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2010 ALUCA TurksLegal Scholarship

First Runner Up Tim Hulme

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Question 4: Rehabilitation and the Management of Subjective Pain. Customers who experience subjective pain present special claims management issues. Has rehabilitation worked for these customers an ultimately for your company? Please explain the problems implementing rehabilitation solutions in these situations. What techniques has your company used? When have they been effective and why?

Please include specific recommendations about to effectively implement rehabilitation when the customer’s condition is not well understood from a medical point of view or the customer may be uncooperative. Please include some practical suggestions about how claims managers can set up, monitor, and evaluated the results of rehabilitation strategies for claims of this kind.

Occupational Rehabilitation can provide a win-win outcome for the customer and the insurer when subjective pain is the source of ongoing disability, or when the claimed condition is not medically well understood. However firstly the claimant’s situation needs to be carefully reviewed before rehabilitation resources are allocated as the types of rehabilitation interventions that are appropriate vary greatly depending on their biopsychosocial situation. We first need to understand their medical, occupational, family, financial, and social situation.

Once we have sufficient information about the person’s background situation I believe they can be placed into one of four categories. I will describe each of the categories for income protection claims for subjective pain that I have seen in my reviews and the corresponding rehabilitation strategies that I have found most effective for each of these categories. Firstly however we need to define some important terms.

The term subjective pain is used widely in our industry. However, the term requires defining as it covers a wide range of conditions and situations. When we use the term subjective pain we seek to describe claimant conditions where the claimant reports ongoing pain in the absence of ongoing objective pathology or injury. However, there is actually no objective measure of pain and therefore

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all pain can be said to be subjective. However the term is used to describe pain symptoms that no longer have, or never had, objective measureable underlying pathology.

I believe there are four categories of income protection claims for subjective pain and the management of these claims varies depending on the category. The categories that I use are: Malingering, Somatoform Disorders (including Hypochondria), Complex Regional Pain Syndrome (CRPS), and undiagnosed medical conditions. Most subjective pain claims fall into one of these categories, however some can represent a combination of these.

1. Malingering: Typically this occurs following a claim a legitimate injury where the persons was disabled for a period and legitimately claimed income protection through this period. However following their recovery they continue to report pain to their doctor(s) despite knowing that the pain has mainly resolved and no longer causes disruption to their occupation function. Most commonly I see the pattern with musculoskeletal claims. The person may or may not have ready returned to work in some capacity. They often are resistant to obvious treatment, such as further surgery and if they are referred to occupational rehabilitation, they will only engage in a token manner to be seen to comply with the insurer’s requests.

Management of these claims produces the best results when we focus our efforts on building rapport with the doctor(s) and demonstrate that the person is engaging in treatment and rehabilitation in a manner that is inconsistent for someone with their claimed level of disability. This approach can work to demonstrate to the doctor(s) that their condition is no longer as significant as claimed and the doctor(s) will withdraw support. If rapport is developed with the treating doctor(s), and options for no longer providing medical certification for disability are provided, then we maximise the chances of the claim being finalises on medical grounds. This strategy can be effective depending on the stance of the particular doctor(s). Surveillance, rather than rehabilitation, is often a useful tool in this process if the person is genuinely malingering.

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2. Somatoform disorders (including Hypochondria): DSM IV defines Somatoform disorders as “the presence of physical symptoms that suggest a general medical condition and are not fully explained by a general medical condition…in contrast to Factitious Disorders and Malingering, the physical symptoms are not intentional” i.

In these situations, the person has a genuine benefit that they have continuing disability despite having made a physical recovery. This belief can be motivated by a genuine fear of RTW or fear of reinjury.

Attention

seeking

from

family,

treating

doctor(s),

can

also

be

a

motivation.

As the person has a genuine belief in their disability, their behaviour is consistent with their claimed illness or injury, and surveillance does not assist in the overall management of the claim. They can be successful in gaining the support of their doctor(s) and therefore it can be difficult to achieve medical sign off to finalise the claim. The most effective approach is to try to engage them in appropriate treatment for the underlying psychological condition. Once this is resolved with treatment such as cognitive therapy, then the person is able to recover and return to work.

Claimants with this presentation may often engage in extensive occupation rehabilitation, particularly if attention seeking from treating professionals is an underlying issue, however rarely is an outcome achieved. Therefore they can be a significant “black hole” for rehabilitation resources until their underlying psychological condition is addressed.

3. Complex Regional Pain Syndrome (CRPS) and Chronic Pain:

The Mayo Clinic describes CRPS as “an uncommon, chronic condition that usually affects your arm or leg. Rarely, complex regional pain syndrome can affect other parts of your body. Complex regional pain syndrome is marked by intense burning or aching pain. You may also experience swelling, skin discoloration, altered temperature, abnormal sweating and hypersensitivity in the affected area. The cause of complex regional pain syndrome isn't clearly understood, though it often follows an illness or

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injury. Treatment for complex regional pain syndrome is most effective when started early. In such cases, dramatic improvement and even remission are possible.”

ii

This is a well recognised medical condition with a US based study finding CRPS has a population incidence rate of 20 per 100,000. iii

In income protection claims, CRPS might often be seen to develop following an injury; for example a crush injury to the hand, the normal pain nerves in that hand begin to re-wire and become hypersensitised. Even once the original physical injury has resolved the peripheral nerve changes in the pain pathways remain. The peripheral nerves for touch and heat all reroute to the pain pathway and therefore even small amounts of touch, which cause not physical damage, send a signal of pain. Even if the crushed hand is later amputated pain signals will still remain, a condition known as phantom limb pain. If CRPS is not formally diagnosed, as the person’s symptoms are considered subclinical, the same underlying processes lead to the development of chronic pain. These condition previously have been considered subjective, however it now recognised that there is an underlying physical process.

