An Open Letter to The California Dept. of Workers Compensation Regarding Proposed Treatment Guidelines for Chronic Pain
The California Dept. of Workers Compensation is entertaining public opinion and feedback on their proposed Chronic Pain Medical Treatment Guidelines. Feedback is open until Thursday, December 18th. Please contribute your own thoughts to the discussion. Here's my response:
Dear Sirs,
I write these comments on your proposed Chronic Pain Treatment Guidelines as a former injured worker who spent five years in the California workers’ compensation system. I remain a chronic pain patient, 14 years later. I’m also a former board member of the Los Angeles Repetitive Strain Injury Support Group and the Cumulative Trauma Disorders Resources Network, as well as the author of The Truth About Carpal Tunnel Syndrome.
Overall, your guidelines take the view that chronic pain happens through psychosocial factors that are arguably not work-related, and believe me, lawyers will argue about that. Where does that leave the injured worker? You should be aware that, to patients, chronic pain happens when medical science fails. Fails to understand, fails to accurately diagnose, fails to effectively treat, fails to adequately provide care. Because of your own treatment guidelines, and the legal questions at the crux of the workers’ compensation system, the system itself is a psychosocial factor that should be included. A statistical analysis of the injuries and illnesses most prevalent in chronic pain patients in the system, you will see a very definite pattern: those that are difficult to diagnose, require multidisciplinary approach, or who respond far better to treatments not sanctioned by the workers’ compensation system.
Specifically, the characterization of chronic pain in these guidelines is taken completely out of context of the workers compensation system itself, which, in my view will provide some improvements in pain management, but do very little to effect the bottom line. Since “Studies have shown that the longer a patient remains out of work the less likely he or she is to return. Similarly, the longer a patient suffers from chronic pain the less likely treatment, including functional restoration efforts, will be effective”, the best way to reduce chronic pain in the workers compensation system is to address the delays and inadequacies of care, and delays in disability benefits endemic to the system itself. While I applaud broadening the proposed guidelines to encompass a multidisciplinary approach, absent solutions to the above I believe these new guidelines will only produce limited
results. Particularly in the case of repetitive strain injuries, which account for 60% of all work-related injuries, where, in California, such patients are three times more likely to end up with permanent disabilities and get stuck in the system three times longer than any other injury or illness.
In my opinion, the definition of chronic pain contained in your proposed guidelines is again out of context and shortsighted. “Chronic pain persists beyond the usual course of healing of an acute disease or beyond a reasonable time for an injury to heal.” In my experience, chronic pain also persists when an injury is either inadequately treated or is poorly understood by medical science. I recognize there are many reasons for this outside the scope of your guidelines, however, rather than attempt to deny these conditions, these are exactly the ones most likely to produce chronic pain.
I would propose that certain work-related injuries and illnesses most likely to lead to chronic pain, be handled differently from the beginning of an injured worker's course of treatment. That pain interventions, self-management and functional restoration be addressed immediately with the patient, rather than once their pain is deemed to have transferred from acute to chronic.
Your discussion on functional restoration is really about patient engagement. While it may seem to an outsider that having an excuse to get out of work, any excuse, is better than working, in my experience, this is not true at all. I say this not just for myself, but for all the patients I met in physical therapy, pool therapy, and group psychotherapy, in waiting rooms at every appointment I went to throughout my five years in the system. These number close to a thousand. Each and every one would have been much better off had they been able to maintain some sort of work activity. Work gives us purpose, even if we don’t like our job and even if we think we don’t want to work. Purpose helps us go on when the rest of our lives have disintegrated entirely, which is what it feels like when you have a catastrophic medical condition, have lost your job and your income. Finding ways to enroll injured workers in their own functional outcomes from the very beginning would provide this purpose and, I believe, present far better return-to-work outcomes.
I suggest this be constructed similar to a vocational rehabilitation model, require employers have a return-to-work program in place, and be implemented as quickly as a claim is filed.
