Musculoskeletal disorders — and the difficulties associated with treating them — have long vexed the workers’ comp industry.

MSDs account for approximately one-third of all workers’ compensation costs. The Bureau of Labor Statistics estimates that direct economic costs of MSDs are around $20 billion annually, with indirect costs of up to 5x that.

In a comprehensive 2016 report, the United States Bone and Joint Initiative estimated the annual U.S. cost for treatment and lost wages related to musculoskeletal disorders at $213 billion, or 1.4% of the country’s gross domestic product.

Researchers further concluded that, “When adding the burden of other conditions affecting persons with musculoskeletal conditions such as diabetes, heart disease and obesity, the total indirect and direct costs rose to $874 billion, or 5.7 percent of the GDP in 2015.”

With an aging workforce at higher risk for MSDs, employers and payers are increasingly pressed for ways to ensure optimal outcomes for workers while limiting opioid use and avoiding unnecessary surgeries or other procedures that could do more harm than good.

The biopsychosocial treatment model — which focuses on the whole patient and everything in the patient’s sphere that could impact recovery positively or negatively — has come to prominence in recent years.

With it has come new thinking and research about MSDs and pain management. Risk & Insurance® spoke with Katie McBee, regional director of Workstrategies at Select Medical Corporation, about what that means for workers’ comp and for injured workers.

R&I: The biopsychosocial model has been around since the ’70s but wasn’t widely adopted in workers’ comp until around the early 2000s. What’s the biggest change you’ve seen in claims management approaches since that shift occurred?

I have been happy to see in the last five years that using terms like ‘psychosocial’ and ‘fear avoidance’ are more widely acceptable.

Katie McBee, regional director of Workstrategies, Select Medical Corporation

Early in my career, I can remember getting confronted by stakeholders about these terms, stating they were either out of my scope of practice or that I was trying to add a psychological diagnosis to a claim. Now it seems most stakeholders are familiar with the terms, and there is a growing understanding with more compassion towards these factors.

There also seems to be more willingness to collaborate and problem solve the best solution to help get our more complex patients back on track.

R&I: What are the top biopsychosocial risk factors that impact musculoskeletal injuries?

That is a big question. For the bio part, I would say it is our typical traumatic and wear-and-tear injuries of the low back, shoulder and knees that are most common, as well as comorbid conditions that add complexity to the system’s ability to heal.

From the psychosocial part — based on the research I am familiar with for workers’ compensation — the largest impact on musculoskeletal injuries comes from non-modifiable components of low socioeconomic status, marginalized populations and limited social support.

For modifiable psychosocial factors, perceived injustice, low self-efficacy, anxiety and fear avoidance, depression and pain catastrophizing are the main factors that I have seen data on that impact the outcome of musculoskeletal injuries.

R&I: From your perspective, what is the most misunderstood aspect of pain and the pain experience?

Pain is a complex perception that involves the central and peripheral nervous systems. It is not a cause and effect phenomenon. There is not always a certain amount of pain that a person will experience predictably with a specific controlled stimulus.

Mood, past experiences, meaning, genetics and current health status can all potentially have an impact on pain as well as many other things.

So, for an example, let’s say I stub my toe while chasing and playing with my toddler. He is laughing; we are having fun. I may not even feel pain in this situation and may take off my sock later and realize there is a bruised toe or blood. In this case, I had a tissue injury and I never noticed any pain experience.

In another example, let’s say I am stressed out due to a deadline at work, and I have to be on my feet on a job site the next day for 15 hours, and I am running through the house, prepping for work and chasing a toddler. I stub my toe. This situation may cause more pain, because my nervous system is already primed and heightened to threat and stress.

The meaning is different, because if my toe is sore, I may not be able to perform my work, and this could amplify the output from my central nervous system.

Pain is different in different moments and circumstances. There are a lot of variables that can alter a pain experience beyond the magnitude of tissue injury. We can never know all of the variables involved with an individual’s pain output. When we focus on biomedical causes of pain, we miss a lot of potential factors.

R&I: What does mindfulness have to do with pain?

There is a lot of overlap in brain activity for pain and negative emotional states like stress, anger, depression, etc. Pain can potentially cause a negative emotional state, and a negative emotional state can potentially prime your brain to produce a stronger pain output.

Research has shown that one of the best ways to predict future chronic pain is to do a brain scan and if someone has a larger amygdala or increased activity in reward centers of the brain, they are more at risk of developing an ongoing pain issue. This is an expensive way to screen, so it is uncommon.

It is cheaper to treat the potential issue than to screen it, and this is where mindfulness comes in.

Research by Grant et al in 2011 has shown that meditation and mindfulness can result in reduced activity in the emotional areas of the brain, like the amygdala, and mindfulness enables individuals to be aware of painful stimuli with a more neutral emotional response, basically mitigating psychosocial risk factors around pain.

Zeiden et al, in 2011, showed that even short trainings in mindfulness meditation can lead to a 40% reduction in pain and a 57% reduction in pain unpleasantness. Hilton et al, in 2017, showed that mindfulness meditation can improve pain, depression and quality of life in individuals with pain disorders.

Mindfulness Based Stress Reduction (MBSR) has moderate quality evidence as an effective treatment for chronic low back pain, as published in the American College of Physicians Low Back Pain Clinical Practice Guideline.

Herman et al, in 2016, showed MBSR reduced health care costs to the insurance payer by $982 per participant. In its study, Cognitive Behavioral Therapy did not show any cost savings compared to usual care.

R&I: Is it sometimes a heavy lift to get injured workers on board with a mindfulness approach, and how do you address that?

I have found, with education on how the brain works with pain and how different pain can be with everyone, a lot of my patients start to notice stress plays a role in their pain experience. This is a great opportunity to explore mindfulness as a stress-reduction activity.

I do have some patients who are too acutely upset or have underlying mental health disorders that do not respond well to mindfulness, and we look at other treatments for them that can be beneficial, like joyful activities and exercise.

I also have some folks who think meditation is not for them or that meditation is a foreign religion. If they are not interested and won’t try after a discussion, we move on with other treatments.

However, from my experience, the majority of folks are open to trying mindfulness when they are participating in our chronic pain program. The widespread popularity of mindfulness these days seems to help versus five years ago. It used to take a little more selling. &