Treatment for CRPS and chronic pain is now widely available. Pain clinics such as ADAPT at Royal North Shore Hospital in Sydney represent the gold standard in this treatment. They describe their treatment as being “For more generally disabled, distressed and/or medication-dependent patients, one

of

our intensive

cognitive-behavioural,

multidisciplinary

treatment

programs

may

be

recommended after comprehensive assessment. Features include:

medically supervised medication rationalisation/withdrawal,

withdrawal of unnecessary aids (sticks, braces, etc.),

functional upgrading (individually-tailored)

help with mood and sleep disturbances,

family/partner involvement, and

rehabilitation planning for return-to-work steps (linked to local doctor and rehabilitation provider/employer as appropriate) “iv

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See appendix for the model on which they base their program.

In income protection for claims where the customer has a chronic pain condition, other options are available, as waiting lists for programs such as ADAPT can be extensive. A program that has recently arrived on the Australian rehabilitation market is the ABILITA program. This program is delivered by an ABILITA accredited rehabilitation provider. ABILITA describe their program as being based on the Biopsychosocial Injury Management model and involves:

“teaching you information about the science of pain, why the physical injury causes your nervous system to respond the way it does and how you can deal with this pain using a variety of selfmanagement exercises. This course gives you a deeper understanding of the complexity of injury, and offers you the tools to manage the impact of your injury, maintain or achieve your best functional capacity, and develop confidence to safely remain in, or return to work” v.

The advantage of this program for people with claims for subjective pain is that it can be funded under the rehabilitation benefit and delivered quickly on a one-one basis. This avoids expensive delays incurred as the person waits for months, while receiving monthly income protection benefits, to start the hospital based programs. Therefore the rehab expense can easily be justified in the context of pro-active claims management.

These programs lead to strong RTW outcomes once the person has learnt to better manage their pain and can now better manage in their occupation. Once the ABILITA program is complete vocational rehabilitation should then be engage to assist the person to develop a gradually RTW. Occupation Rehabilitation needs to be engaged promptly following a pain management program such as ADAPT or ABILITA as the positive momentum from these programs will carrier through to return to work planning and returning to work represents the opportunity for people to put into practice the principles that they have learnt in the programs.

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4. Undiagnosed medical conditions: Claims do occur where there is a genuine underlying medical condition that is not yet properly diagnosed or not well understood. The person may often report genuine pain symptoms as the reason for disability without objective result confirming a formal diagnosis.

They may later be diagnosed with a condition such as Multiple Sclerosis or a similar neurological condition which explains these subjective pain symptoms, but until this diagnosis occurs the condition is still ”subjective pain” and

the management of the claim and determining the suitable rehab

invention remains challenging.

In the absence of a meaningful diagnosis rehab efforts need to be focused on determining the person’s objective functional tolerances. This approach is also appropriate for cases where there is symptom based diagnosis such as Chronic Fatigue Syndrome or Fibromyalgia. Assessment of these symptoms through a formal functional assessment, a graduated exercise program, or if possible a work trial will allow an accurate assessment of the person ability to cope with work.

Given their medical prognosis is uncertain it is essential to explain to the person that their income protection policy supports a graduated return to work through the partial benefit arrangement. Explaining this provides them with the confidence to commence a graduated return to work in the knowledge that they will be financially supported. Explaining that they can return to total disability benefits in the event of their condition deteriorating, also allows them to return to work in the confidence that they are not jeopardising their financial situation by doing so.

When an income protection claim is for a condition that is uncertain or not formally diagnosed, careful monitoring of rehabilitation interventions needs to occur to ensure that costs are limited on cases that are not progressing towards a return to work outcome. Best practise for monitoring progress is by measuring objective changes in functional capacity, such as improved exercise tolerance or increased hours in a worktrial. If progress is not being made in these areas, the program needs to be limited to

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ensure extensive rehabilitation costs are not incurred on cases that or not progressing to a return to work outcome.

Summary: I have found that Occupational Rehabilitation has proven to be effective in the management of income protections claims when the customer’s condition involves subjective pain. However, careful and thorough assessment of the person’s biopsychosocial situation needs to occur prior to committing the insurer to funding significant rehabilitation programs. The thorough assessment needs to include both the medical aspects of the claim, along with understanding the social, family, financial, and interpersonal aspects of their situation. Determining which of the four categories describe the person most accurately, then allows rehabilitation invention to be appropriately directed. These rehabilitation programs need to be well integrated into the return to work program, and the income protection claim through partial benefits to achieve a win-win outcome for the insurer and the customer. The recent development and availability of programs specifically designed to assist people with subjective pain conditions improves the chances of delivering a program that achieves this outcome for the insurer and the customer.

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Appendix  

References                                                              i

Diagnostic and Statistical Manual of Mental Disorders, Forth Ediition, Text Revision. American Psychiatric Association 2000 ii

Mayoclinic: http://www.mayoclinic.com/health/complex-regional-pain-syndrome/DS00265

iii

Pain. 2003 May;103(1-2):199-207.Complex regional pain syndrome type I: incidence and prevalence in Olmsted county, a population-based study. Sandroni P, Benrud-Larson LM, McClelland RL, Low PA. Mayo Clinic, Rochester, MN 55905, USA. psandroni@mayo.edu iv

Pain Management research institute: http://www.pmri.med.usyd.edu.au/clinical/adapt.php v

ABILITA: http://www.abilita.net.au/individuals/how‐it‐works 

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Rehabilitation and the Management of Subjective Pain  

Rehabilitation and the Management of Subjective Pain