Yours,
Jill Gambaro
Dear Sirs,
I write these comments on your proposed Chronic Pain Treatment Guidelines as a former injured worker who spent five years in the California workers’ compensation system. I remain a chronic pain patient, 14 years later. I’m also a former board member of the Los Angeles Repetitive Strain Injury Support Group and the Cumulative Trauma Disorders Resources Network, as well as the author of The Truth About Carpal Tunnel Syndrome.
Overall, your guidelines take the view that chronic pain happens through psychosocial factors that are arguably not work-related, and believe me, lawyers will argue about that. Where does that leave the injured worker? You should be aware that, to patients, chronic pain happens when medical science fails. Fails to understand, fails to accurately diagnose, fails to effectively treat, fails to adequately provide care. Because of your own treatment guidelines, and the legal questions at the crux of the workers’ compensation system, the system itself is a psychosocial factor that should be included. A statistical analysis of the injuries and illnesses most prevalent in chronic pain patients in the system, you will see a very definite pattern: those that are difficult to diagnose, require multidisciplinary approach, or who respond far better to treatments not sanctioned by the workers’ compensation system.
Specifically, the characterization of chronic pain in these guidelines is taken completely out of context of the workers compensation system itself, which, in my view will provide some improvements in pain management, but do very little to effect the bottom line. Since “Studies have shown that the longer a patient remains out of work the less likely he or she is to return. Similarly, the longer a patient suffers from chronic pain the less likely treatment, including functional restoration efforts, will be effective”, the best way to reduce chronic pain in the workers compensation system is to address the delays and inadequacies of care, and delays in disability benefits endemic to the system itself. While I applaud broadening the proposed guidelines to encompass a multidisciplinary approach, absent solutions to the above I believe these new guidelines will only produce limited
results. Particularly in the case of repetitive strain injuries, which account for 60% of all work-related injuries, where, in California, such patients are three times more likely to end up with permanent disabilities and get stuck in the system three times longer than any other injury or illness.
In my opinion, the definition of chronic pain contained in your proposed guidelines is again out of context and shortsighted. “Chronic pain persists beyond the usual course of healing of an acute disease or beyond a reasonable time for an injury to heal.” In my experience, chronic pain also persists when an injury is either inadequately treated or is poorly understood by medical science. I recognize there are many reasons for this outside the scope of your guidelines, however, rather than attempt to deny these conditions, these are exactly the ones most likely to produce chronic pain.
Your definition of “Illness behavior model” again omits the
critical impact of the stress of navigating the system, of the patient/injured
worker at the center of a legal battle, perhaps for the first time in their life,
of having so little control over their healthcare, finances, and job status.
Enroll them as partners in their care from the onset and you will tremendously
reduce their stress, and their chronic pain.
I would propose that certain work-related injuries and illnesses most likely to lead to chronic pain, be handled differently from the beginning of an injured worker's course of treatment. That pain interventions, self-management and functional restoration be addressed immediately with the patient, rather than once their pain is deemed to have transferred from acute to chronic.
Your discussion on functional restoration is really about patient engagement. While it may seem to an outsider that having an excuse to get out of work, any excuse, is better than working, in my experience, this is not true at all. I say this not just for myself, but for all the patients I met in physical therapy, pool therapy, and group psychotherapy, in waiting rooms at every appointment I went to throughout my five years in the system. These number close to a thousand. Each and every one would have been much better off had they been able to maintain some sort of work activity. Work gives us purpose, even if we don’t like our job and even if we think we don’t want to work. Purpose helps us go on when the rest of our lives have disintegrated entirely, which is what it feels like when you have a catastrophic medical condition, have lost your job and your income. Finding ways to enroll injured workers in their own functional outcomes from the very beginning would provide this purpose and, I believe, present far better return-to-work outcomes.
I suggest this be constructed similar to a vocational rehabilitation model, require employers have a return-to-work program in place, and be implemented as quickly as a claim is filed.
Yours,
Jill Gambaro
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