One of the most common comments you will hear in the orthopaedic world is –
“The results of management, various interventions and surgeries are much worse in patients with a compensable injury and that is the fault of the ‘SYSTEM’ “
It is safe to say that this comment is widely agreed and it is also well supported by actual research looking at outcomes in terms of improving pain, function etc in a meaningful and sustainable manner. The corollary of this is that other non-compensable, self-funded patients fare so much better with the same treatment.
And yet, despite compensation patients doing regularly so much worse, almost all practitioners will similarly declare –
“Do you expect me to treat my patients differently?! That would be just SO wrong!”
Now, let’s think about this.
All these patients get the same management which focusses highly on STRUCTURAL targets. The primary intention of manual treatments, injections, surgeries etc are all focussed on affecting a STRUCTURAL target ie: the possible nociceptive electrical signalling input to pain only (read my explanation document).
By this logic, it would therefore seem unavoidable to conclude that somehow magically, or by as yet undetected mechanisms, the actual biological STRUCTURE of compensable patients is either intrinsically different to other patients from the outset (unlikely) or somehow magically alters during the compensation process.
This is quite difficult to comprehend.
I have posed this concept regularly with a variety of practitioners managing compensable patients with persistent pain and pain related disability with various pharmacies and interventions. As yet I have received generally evasive responses or I have simply been misunderstood. I haven’t as yet received a response reflecting a logical alternative idea to consider.
As stated, typically, the problem is blamed on the ‘system’ which includes adversarial case management and especially the delay in management because of having to get funding approvals. So this means that targeted structural changes possibly producing nociceptive electrical signalling input to pain are in fact changed by stress but also somehow by ‘timing’. But hang on a minute, back pain consensus guidelines (as well as many other pain conditions) favour patience and comprehensive conservative treatment that takes quite a while to complete rather than early surgery. And this generally works well overall. So does that mean that it is only once you decide that surgery is required that the time delay in having the surgery somehow alters the faulty structure from then on making it less responsive to interventional effects? Go figure that time could do that … it’s as if we go stale like bread, but somehow this only happens after we decide to have surgery.
The most common research cited supporting spinal surgery is the SPORT series of studies in the USA. Curiously this research also suggested that the poor compensation patient’s body structural input to pain was different as the improvements seen in general patients were not the same in the compensation group despite having the same treatment:
The Impact of Workers’ Compensation on Outcomes of Surgical and Non-operative Therapy for Patients with a Lumbar Disc Herniation SPORT. Atlas et al. Spine. 2010 January 1; 35(1): 89–97:
“Conclusion—Patients with a lumbar IDH improved substantially with both surgical and non-operative treatment. However, there was no added benefit associated with surgical treatment for patients with workers’ compensation at 2 years while those in the non-workers’ compensation group had significantly greater improvement with surgical treatment.”
And it doesn’t end there! Recent research looking at a “no fault” insurance system ie: the New Zealand Accident Compensation Corporation (ACC) which is a universal NO-FAULT system offering early treatment and salary reimbursement etc… (see the reference below which is hot off the press) somehow again mysteriously proves that ‘FAULT’ influenced surgeries to the spine fare comparatively quite poorly. So, if you have someone to blame then that alters your structure but if you don’t then your structural contributors to pain, that can be fixed by surgery, are the same as everyone else. Fascinating … Perhaps they operate earlier in NZ before they go stale. Perhaps all people with pain / back pain should have an early operation if the scan shows a structural change and then we would get even better results?!!
But wait … what do the ‘Choosing Wisely’ program and other back pain treatment consensus guidelines consistently advise?? I’m so confused.
Therefore, according to this model, I can only conclude that the compensation patient’s STRUCTURAL input to pain when they get injured, or simply develop maladaptive pain without trauma, is different or becomes (more) different with (more) time.
The other explanation that seems so much more logical to me, and is so very consistent with my observations, is that it is definitely the CONTEXT of the injury / pain that is the overriding significant factor to the outcome including any interventions. Ie: the well researched ‘bio-psycho-social’ model is the robust model with proper consideration of pain neurobiology principles and placebo / nocebo expectation-based responses. At this point if you still haven’t read my explanation on the ‘for patients’ page of my website you definitely should.
Unfortunately, this perspective is very likely to be confronting to most health professionals. That is because it means that the compensable group do NOT have extraordinary structure at all; they are indeed the same as the rest of us (or the same as themselves when they have pain and there is no one to blame).
It also means that it is actually the non-compensable group who are almost certainly obtaining a higher placebo construct response* from the various commonly provided pharmacies and interventions including surgery that many ardently believe are so very effective.
Why? Because their context is usually so much better.
* Placebo controlled trials have long been the standard in assessing effectiveness of eg: medication. Surgery is finally being subjected to similar trials eg: knee arthroscopy surgery. That is not to say the surgery has no chance of being effective for pain / pain related disability, it is saying that it is being indirectly effective via a placebo construct. Unfortunately, this is not a pathway without significant harms, life-changing complications or simply persistent pain despite structurally successful surgery.
Additional specific references to consider in relation to this blog include:
The relationship between compensable status and long-term patient outcomes following orthopaedic trauma. Gabbe et al. MJA 2007; 187: 14–17
The Influence of No Fault Compensation on Functional Outcomes After Lumbar Spine Fusion. Montgomery, Cunningham, Robertson. Spine 2015 Jul 15;40(14):1140-7 (abstract available only so far)
- Universal No Fault Compensation is associated with Improved Return to Work Rates in Spine Fusion. Manson et al. Spine 2015; Epub ahead of print (again only the abstract is available to me so far)
- Spine surgery outcomes in a workers’ compensation cohort – Harris et al. ANZ J Surg 82 (2012) 625–629
- Long-term Outcomes of Lumbar Fusion Among Workers’ Compensation Subjects: A Historical Cohort Study. Nguyen et al. Spine 15 February 2011 – Volume 36 – Issue 4 – p 320–331
- Workers’ Compensation Status: Does It Affect Orthopaedic Surgery Outcomes? A Meta-Analysis. Moraes et al. www.plosone.org 1 December 2012. Volume 7 / Issue 12
- Association Between Compensation Status and Outcome After Surgery. Harris et al. JAMA, April 6, 2005—Vol 293, No. 13
- The Role of Emotional Health in Functional Outcomes after Orthopaedic Surgery: Extending the Biopsychosocial Model to Orthopaedics. AOA Critical Issues. Ayers et al. J Bone Joint Surg Am. Nov 6 2013
- The role of perceived injustice in chronic pain and related references. Nov 2013 available via: http://www.bodyinmind.org/the-role-of-perceived-injustice-in-chronic-pain/
Use of placebo controls in the evaluation of surgery: systematic review. Wartolowska et al. BMJ 2014;348:g3253 doi: 10.1136/bmj.g3253 (Published 21 May 2014)
And another very more recent article “Association between compensation status and outcomes in spine surgery: a meta-analysis of 31 studies. Cheriyan et al. The Spine Journal 15 (2015) 2564–2573”, which concludes the following curious outcome proving my point again –
“… Conclusions: There is a two-fold increase of an unsatisfactory outcome in compensated patients when compared with noncompensated patients in spine surgery. Further research investigating the possible etiology of this association is necessary.”