Within California Workers’ Compensation, Injured Workers are frequently given labels or diagnoses to describe their industrial injuries. Physicians, who either treat or evaluate Injured Workers, frequently describe different types of pain that injured workers experience. The description of pain provided by the physician can have a significant impact on an Injured Worker’s entitlement to workers’ compensation benefits.
In some circumstances, “pain” may become part of the injury diagnosis. For some Injured Workers, physicians will describe their pain as “chronic.” Further, in some circumstances, the physician will provide a diagnosis of “chronic pain.”
This article is meant to explore the meanings of “Pain” and “Chronic Pain” within the workers’ compensation system and how it has an impact on treatment. It will also discuss its impact on permanent disability impairment.
The State of California propounded a MEDICAL TREATMENT UTILIZATION SCHEDULE (MTUS) CHRONIC PAIN MEDICAL TREATMENT GUIDELINES Part 1: Introduction July 28, 2016, which discusses the challenges of treating Injured Workers with Chronic Pain. This text will be referenced in the article as “MTUS Intro.”
What Is Pain?
Per the MTUS Intro, “[d]efinitions: Pain: The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” (Merskey, 1994) This definition describes the pain as a subjective experience; therefore, unlike hypertension or diabetes, there is no objective measurement for pain. Analysis of the objective data (history, psychosocial assessment, physical findings, imaging results, lab tests, etc.) Is needed to evaluate the patient’s subjective report of pain.”
Note: This statement recognizes the fact that pain is a subjective experience and that it varies differently with each individual. The goal within workers’ compensation is to have a uniform assessment of pain in order to provide compensation and benefits based upon it.
Are There Different Types Of Pain?
Yes. There are different types of Pain.
Per the MTUS Intro, “ Types of Pain (Acute vs Chronic): Pain comes in many forms. Understanding which kind or kinds of pain a person is experiencing is a first step toward treatment. Although acute and chronic pain is considered separately below, an individual can experience them simultaneously. Furthermore, current research shows that pain exists more on a continuum than in discrete categories of “acute” or “chronic” pain. This means that, for some patients, the mechanisms responsible for pain persistence are engaged early in the injury process. Therefore, it is important to identify persons at risk for the development of chronic pain and to establish preventative measures to reduce the likelihood of pain persistence.”
What Is Acute Pain?
Per the MTUS Intro, “Acute pain, by definition, is of sudden onset and expected to be of short duration. It can usually be linked to a specific event, injury, or illness—a muscle strain, a bone fracture, severe sunburn, or a kidney stone, for example. People can self-manage many types of acute pain with over-the-counter medications or a short course of stronger analgesics and rest. Acute pain usually subsides when the underlying cause resolves, such as when a fracture heals, or kidney stone or diseased tooth is removed. In the “MTUS Opioids Treatment Guidelines,” acute pain is defined as pain lasting up to one month and subacute pain as pain last between one and three months.”
In sum, Acute Pain is the pain of short duration. It does not last too long.
What Is Chronic Pain?
Per the MTUS Intro, “Chronic pain is any pain that lasts three (3) or more months from the initial onset of pain (i.e., over 12 weeks) and can be frustratingly difficult to treat.”
Note: Based upon this definition, it is important that the Injured Worker makes sure that the reporting physicians document the initial reporting of the pain.
Are There Conditions That Involve Chronic Pain?
Yes. There are a variety of medical conditions that can be considered as a chronic pain disease. These include such conditions/diseases as fibromyalgia, irritable bowel syndrome, vulvodynia, chronic headaches, and temporomandibular joint disorder (TMJ or TMD).
How Does A Physician Make A Chronic Pain Determination?
Per the MTUS Intro, “the physician begins by assessing the presenting complaint and determining whether there is a “red flag for a potentially serious condition” that would trigger an immediate intervention. Upon ruling out a potentially serious condition, the physician should provide conservative management, that is, a treatment approach designed to avoid surgical and other medical and therapeutic measures with higher risk of harm compared to benefit.(Singh, 2013). If the complaint persists, the physician needs to reconsider the diagnosis and decide whether a specialist evaluation is necessary.”
Chronic Pain can be complicated. Physicians can employ a biopsychosocial model of pain. In using this model, physicians will look at pathophysiology, psychological state, cultural background, and belief systems. It can also involve relationships and interactions with the environment. This can include interactions with the workplace, home, the disability system, and the health care providers.
