The national guidelines described elsewhere at this site have been widely recognized, and have influenced the development of regulations on the State level. For example, in 1995 the Colorado Division of Worker's Compensation produced Treatment Guidelines for Back Injuries, Upper Extremity Injuries and Lower Extremity Injuries. These guidelines state that there should be a psychological component to work hardening programs, functional restoration programs, and chronic pain programs. These guidelines also recommend psychological evaluations for cases of delayed recovery from injury. They state, "Strongly consider a psychological screening, as well as initiating interdisciplinary rehabilitation treatment and vocational goal setting, for patients who are failing to make expected progress six to 12 weeks after an injury." These regulations go on to state that:
Personality/psychological/psychosocial evaluations are generally accepted and well established diagnostic procedures . . . These procedures may be useful for patients with delayed recovery, chronic pain, recurrent painful conditions, suspected concomitant closed head injury, disability problems and preoperative evaluation, as well as a possible predictive value for postoperative response . . . to determine if further psychosocial interventions are indicated in patients not making expected progress within six to 12 weeks following injury and whose subjective symptoms do not correlate with objective signs and tests, formal psychological and psychosocial screening should be implemented.
More recently, the 1998 Colorado State Division of Worker's Compensation Chronic Pain Guidelines have taken a very clear position on the value of psychological evaluation and treatment. Chronic pain is defined in Colorado as:
. . . pain that persists for at least 30 days beyond the usual course of an acute disease or a reasonable time for an injury to heal or that is associated with a chronic pathology (e.g. Reflex sympathetic dystrophy). The very definition of chronic pain generally indicates that there has been a delay or a outright failure to relieve the pain associated with some specific illness or accident (the term 'delayed recovery' is sometimes used here).
These guidelines go on to define chronic pain as a "biopsychosocial phenomena", and states that "such patients virtually always have psychosocial issues which can be identified as being operational in their suffering." It goes on to recommend an initial diagnostic workup consisting of medical, psychological and other aspects, which may include physical therapy and biofeedback. These guidelines see the physician and the psychologist as being the two central components of the pain treatment team. They recommend a thorough psychological evaluation by a professional specializing in this area, with a minimum of 18 different areas to address. The guidelines state:
All patients who are diagnosed as having chronic pain should be referred for a Psychosocial Pain Evaluation as well as initiating interdisciplinary rehabilitation treatment whenever appropriate... Psychosocial Pain Evaluations are generally accepted as well established diagnostic procedures with selected use in acute pain problems, but with more widespread use in subacute and chronic pain populations. Diagnostic workups should clarify and distinguish between preexisting vs. aggravated vs purely causative psychological conditions, and treatment directed appropriately.
Regulations, such as the ones above, do not address why such psychological evaluations are so important. To understand the value of assessing psychological factors, one must turn to the research.
In most cases, recovery from an injury is a straightforward and relatively inexpensive process. However, in a small number of cases, the costs are extremely high. Frymoyer (1988) reported that about 5% of back pain cases accounted for about 75% of all medical costs. We will refer to this 5% of more expensive patients as being "slow recoverers".
If we compare the medical costs for slow recoverers versus the other patients using Frymoyer's statistics, we will find that the average slow recoverer is 57 times more expensive to treat than the other patients. In some cases, this is because the slow recovery patient simply has a more complex medical condition. However, in many cases these slow recovering patients have no objective medical findings. As far as the best objective medical tests can discern, there are no objective reasons as to why this person's recovery should be delayed. Under such circumstances, there is an increased possibility that psychosocial factors are causing a delayed recovery to injury.
An article in JAMA reported that patients treated in a functional restoration treatment program for chronic low back pain and were compared with 72 patients not treated. A two-year follow-up that 87% of the treatment group was actively working after two years, as compared with only 41% of the nontreatment comparison group. (Mayer TG , et al, 1987)
A research team led by Stanley Bigos, M.D. at the Boeing Plant in Seattle found that psychological factors played the dominant role in determining who would file a Worker's Compensation claim for back pain (Bigos, et al., 1992). About 100 different variables were explored, most of which were medical in nature. Despite this, the only factors found to predict who would file a Worker's Compensation claim for back pain were job dissatisfaction, hysterical personality traits and antisocial personality traits.
It has recently been found that psychological factors could predict 91% of the time which back pain patients would recover from an injury and which would go on to become disabled (Gatchel, et al., 1995). In another study, it was found that psychological variables alone could predict delayed recovery 76% of the time (Burton, et al., 1995).
In contrast, commonly used medical tests have not demonstrated much predictive validity . In a study of the MRIs of 98 "normal" persons with no back pain symptoms, 52% had bulging disks, 27% had a protrusion, and 1% had an extrusion (Jensen, et al., 1994).
Childhood sexual assault has been found to be closely associated with failure to recover from surgery, even when that surgery occurs decades later. One study compared lumbar surgical outcome for adult patients, some of whom reported being abused as a child and others who did not. The persons who reported having not been abused as a child had exhibited a 95% successful surgical outcome. In contrast, the persons who reported having been abused as a child exhibited only a 15% successful surgical outcome (Schofferman, et al., 1992).
A meta-analytic procedure was used to determine the relation between disability compensation and pain. A total of 157 studies on this topic were reviewed, and comparisons were made on the basis of 3,802 pain patients and 3,849 controls. The results indicated that compensation is related to increased reports of pain and decreased treatment efficacy (Rohling et al, 1995). Similarly, a meta-analytic study of 2,353 traumatic brain injury subjects assessed in 17 research studies also found a relationship between compensation and symptoms. The studies findings were strongest with regard to mild brain injury, where it was found that compensation was associated with more disability from a less severe injury (Binder, et al, 1996).
After a review of the literature, it was concluded that mild traumatic brain injury typically resulted in mild persistent symptoms at worst, which were rarely disabling. Catastrophic outcomes following such injuries generally indicated that either a severe injury had gone undetected, or that underlying psychosocial factors were playing a significant role in symptomatology (Gualtieri, 1995).
In a World Health Organization study of 26,000 subjects in 14 countries, it was found that physical disability was more closely associated with psychological factors than it was with medical diagnosis (Ormel, et al., 1994).
American corporate health and safety costs are estimated to be $418 billion in direct costs annually, $837 billion in indirect costs, for a total of $1.256 trillion in annual costs (Brady, et al, 1997).
Estimates of the percentage of chronic pain patients with a diagnosable psychological conditions range from 86.5% (Katon et al, 1985) to 90% (Large, 1986). Furthermore, from 40% (Large, 1986) to 59% (Fishbain, et al 1986) of these patients have a personality disorder.
If patient psychological risk factors are assessed and treatment in a functional restoration program is structured to address these difficulties, then patient psychological difficulties do not have to interfere with outcome. (Gatchel RJ, et al, 1994)
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