Pain, 48(1992) 121-123 0 1992 Elsevier Science
121 Publishers
B.V. All rights reserved
0304-3959/92/$05.00
PAIN 01894
Guest Editorial Compensation
and chronic pain
George Mendelson Department of Psychological Medicine, Monash University, Clayton, Victoria 3168 (Australia) and Pain Management Centre, Caulfield General Medical Centre, Caulfield, Victoria 3162 (Australia) (Received
1 February
The first reported case of an employee seeking compensation from an employer for a work injury reached the High Court in England during 1837. The plaintiff employee had been travelling in the employer’s van which “broke down, and the plaintiff was thrown with violence to the ground, and his thigh was thereby fractured.” The lower court entered a verdict of f 100 in favour of the plaintiff. On appeal, however, the judgment was reversed, Lord Abinger C.B. noting that “if the master be liable to the servant in this action, the principle of that liability will be found to carry us to an alarming extent” (Priestley v. Fowler 1837). It was not until 1897 that the Workmen’s Compensation Act introduced a statutory scheme in Great Britain which provided income support for injured workers on a no fuuft basis (Bartrip and Burman 1983). Similar legislation was subsequently passed during the early part of this century in the United States (Larson 19.52). In discussing the effects of the introduction of workers’ compensation laws, Collie stated that “fraud is a product of the age, of the Workmen’s Compensation Act, of Trade Unions and allied Clubs. There are no malingerers in countries where there is no Workmen’s Compensation Act” (Collie 1932, p. 1). Several publications appeared during the early decades of this century on the subject of the detection of malingering among compensation claimants (Collie 1912, 1913, 1932; McKendrick 1912; Jones and Llewellyn 1917). One of the areas of concern discussed by the authors was pain (Slot 1927). Thus, according to Collie, “In dealing with a back injury, it is necessary to make up one’s mind on two points. First, is the pain real, psychic or assumed; second, is it due to disease or accident? In the vast majority of cases, alleged pain in the back is mental and not physical. The idea of a tender spot or of pain takes possession of the patient,
Correspondence to: Dr. George Melbourne, Victoria 3004, Australia.
Mendelson,
33 Queens
Road,
1991, accepted
9 April 1991)
and has the same effect and requires the same treatment as obsessions in regard to other parts of the body” (Collie 1932, p. 221). Until 1970 the predominant theme in the professional literature dealing with the medico-legal aspects of compensation was concern about the putative clinical entities of ‘accident neurosis’ (Miller 1961) or ‘compensation neurosis.’ In an oft-quoted aphorism, Foster Kennedy defined ‘compensation neurosis’ as “a state of mind, born out of fear, kept alive by avarice, stimulated by lawyers, and cured by a verdict” (Kennedy 1946). In 1970 two articles published in Australia drew attention to the adverse emotional effects of the compensation process (Balla and Moraitis 1970; Ellard 1970) and reported that, contrary to the viewpoint forcefully espoused by Henry Miller (19611, patients do not all improve and return to work after the finalization of the compensation claim. The finding that patients continue to experience symptoms and require treatment following the finalization of litigation has now been supported by other studies (Hohl 1974; Enccl and Johnston 1978; Kelly and Smith 1981; Mendelson 1981; Sprehe 1984; Tarsh and Royston 1985); significantly, there have been no published reports to confirm Miller’s findings. Miller’s results may have been due to the biased nature of his sample, which consisted of 50 litigants selected out of several thousand on the basis of their ‘gross neurotic symptoms’ noted during examination. Patients in receipt of compensation benefits or involved in litigation form a significant proportion of those attending pain clinics; Carron et al. (198.5) reported that 49% of patients with chronic low back pain attending a pain clinic in the United States were in receipt of pain-related benefits. Studies which have examined the relationship between chronic pain and compensation have used three methodological approaches: (1) comparison of the pain characteristics of patients who are receiving compensation with those of patients who are not involved in
122
litigation or compensation; (2) comparison of the treatment response of patients in receipt of compensation with those who do not receive pain-contingent benefits; and (3) examination of the duration and characteristics of chronic pain patients under different systems of compensation (Melzack et al. 1985; Mendelson 1986). Comparisons of the pain described by litigants or compensation beneficiaries with that described by non-litigants do not support the oft-repeated assertion that patients claiming compensation describe their pain experience as more severe than a comparable group not in receipt of pain-related benefits. While several studies have shown that pain patients in receipt of compensation have a worse response to treatment, other studies have demonstrated that specific management programmes are effective in helping such patients return to work and in preventing chronicity (Wiesel et al. 1984; Deyo et al. 1986; Fordyce et al. 1986; Mealy et al. 1986). Once a pattern of pain behaviour and disability is established, it may become entrenched as a result of factors within the environment, including the