What is Persistent Pain?
Pain is classified as persistent pain (or chronic pain) when it has continued beyond normal healing time after injury or illness and occurs in about 20%of the population. Persistent pain is a condition in its own right because of the changes in the nervous system unrelated to the original diagnosis or injury, if there was one.
Consequently, for this group of people, their persistent pain can be characterised by ongoing pain, as well as flare ups in pain; depression, anxiety, stress and sleep difficulties can become significant issues, as can fear of engaging in activities due to a fear of an increase in pain or fear of re-injury. As a result of this low mood and activity avoidance, the person can become physically deconditioned and find it harder to cope with everyday activities and common stressors.
Persistent pain may not be one single condition, and may originate from a range of injuries, however the principles of managing persistent pain are as follows:
- A comprehensive assessment needs to consider the whole person by assessing the biological, psychological and social (biopsychosocial) factors in order to develop a coordinated treatment plan.
- Utilise a multi or interdisciplinary approach by involving medical pain specialists, psychologists and physiotherapists who have specific training in the management of persistent pain.
- Exclude red flag conditions (such as fracture or other conditions needing immediate attention)
- Appropriately evaluate treatments, procedures, and trials of medication for persistent pain to ensure they are evidenced based treatments they lead to measurable sustained functional improvements, otherwise they should be ceased.
- Treat comorbidities which may be impacting on the person’s ability to manage their pain – these may include depression, anxiety and medication dependence.
- Ensure the person with pain is actively engaged in their recovery, including discussions regarding any new treatments such as a multidisciplinary pain management program, and that treatment has a focus on self-management.
For further information on understanding, assessing and managing persistent pain, please refer to the reference guide.
Treatments recommended for persistent pain
A range of medications may be appropriate, including Paracetamol and Non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen. Anti-depressants and Anti-convulsants may also be appropriate in reducing pain. Opioids may be considered but only for short bursts (from several days up to two weeks). Benzodiazepines are also considered to be unsuitable for long-term use with people with persistent pain.
Injections of anaesthetic and/or steroid, radiofrequency denervation (see Clinical Guideline – Diagnostic Medial Branch Blocks and Radiofrequency Denervation) and neurostimulation device implantation are all forms of interventional procedures. Injections are expected to have an impact in the short term (weeks), radiofrequency denervation over the medium term (months to a year) and neurostimulation over the longer term (years). The evidence for and effectiveness of these procedures varies greatly. These therapies should not usually be considered in conjunction with a PMP or in the 6-12 months following PMP.
Targeted psychological therapy focusing on addressing identified psychosocial risk The probability of the worker not returning to work is known as the risk or risk factor. For example: if a worker is likely to return to work, the claim is categorised as low risk. factors soon after an injury (in combination with an active rehabilitation approach) can reduce the likelihood of developing persistent pain, disability and distress in those identified as high risk Accepted high risk claims are managed in the 0-78 weeks, 78-130 weeks and 130+ weeks segments..
Some people may benefit from seeing a psychologist Registered psychologist means a person registered under the Health Practitioner Regulation National Law to practise in the psychology profession (other than as a student). to address sleep issues, grief, adjustment to changed functional capacity, managing emotions, including depression and anxiety, addressing anger and injustice beliefs and communication and conflict strategies. This may occur within or separate to a PMP. Some people may also benefit from having some additional psychological therapy following a PMP to assist with adherence to the behavioural changes made during a PMP and further develop skills and address barriers to recovery.
Exercise and activity are key strategies in a PMP. Following the program there may be some benefit in the person independently attending a pool or gym. There may be benefit in some periodic reviews with a physiotherapist Registered physiotherapist means a person registered under the Health Practitioner Regulation National Law to practise in the physiotherapy profession (other than as a student). or exercise physiologist to facilitate further upgrades in physical capacity whilst empowering self-management.
Pain Management Programs
WorkSafe can pay the reasonable costs of Pain Management and Network PM Programs to assist workers in their rehabilitation of a work-related An injury/disease is work related if it arose out of or in the course of employment and the scope of employment. injury or illness.
Pain Management and Network PM Programs are multidisciplinary interventions which are designed to assist workers with musculoskeletal injuries and persistent pain to manage their condition and reduce the disability associated with their pain.
Pain Management and Network Pain Management Programs also aim to assist workers who are having difficulties:
- managing their injuries and participating in functional activities at home, work or in the community due to their pain or
- reducing their dependency on medications and allied health treatment due to their persistent pain.
Procedures such as elective surgery, implantable pain therapies, radiofrequency denervation or detoxification are not considered to be part of Pain Management Programs or Network PM Programs.
Network Pain Management Programs are:
- programs delivered by multidisciplinary teams of providers who have signed a contract with WorkSafe with agreed reporting requirements and treatment timeframes
- specific evidence-based outpatient programs that provide multidisciplinary interventions to workers
- programs provided by a team of medical and allied healthcare providers that have skills and experience in the management of workers and in the delivery of pain management programs.
Pain Management Programs are:
- programs delivered by a multidisciplinary team of medical and allied healthcare providers
- inpatient or outpatient services that provide multidisciplinary interventions to workers.
Pain Education Programs are:
- seminar based multidisciplinary programs that meet the criteria of a pain management service
- designed to provide education and skills to workers with persistent pain.
Pain Education Programs are conducted as an outpatient public hospital service.
The policy provides guidelines for network pain management programs and pain management services.
The policy provides guidelines about:
- definition of programs
- what costs can be paid for
- who can provide programs.
Treatments that are not recommended for persistent pain
Passive therapies (massage, spinal adjustment/manipulation or other manual therapies)
Passive treatments do not rely on worker participation to be performed. In contrast active therapies (e.g. exercise programs, relaxation practices, homework set by the treater) rely on the patient to actively participate in these techniques at home, away from the provider. Passive therapies do not usually have a role in the management of persistent pain. This is because over time they become less effective and limit opportunities for the person with pain to undertake their own independent pain management.