Musculoskeletal injury and chronic pain

Despite significant advances across the world in medicine and technological treatment of disease, chronic pain has "remained an enigma that health care professionals often manage poorly". Scientific evidence shows that despite a range of medical, therapeutic and multimodal biopsychosocial approaches, successful outcomes and long-term benefits of treatment and management of chronic pain remain inconclusive, and the results of clinical trials are often contradictory.

Chronic pain, by definition, is characterised by the persistence of pain for at least three months, often beyond six months or more, so that the initial period of expected healing of the original injury has passed.

In Australia, chronic pain is strongly associated with socio-economic disadvantage, high levels of unemployment and significant social costs. Chronic pain is also strongly associated with social disadvantage. New South Wales WorkCover figures confirm that where injured workers have not been able to return to work within 12 months after an injury, as is the case for many with chronically painful musculoskeletal injuries, then their ongoing chances of regaining employment are minimal. This means the personal costs experienced by injured workers with chronic pain arising from musculoskeletal conditions are often immense. Others are also significantly affected. Employers, for example, incur increasing costs in terms of sick leave, lost production, recruitment and retraining, and social welfare services bear the costs associated with supporting people with work-related disabilities whose claims for long-term workers compensation payments are refused by insurance companies.

The findings of this study provided insight into how injured workers with chronic pain and treating professionals understood success and also what they saw as barriers to success. Emergent themes and rich descriptions that supported the analysis showed that workers' experiences were shaped significantly by social factors, and that social influences were key determinants of success in terms of how individuals regained their sense of independence and control over their lives - as opposed to losing control, remaining helpless and dependent on others, or becoming intent on revenge and validation of their pain and disibility.

Three distinct groups emerged: those who were 'disempowered', depressed and who became increasingly dependent on social benefits and ongoing health care; those who were able to become 'empowered' through social mobility; and those seeking validation of their injury by remaining 'angry and intent on revenge', and by pursuing justice through ongoing litigation.

Disempowered injured workers

In the disempowered group, all had left school early. They had very little formal education and had started paid work at a relatively early age. Disempowered participants were predominantly unskilled and the work they had undertaken was physically demanding or they were performing tasks that were repetitive in nature.

This meant that their options for moving into other less demanding work were limited by their lack of education, skills and ongoing physical limitations due to the ongoing effects of their injury. For these participants, rehabilitation had resulted in several failed return-to-work programs that added to their sense of helplessness, loss of control, depression and disempowerment. As one injured worker proclaimed:

But the work in a chicken factory is hard work. It's repetitive and there's no stopping. They give you a break for tea-time and a lunch break, but it's not enough. I think I've been at work for too long doing things that have broken down my body. You can't turn back the clock. So what do you do?

Empowered

Alternatively, many of those in the empowered group, although they also had undergone similar attempts to help them return to their previous line of work without long-term success, had overcome these barriers. They were able to identify a new future career and identity. Failure to regain full-time work or their previous employment was common but they differed from their disempowered counterparts in the ways in which they reacted to such a situation. One such participant who had been off work for two years, having continued to participate in a 'light duties' program at work for about 12 months, and for whom the traditional approaches had been unsuccessful, stated: "I'm doing my own rehab now - I'm actually back at Uni retraining myself because I can't do what I did before. So the rehab didn't work for me. I'm doing my own rehab now."

Those who were able to become 'empowered' had more advantaged socio-economic backgrounds and higher levels of education. They tended to be employed as white-collar workers prior to their work injuries. They were not defeated by their experiences with failed return-to-work programs. Rather, they decided on new career paths regardless of the decisions of rehabilitation providers or insurance company decisions. These workers were not commonly referred to rehabilitation in relation to their ongoing pain and disability.

Angry and seeking revenge

The third group - those who were 'angry and seeking revenge' - consistently experienced return-to-work rehabilitation processes that they found unsatisfactory.

