Our bodies have two sets of nerve fibers that go from the body to the brain; pain travels on the small nerve fibers while the larger nerve fibers are used more for movement. Both sets of nerve fibers head toward the brain and converge at the same point on the spinal cord — a gate, essentially. Only one set of nerve fibers can predominantly get through the gate at a time. Therefore, doing bigger movements and being physically active can be instrumental in closing this ‘pain gate.’ People in chronic pain who sit for long periods of time may experience excruciating pain, while those who engage in movement see their pain levels decrease or even disappear.
No. Contrary to what many believe, pain is an experience; it is as least as much psychological as it is physical. Pain is actually a combination of thoughts, emotions, environmental factors and physical stimuli. By understanding that, injured workers with long-term, chronic pain can learn to change their thoughts and behaviors to manage their pain and return to function.
This occurs when the emotional part of the brain essentially hijacks the thinking part of the brain. Pain travels through various areas of the brain; first the primal area — where the flight/fight/freeze response is located. Next it goes to emotional part of the brain where memories of past occurrences of pain stimuli are stored. It heads next to the thinking area of the brain, where all options are considered. Finally, it goes to the action part of the brain which sends a signal telling the body what to do. This acute pain comprises about 5 percent of each area of the brain. With some people, the body and brain response continues for months, causing changes in the brain. Those 5 percent areas of the brain with pain grow to about 25 percent. Pain maps in the brain begin to smudge from one part of the brain to the motor area. Even though the actual tissue damage has healed, the brain continues to act as if the body is still being harmed. Injured workers with chronic pain often have a variety of surgeries, treatments and medications — none of which work. What is needed is a strategy to change the person’s thoughts and behaviors to reverse the changes to the brain.
Yes. A variety of strategies have proven to help reduce the incidence of PTSD among those most likely to encounter traumatic events, such as first responders. For example, we know that personal resilience, hardiness and ability to manage intense emotions are factors that can arm one against the development of PTSD. Effective, preventive strategies have been developed, based on this knowledge. Intervening immediately after someone has experienced a traumatic event can also help prevent the development of PTSD. Psychological first aid is the first step; with care limited to making people feel more secure by informing them of the possible psychological consequences and providing them with tangible emotional support. Within the first month of the event, strategies such as W-CBT can be provided.
No. In fact, the vast majority of people exposed to trauma will recover. Research shows that up to 12 percent of these people may develop PTSD. Among those affected, about half recover within 8 to 12 weeks with appropriate care, such as work-focused cognitive behavioral therapy (W-CBT). Some people do not recover because they do not receive appropriate care, or have pre-existing and comorbid issues that prolong and perpetuate the symptoms.
PTSD can be treated successfully with brief interventional sessions of work-focused CBT, especially if it is provided as soon after the event as possible. The affected employee(s) should first be contacted by a psychologist trauma specialist between 1 and 3 days after the traumatic incident and that contact should be maintained until the worker can meet face-to-face with an expert. Employees identified as having PTSD should undergo trauma interventions that have been shown to reduce symptoms and promote recovery, such as W-CBT. This short-term therapy utilizes principles of learning and conditioning to treat the disorder and includes components from both behavioral and cognitive therapy. It focuses on eliminating the workers’ negative beliefs about themselves while gradually exposing them to the thoughts and situations they fear. Done early and properly, PTSD can be successfully treated within 12 weeks or less.
PTSD is a reaction to a traumatic event involving actual or threatened death or serious injury or a threat to the physical integrity of oneself or others. It is characterized as persistent avoidance behavior to a stimuli associated with the incident and a general numbing of reactions. The person may constantly relive the trauma and experience a significant deterioration in his ability to function. It can trigger depression, anxiety disorder, drug abuse, divorce and suicide.
A variety of risk factors can predispose someone to develop full-fledged PTSD, while others who experience the same trauma do not. These include issues present before, during and after the trauma. Among them are:
- Continued exposure to trauma without sufficient recovery time and resources (i.e., first responders)
- Hardiness, or personal resilience
- Ability to withstand and manage emotional stress
- A perception of social support of colleagues during and immediately after the event
- The presence of strong negative reactions during the event; such as fear, guilt, shame, anger or disgust.