How Does One Get Treatment For Chronic Pain Within The Workers’ Compensation System?
All medical treatment within California Workers’ Compensation is determined by the Labor Code. Labor Code Section 4600(a) which provides that
“(a) Medical, surgical, chiropractic, acupuncture, and hospital treatment, including nursing, medicines, medical and surgical supplies, crutches, and apparatuses, including orthotic and prosthetic devices and services, that is reasonably required to cure or relieve the injured worker from the effects of his or her injury shall be provided by the employer. In the case of his or her neglect or refusal reasonably to do so, the employer is liable for the reasonable expense incurred by or on behalf of the employee in providing treatment. (b) As used in this division and notwithstanding any other law, medical treatment that is reasonably required to cure or relieve the injured worker from the effects of his or her injury means treatment that is based upon the guidelines adopted by the administrative director pursuant to Section 5307.27.”’’
Further, treatment is subject to Utilization Review. If Utilization Review is denied, Injured Workers can appeal via the Independent Medical Review process.
As noted above, if there is persistent pain and such pain fits within the Guidelines, then special Chronic Treatment Guidelines are applicable.
What Type Of Physician Treats Chronic Pain?
Per the American Society of Regional Anesthesia and Pain Medicine, “ [a] pain management specialist is a physician with special training in evaluation, diagnosis, and treatment of all different types of pain. Pain is actually a wide spectrum of disorders including acute pain, chronic pain and cancer pain and sometimes a combination of these. Pain can also arise for many different reasons such as surgery, injury, nerve damage, and metabolic problems such as diabetes. Occasionally, pain can even be the problem all by itself, without any obvious cause at all.”
The specialty that usually treats chronic pain patients is Anesthesiology.
With respect to treatment, Chronic Pain Physicians can provide such treatment as medications, trigger point injections, and epidural injections.
What Are The Problems With Chronic Pain?
There are many problems with Injured Workers with Chronic Pain. One of the biggest concerns is the impact of Chronic Pain on the Injured Worker’s life. Injured Workers with chronic pain patients can become dysfunctional with respect to many aspects of both life and work. Chronic Pain, due to the pain or the pain medications, can prevent the injured worker from engaging in a variety of activities.
As a result of Chronic Pain, Injured Workers can be prevented from performing activities of daily living. For example, if they are taking narcotics, they may be precluded from driving a car. Sometimes, the Chronic Pain sufferers can be so debilitated that they can no longer clean their house or do their laundry. In addition, Chronic Pain may impact the quality of their relationships with family and friends.
Chronic Pain may prevent Injured Workers from returning to their usual and customary occupation or the labor market in general. As noted above, an Injured Worker may be taking narcotic medication that may prevent them from performing work activities such as driving a car. Further, Chronic Pain may prevent them from concentrating at a level to perform cognitive tasks.
How Does Chronic Pain Impact Permanent Disability?
To access Permanent Disability, California Workers’ Compensation Law uses the AMA Guides for the Evaluation of Permanent Impairment, 5th Edition. Within the Guides, there is a Chapter dedicated to Pain.
Chapter 18 of the Guides is the Pain Chapter. Chapter 18, “provides information that ..[to] enable physicians to understand pain and develop a method to distinguish pain that accompanies illnesses and injuries from the pain that has become an autonomous process, and provide physicians with a qualitative method for evaluating permanent impairment due to chronic pain.” AMA Guides, 5th Edition, at P. 565. In sum, Pain, in and of itself, may take on a life of itself beyond that of the pain that ordinarily emanates to the underline injury or illness. In those circumstances, there may be the basis for assigning additional impairment.
In sum, the diagnosis of Chronic Pain may allow for an assessment of Whole Person Impairment to the Injured Worker based upon this condition. This can occur when the pain is considered in addition to the ordinary underline illness or injury. This Chronic Pain Whole Person Impairment is then placed into a rating formula to determine the Injured Worker’s Permanent Disability Percentage
What If I Need Advice?
If you would like a free consultation regarding your workers’ compensation claim, please contact the Law Offices of Edward J. Singer, a Professional Law Corporation. They have been helping people in Central and Southern California deal with their worker’s compensation cases for 26 years. Contact us today for more information.