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People on compensation experience more pain, but not because of economic gain

At a glance:
Patients who are seeking or receiving compensation were found to have different characteristics that those who are not. Although they have similar results for medical tests, they report worse pain, more distress
distress
Severe suffering, pain, anxiety or sorrow
 and more disability. This is sometimes assumed to be because they are seeking financial gain, but this paper suggests different explanations.

Chronic pain patients whose pain began with a traumatic event may require a different treatment approach to patients whose pain began gradually or spontaneously. This study found that patients who experienced trauma have similar results to others on medical tests, but report worse pain, more disability
disability
A condition or function that leaves a person unable to do tasks that most other people can do.
 and more psychological
psychological
Refers to a person's perceptions, thought processes, emotions, personality and behaviour. Psychologists can treat mental health problems.
 distress. This paper explores some possible explanations for this difference.
Perspectives:
Employee
People deal with pain in different ways and many different factors influence what happens to a person with longer-term pain. This study found that patients who were compensated for their injury had more distress and reported more disability, even though the results of their medical tests were similar to those of patient who were not compensated. Perhaps this happens because they lose some control over the situation, worry more, and have to tell others -or maybe even convince others - about their condition.

The person's approach to and beliefs about their condition have a greater influence on their experience than the results of medical tests. Having a good understanding of your condition, the confidence that you will be able to manage, and determination to return to activity at home and in the workplace can help you cope with long term pain.

It may help to have a frank discussion with your doctor or other health professionals about what you can do to improve your problem. Depression, isolation, frustration, marriage breakdown and mental health
mental health
Emotional wellbeing. Ability to cope with difficulty and enjoy life. THe absence of a mental health problem.
 problems are common in people when they don't feel they have control over their situation. These consequences are lessened when people play an active role in their own recovery.
Employer
This study shows that people with compensable injuries report more pain, distress and disability and have higher rates of depression
depression
A symptom of mood disorder characterized by intense feelings of loss, sadness, hopelessness, failure, and rejection. Major depression is likely to interfere significantly with everyday activity, with symptoms including insomnia, irritability, weight loss, and a lack of interest in outside events. The disorder may last several months or longer and may recur, but it is generally reversible in the short run.
 than those who are not treated under a compensation system. People tend to assume this is because they are seeking financial gain. However, a range of factors can affect people who are treated under a compensation system:
  • They have to regularly report to others regarding their ill health
  • They lose control over some areas of their life. For example, people with compensable injuries are given a written list of restrictions for home activities.
  • There are often delays in getting treatments.
  • Finding treating practitioners
    treating practitioner
    A health professional that treats patients. In return to work this may include doctors, physiotherapists, chiropractors, osteopaths, psychologists, masseurs, etc.
     can be more difficult.
  • The compensation system regularly reminds people about their condition through the everyday operation of the system.
Studies show the more a person focuses on long-term pain, the more they will suffer from their condition.

Employers can assist by removing the obstacles to the employee's return to activity, and by encouraging and welcoming them back to work. Any disputes are best dealt with quickly.
Treater
Many treating practitioners find treating patients under a compensation system challenging. This study indicates people with compensation claims have more distress, disability and depression. This will be no surprise to most doctors.

Treating practitioners can help improve results through:

Acknowledging that compensation status can affect the situation and outcome
Discussing the effect of compensation with patients frankly
Actively encouraging the person back to their normal life as quickly as possible. This can be helped by
  • Early return to work
  • Avoiding over-medicalisation of the condition
  • Explanations the condition to the patient (including its natural history). Patients are particularly keen to understand what they can do to help themselves.
  • Encouraging patients to remain active and avoid inactivity. Rest is dangerous for musculoskeletal
    musculoskeletal
    Involving the muscles and the skeleton. This term includes the limbs, neck, shoulders and back. 'Musculoskeletal problem' refers to many different conditions that can affect the tendons, muscles and related structures.
     conditions
  • Encouraging an ongoing relationship with the workplace.
Insurer
Working with patients with chronic
chronic
continuing a long time or recurring frequently
 pain can be complex. Increased psychological distress, disability and depression levels are reported for compensated patients.