- The appearance of physical reactions during the trauma, such as palpitations, trembling, dizziness, sweating, hot flashes and shivering.
- The loss of emotional and/or physical control
Work-Focused Cognitive Behavioral Therapy (CBT)
Work-focused CBT is a short term program in which the patient, or injured worker, is actively engaged. They become an integral part of their own treatment, giving them a sense of empowerment. It includes training in techniques to help the person change his thoughts and behaviors — basically, rewiring the brain to return it to its state before the chronic pain or trauma began. Injured workers learn to focus on functional goals; steps that will enable them to decrease their pain response and increase their activity level, which teaches them how to cope with their pain. W-CBT has also been successful in helping injured workers with opioid dependence reduce their medication use.
No. Despite frequent concern voiced by workers’ compensation payers, injured workers treated for a physical condition can reap the benefits of work-focused CBT without an associated psych claim. Due to changes in medical billing codes, there are now descriptions that cover assessments and interventions for behavioral, social, and psychophysiological procedures for the prevention, treatment or management of physical health problems. The six new health and behavior CPT codes — 96150 to 96155 — are not allowed for psychotherapy services that address an injured worker’s mental diagnosis. Also, they are reimbursable only when performed by a licensed non-physician behavioral health provider, generally a psychologist trained in the area. The psychologist works in conjunction with the treating medical physician.
Injured workers in chronic pain on extended opioid therapy need help from experts trained in assessment and treatment. The same techniques and skills that help injured workers with chronic pain can help those with opioid dependency. After assessing the injured worker, a recommended treatment plan should developed based on the person’s specific needs. There may be psychosocial factors to be addressed, for example. The opioid withdrawal is one aspect of the overall treatment plan. One of the most important pieces of the plan is to help the injured worker understand what chronic pain really is so he doesn’t have unrealistic expectations. The injured worker needs to understand that, like other chronic conditions, there is no cure. That doesn’t mean that injured workers have to be in debilitating pain forever. Once they understand and accept the facts about their pain, they can learn how to manage it instead of being controlled by it. Learning to cope with the pain is done simultaneously with opioid withdrawal. The injured worker learns techniques to manage his pain without the use of opioids, which are typically ineffective in relieving the pain.
Traditional ‘talk therapy’ and work-focused CBT are both types of psychotherapy and are both effective — in certain circumstances. More traditional therapy tries to uncover the patient’s deeper motivations for feelings and behavior. W-CBT, on the other hand, helps train the patient’s mind to think and perceive in different ways to help alleviate suffering. It is structured and focused on the person’s present situation; such as chronic pain, PTSD or opioid dependence. The person learns and practices techniques such as problem-solving and realistic thinking.
Injured workers with chronic pain or PTSD have thoughts and emotions that are essentially working against them. Work-focused CBT can lead to improved symptom management because thoughts are deeply connected with automatic, unconscious survival needs and, therefore, preventions and defense behaviors. These cognitive distortions decrease individuals’ functioning by influencing the way they represent their own lives and how they act and behave daily. Rooted in science, W-CBT remaps the brain to redirect the signals sent by the nervous system. Changing our thoughts and actions can retrain the brain back to the way it was before the chronic pain or trauma occurred. Injured workers in chronic pain or PTSD may never be completely ‘cured’ of the pain, but by working with a highly trained, skilled health psychologist they can learn to intervene in the cycle of stress-pain-stress.
The way pain travels through the body and brain can automatically increase a person’s heart rate, blood pressure and breathing. This leads to an increase in the stress arousal — the part of the brain where the fight/flight/freeze response is created. The result is an increase in the pain experience. An injured worker can control his fear level and, in turn, his pain, by doing the following ‘holding your breath’ exercise:
- Inhale for a count of 3 seconds.
- Exhale for another count of 3 seconds, so there is no breath in the lungs.
- Hold the breath for 10 seconds.
- Take a breath.
