politics brings no votes’. What I mean is, the system needs a huge plan and to draft and execute that earns politicians 0 votes. Is it getting left behind for this reason? Is it being left to a current system that works on detering injured workers from having to fight for their rightful compensation to save those many quick bucks via money hungry WorkSafe Agents? Afterall an investment in updating the system (a move on from the 1985 Act and acceptance of the pain chapter that we exclude from the AMA Guidelines) would cost alot in the interim for a long term benefit. In the long run it makes sense, employment for injured workers means tax dollars, but who’s going to put their face to this unsexy workers comp system and represent it?