Many of these situations can be prevented by early, coordinated management. Working in partnership with the patient's employer and treater can minimise disputes, delays, and disruption to the patient's life.

Teaching a person how to deal with a compensation system may also help reduce their distress. For example, explaining pay rates, pay step downs, when to follow up if there is a delay, who to call for claims assistance, how disputes are resolved etc. can help a person feel more in control and improve their recovery.
Original Article, Authors & Publication Details:
D. C. Turk1 and A. Okifuji1 (1996).

Perception of traumatic onset, compensation status, and physical findings: Impact on pain severity, emotional distress, and disability in chronic pain patients. Journal of Behavioral Medicine 19(5): 435-453.

1Pain Evaluation and Treatment Institute, University of Pittsburgh School of Medicine, 4601 Baum Boulevard, Pittsburgh, PA 15213.
Background, Study Objectives, How It Was Done:
Chronic pain is a common problem that causes extensive suffering and health care costs. This study investigated two factors that might influence a person's experience of chronic pain. These were:

Whether or not the person receives compensation for their pain
The nature of the onset of the pain (whether the pain began with a specific event or not)

Compensation

There is conflicting evidence on the role of compensation in chronic pain. Some studies argue that compensation may be a strong incentive for people to continue reporting pain, problems functioning and psychological distress. Other studies have found that compensated and uncompensated individuals show no differences in their time taken to recover or return to work.

The onset of pain

Chronic pain patients tend to fall broadly into two groups. There are those whose pain began with a specific event, such as a motor vehicle accident or work-related accident and those whose pain either developed gradually, or suddenly appeared (“I woke up one morning with a severe pain in my back').

The condition of people in the two groups might progress differently, and they might require different approaches to treatment.

Previous studies have shown that people who experience traumatic injuries (such as motor vehicle accidents) are likely to suffer more severe and long-lasting pain and disability. Traumatic injuries frequently have psychological consequences, including depression and post-traumatic stress disorder. These psychological symptoms tend to persist for months or years after the incident. And people whose pain began with a traumatic event often have to deal with complicated legal and financial issues.

For people who do not attribute their pain to a specific event, the condition may be equally frustrating and distressing. Because the cause of their pain is unknown, doctors, family members and employers may see it as a psychological problem. These people may therefore have less social support, or even experience hostility leading to severe distress.

In this study, the subjects were 158 patients (69 male, 89 female) who had been referred to a pain treatment facility for evaluation and treatment by a team of health professionals (including doctors specializing in pain medicine, physiotherapists, occupational therapists, nurses and psychologists). The patients were aged between 20 and 78, with an average age or 43. Over 85% of the patients had completed at least high school education, and approximately 50% were married. Less than 13% were employed full-time and less than 4% were employed part-time.

Patients had been experiencing pain for an average of 5 years, most in either their lower back (29%) or legs (21%). 22% reported that they had pain in multiple locations. Most patients were taking medication. 72% were taking non-opioid pain-relief medication and 39% were taking opioids. 31% were on antidepressants. 13% were on muscle relaxants.

119 of the patients (75%) reported that their chronic pain had begun with a traumatic event, while for 39 patients (25%) the pain had begun gradually or spontaneously.

Of the patients whose pain had begun traumatically, 69% were receiving or seeking financial compensation. Of those whose pain began gradually or spontaneously, 33% were receiving or seeking compensation.

Each patient underwent a 3-hr pain evaluation that included medical, physical and psychological assessment. The findings of any previous medical examinations were recorded and research-supported questionnaires were completed by the patient to assess their pain, depression and disability. This assessment was voluntary, and it was only possible to complete the entire set of examinations for approximately 50% of the group. The researchers did not find any significant differences between patients who underwent the full set of examinations and those who did not.
Study Findings:
The severity of physical injury measured by the doctor correlated only weakly with the severity of pain and disability reported by the patient. This means that reported pain and disability can not be explained by the level of visible physical damage alone.

People whose objective assessments showed worse physical problems experienced less positive support and more negative attention from significant others.