Taking a breath after holding the breath longer than our comfort level causes a sense of relief, as the pleasure response kicks in. This simple exercise introduces the concept of how the pleasure response can help relieve pain. Chronic pain patients who are gripped with fear need ways to activate the brain’s pleasure response. This is one exercise to do that.
Psychosocial Risk Factors
The sooner an injured worker with psychosocial risk factors is treated with work-focused CBT, the fewer the number of treatments needed and the shorter the healing time. But getting this treatment to injured workers can be difficult for persons who live in rural areas, do not have adequate transportation to a physician or need integrated treatment. Thanks to telemedicine and telepsychology, these are no longer barriers to immediate treatment. A psychiatrist, for example, can now do a virtual visit with the injured worker through remote sessions via computer. Interdisciplinary treatment can be achieved by having a physical therapist working with the injured worker and talking to a W-CBT-trained psychologist at the same time via computer, tablet or smart phone. Finally, workers exposed to traumatic events can meet via telemedicine with a specialist remotely.
Psychosocial risk factors gone unchecked can be debilitating, leaving the injured worker in chronic pain and unable to function much at all. Work-focused CBT is an invaluable tool to help injured workers with destructive thinking patterns that cause or perpetuate their chronic pain. More than anything, it engages the patient and teaches him to take charge of his pain and his life. The techniques teach the injured worker first to be aware of and monitor his thoughts, then to change them. By taking control of their thoughts, injured workers can take charge of their lives and their pain. The positive thoughts help decrease the stress arousal response.
Many, if not most injured workers with chronic pain have psychosocial risk factors that are at least partly responsible for their disability. Masking the pain with medications rather than addressing the underlying issues does little to actually help. Interestingly, many of the effects of medications, such as gabapentinoids and cannabis can be generated naturally. GABA is an inhibitory molecule that slows the firing of neurons and creates a sense of calmness. Some refer to it as the ‘anti-anxiety’ molecule. Yoga and meditation are very effective in naturally increasing GABA levels. Another molecule, endocannabinoids, is a cannabis the body produces on its own. Called the ‘bliss’ molecule, there has been some speculation that these are related to the high someone gets after running for a sustained period; and we know that exercise is one of the best treatments for injured workers with chronic pain.
These are among the most telling psychosocial risk factors. Vast amounts of research point to these three as highly predictive of a poor workers’ compensation claim outcome.
- Catastrophizing. This entails ruminating about irrational worst-case outcomes, exaggerating the threat value of pain sensations, and feeling helpless to deal with pain. Think of it as anxiety run amok. People who catastrophize believe in negative outcomes, with thoughts such as “the pain is terrible and I won’t ever get better,” “I can’t cope with the pain,” and “something must be terribly wrong with me.
- Fear avoidance behavior. Also called guarding behavior, the person with this fears that any movement he makes could aggravate his condition and worsen his pain. He is so preoccupied with his symptoms he avoids all activity, including rehabilitative efforts.
- Perceived injustice. Often closely tied in with catastrophic thinking and fear avoidance behavior, this describes a sense of unfairness and blame. That might be faulting the employer for having an unsafe work environment, another employee, or something else. They may also think about retribution in some way. People with perceived injustice feel greater pain intensity, often leading to further delayed recoveries. Some studies also suggest perceived injustice is correlated with opioid prescriptions.
Noted in several research studies as the biggest barrier to positive claims outcomes and increases in claim costs, these have been proven to lead to delayed recoveries of injured workers. While they may only impact a small percentage of injured workers, they drive the greatest costs. Often called ‘creeping catastrophic’ claims, these involve seemingly minor injuries that go off the rails, often unnoticed by those managing them. The term ‘psychosocial’ generally refers to behavioral issues, rather than traditional psychiatric problems. Among the most prevalent factors seen in injured workers are:
- History of childhood abuse
- Perceived injustice
- Fear avoidant behavior
- Catastrophic thinking.
- History of substance abuse
These and other psychosocial issues are not dependent on the nature of the injury; meaning an injured worker’s medical report by itself won’t signal a claim as one with risk factors.