This fuelled their intent to pursue litigation, a means by which they could seek revenge for being disabled by their ongoing pain experiences. There was a strong sense of grievance and discontent among these participants regarding their rehabilitation experience. As one injured worker commented: "They tried to have me go back to the same work that caused my pain in the first place." Indeed, such rehabilitation, was seen as useless: "it only made my condition worse", and caused further insult. Rehabilitation professionals were regarded as inexperienced: "just out of college", and more interested in "pleasing the boss" and "representing the insurance company" than in assisting injured workers. For these workers, their rehabilitation experiences and difficulties with insurance companies added to a lack of trust in, and cynicism about, what "the system" and rehabilitation had to offer. Their experiences of being let down by others and of trying to work "despite the pain" only intensified their anger.

All participants in this group confirmed that third-party and workers compensation systems were instrumental in disrupting their lives, particularly those caught up in litigation processes. Professionals confirmed that "the process itself is very distressing" and this was inherently difficult for all injured workers "because they have to prove there's a problem and the problem is difficult to prove because it's a pain problem. There are all sorts of hoops which they have to jump through". This meant that the procedures that injured workers confronted in having to "prove" the legitimacy of their pain and injury were very distressing. As one medical specialist commented, participants in this group were often intent on pursuing litigation as a means of seeking justice rather than on undertaking rehabilitation that focused on returning to employment.

Ultimately what the insurer wants is a return-to-work outcome, but often this is not in the best interest of the patient. If they see that work caused their problems, then often they will see this as adding insult to injury, particularly if the insurer becomes insistent on it. It's a matter of seeking justice for the suffering and insult.

As a result, when the insurance company insisted on return to work, injured workers were more likely to focus on "seeking justice for the suffering and insult". For some, the pursuit of justice became more important to workers than complying with the insurer's demands for them to return to the work, particularly since that type of work had created their injury and subsequent pain and disibility.

Conclusion

According to the interviews with practitioners and injured workers, blue-collar work disadvantaged injured workers. Many practitioners reported that blue-collar workers who incur chronically painful musculoskeletal injuries at work "don't have much more to lose". They have physically demanding, low paid jobs and come from low socio-economic backgrounds that render their chances of recovery and return to work virtually non-existent. Under current pain management and rehabilitation service provision they are set up for failure.

The cluster of themes that emerged from the data reflected the importance of pre-injury occupation and work tasks on injured workers. This was described by treating professionals in terms of the "line of employment which predisposes them to these kinds of injuries, chronic pain and compensation". The socio-economic background of injured workers was also an important factor in relation to recovery from these injuries, as the comment by a rehabilitation consultant indicates:

"These clients all have low socio-economic backgrounds - by way of their line of employment which predisposes them to these kinds of injuries, chronic pain and compensation. So by the time they report their injury they are in big trouble, by the time they lose more money on the compensation system, then they don't have much more to lose. Time is their worst enemy."

As this comment suggests, by having a background in process work, in labouring or in other blue-collar occupations, workers were more likely to become injured and to experience the injurious effects of their work before they actually registered their injury and sought medical help. These findings were consistent with reports from WorkCover NSW that the most common injures are related to blue-collar tasks such as manual handling (34.6%), resulting in musculoskeletal sprains and strains.

Clearly, chronic pain is strongly associated with socio-economic disadvantage, high levels of unemployment and social costs. Further, the 'iatrogenic' effects of injured workers' experiences of compensation systems have potential to further disadvantage them if they have blue-collar backgrounds. Indeed, the study's results show that workers from blue-collar backgrounds experience a double jeopardy in relation to disabling work injury and its management. First, the type of heavy and repetitious work performed by blue-collar workers is more likely to predispose them to musculoskeletal injury. Second, because they have fewer resources on which to draw, such as education and job skills, their capacity to retrain and to regain full employment as required by current compensation and rehabilitation programs is severely constrained. Their experience of work-related rehabilitation is unlikely to be an empowering one.

These findings are consistent with the results of other studies which have also found that chronic pain is associated with socio-economic disadvantage and high levels of unemployment in Australia. They also support claims that chronically painful work-related injuries are imposing growing costs not only on those who incur them but on the community more broadly.

Reproduced from 'Workplace Health & Neoliberalism' (ISBN 0-9750436-4-1, August 2005) with permission of the author and publisher, eContent Management P/L (www.healthsociologyreview.com/workplace-health.php).