Compensation versus no compensation comparison

Of the 158 patients 28 were receiving financial compensation and 67 were in the process of applying for it. These 95 patients in total were classified as “compensation patients' and the remaining 63 were classified as “non-compensation patients.'

Patients who sought compensation were more likely to be male, were younger than those not seeking compensation, and on average had not experienced pain for as long as the non-compensated patients.

Patients who sought compensation did not have significantly different results on medical tests.

Patients who sought compensation reported significantly higher levels of pain, distress and depression.

Compared to non-compensation patients, compensation patients reported that their pain interfered more their life, that they had a more severe disability and that they were less active. Patients receiving compensation were about twice as likely to meet the criteria for depression.

Onset of pain -

Since compensation status affected the experience of chronic pain, the researchers only compared non-compensation patients to observe the effect that the nature of the onset had on the experience of pain. Of the 63 non-compensation patients, 37 reported that their pain began after a traumatic event (19 had suffered work-related injuries, 4 were involved motor-vehicle accidents, 6 were involved in another kind of accident and 8 developed pain following surgery). The remaining 26 patients could not link their pain to a specific event.

There were no differences between the two groups in personal characteristics such as age, gender or marital status

There were no significant differences in the medical assessments for the traumatic or non-traumatic onset patients

Patients whose pain had begun with a traumatic injury reported significantly higher levels of pain, distress and interference in their lives. They were also more likely to report that significant people in their lives help distract them from the pain.
Conclusions:
This study investigated how the levels of pain, disability and psychological distress experienced by patients with chronic pain were influenced by seeking or receiving compensation and by the onset of pain (whether or not the pain began with a specific incident like a workplace injury or a motor vehicle accident.)

The severity of the patient's physical injury as measured by the doctor was only weakly linked with the severity of pain and disability reported by the patient. In other words, patients whose doctors found evidence of a more serious medical problem were not necessarily the patients who reported the worst pain. This means that severity of reported pain and disability cannot be explained by the level of visible physical damage alone; there are other influences on how patients experience and cope with pain.

Patients whose doctors found more evidence of a physical problem were more likely to receive negative responses from others (such as their own family.) While this might seem unexpected, previous research has shown that the reactions of significant others are most influenced by the patient's perceptions and how they communicate their problems.

Chronic pain patients who were seeking or receiving financial compensation were similar to other patients in the results of their medical tests and examinations. Despite this, they showed more severe pain and distress, more interference in their day to day life and higher levels of depression. The researchers, however, did not separate patients who were seeking compensation from those who were already receiving it, and the effect might be different for these two groups. Patients receiving or seeking compensation were also more likely to be young, male and to have experienced pain for a relatively short amount of time compared to non-compensated chronic pain patients.

Patients whose pain began with a traumatic injury experienced more pain, more psychological distress and more disability than patients whose pain began without cause. They did not differ on their results for medical tests.

Previous studies have found that 'thought' influences the experience of symptoms and the restriction of activities. The trauma of being injured in an accident may make patients more aware of discomfort. Expecting pain after the injury could cause them to identify all physical sensations as abnormal, harmful and uncomfortable.

Learned responses are likely to play a role in chronic pain after trauma. Cues that remind the patient of the traumatic event can provoke physical or emotional responses, leading them to avoid certain situations and activities. This reinforces the fear of the cue and in turn the avoidance of the situation. Limiting activities then increases the perception of having a disability, and heightens emotional distress.

A loss of hope about the future might drive these patients to seek disability compensation. Some researchers have concluded that compensated patients display worse symptoms because they are seeking financial gain, but the interaction between psychological factors, physical symptoms and disability needs to be considered.

The researchers conclude that chronic pain patients whose pain began with a traumatic event may need a different treatment approach than other chronic pain patients, in order to help them modify the way they think about their pain and its impact on their life. Patients who have experienced a traumatic event may consider their pain to be an injury that can only get better with a medical cure. Unfortunately, this is likely to inhibit their recovery. Effective treatment for chronic pain involves becoming active despite the discomfort.
References:
PubMed Abstract
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