family and the social milieu (Weinstein 1968; Petroni 1969; Hyman 1971; Cole and Lejeune 1972) and resistant to change. It has been shown that the system of compensation does have an important effect on the presentation of pain complaints and their duration, and this has been recognised in the recommendation by the Committee on Pain, Disability, and Chronic Illness Behavior of the Institute of Medicine that neither ‘chronic pain alone’ nor ‘chronic pain syndrome’ be included among the conditions which “allow a presumption of disability” by the Social Security Administration (Osterweis et al. 1987). The article by Guest and Drummond in this issue examines the effects of compensation on pain severity and emotional state of patients with chronic back pain. The authors have compared a group of compensation recipients with a group who had settled their compensation claims, a study design not previously reported. The finding that there was no significant difference in the measures of pain severity when the two groups were compared is in keeping with the results of other studies. Similarly, the finding that compensation recipients showed more marked anxiety and depression has been previously reported; the importance of the study by Guest and Drummond is that they have confirmed these findings using a different methodology. Their results are also of interest in that they showed that following the settlement of claims patients continued to experience pain at a significant level of severity, again demonstrating that patients are “not cured by a verdict” (Mendelson 1982). The presence of emotional distress among patients with chronic pain in receipt of compensation is impor-
tant to recognise in clinical practice; Leavitt (IYYO)has shown that such patients with psychological disturbance were more likely to have a longer period of disability, irrespective of whether they were in receipt of compensation payments. The effects of compensation on chronic pain patients and illness behaviour is mediated by a complex interaction of not only biological, psychological and social factors but also influenced by economic factors and the legal characteristics of the particular compensation system (Dworkin et al. 1985; Jamison et al. 1988; Mendelson 1988; Tait et al. 1990). The judicial system is paying increasing attention to recent advances in the understanding of mechanisms which determine the experience of pain (Ontario Workers’ Compensation Appeals Tribunal 1987), and there is a continuing need for both descriptive and empirical studies of patients with chronic pain who are within the compensation system so as to further our knowledge of this important and complex problem.
References Balla, J.I. and Moraitis,
S., Knights in armour: a follow-up study of injuries after legal settlement, Med. J. Aust., 2 (1970) 355-361. Bartrip, P.W.J. and Burman, S.B., The Wounded Soldiers of Industry. Industrial Compensation Policy 1833-1897, Clarendon Press, Oxford, 1983. Carron, H., DeGood, D.E. and Tait, R., A comparison of low back patients in the United States and New Zealand: psychosocial and economic factors affecting severity of disability, Pain, 21 (19851 77-89. Cole. S. and Lejeune, R., Illness and the legitimation of failure, Am. Sot. Rev., 37 (1972) 347-356. Collie, J., Medico-Legal Examinations and the Workmen’s Compensation Act, 1906, Bailliere, Tindall and Cox, London, 1912. Collie, J., Malingering and Feigned Sickness, Edward Arnold, London, 1913. Collie, J., Fraud in Medico-Legal Practice, 2nd edn.. Edward Arnold, London, 1932. Deyo, R.A., Diehl, A.K. and Rosenthal, M., How many days of bed rest for acute low back pain? A randomized clinical trial, N. Engl. J. Med., 315 (1986) 1064-1070. Dworkin, R.H., Handlin, D.S., Richlin, D.M., Brand, L. and Vannucci, C., Unravelling the effects of compensation, litigation and employment on treatment response in chronic pain, Pain. 23 (1985) 49-59. Ellard, J., Psychological reactions to compensable injury, Med. J. Aust., 2 (1970) 349-355. Encel, S. and Johnston, C.E., Compensation and Rehabilitation. A Survey of Workers’ Compensation Cases Involving Back Injuries and Lump Sum Settlements, New South Wales University Press, Sydney, 1978. Fordyce, W.E., Brockway, J A., Bergman, J.A. and Spengler, D., Acute back pain: a control-group comparison of behavioral vs. traditional management methods. J. Behav. Med., 9 (19861 127140. Hohl, M., Soft-tissue injuries of the neck in automobile accidents: factors influencing prognosis, J. Bone Joint Surg., 56-A (19741 1675-1682.
123 Hyman, M.D., Disability and patients’ perceptions of preferential treatment: some preliminary findings, J. Chron. Dis., 24 (1971) 329-342. Jamison, R.N., Matt, D.A. and Parris, W.C.V., Effects of time-limited vs. unlimited compensation on pain behavior and treatment outcome in low back pain patients, J. Psychosom. Res., 32 (1988) 277-283. 16 Jones, A. B. and Llewellyn, L.J., Malingering or the Simulation of Disease, Wm. Heinemann, London, 1917. Kelly, R. and Smith, B.N., Post-traumatic syndrome: another myth discredited, J. Roy. Sot. Med., 74 (1981) 275-277. Kennedy, F., The mind of the injured worker: its effect on disability periods, Compens. Med., 1 (1946) 19-24. Larson, A., The nature and origin of workmen’s compensation, Cornell Law Quart., 37 (1952) 206-234. Leavitt, F., The role of psychological disturbance in extending disability time among compensable back injured industrial workers, J. Psychosom. Res., 34 (1990) 447-453. McKendrick, A., Malingering and Its Detection Under the Workmen’s Compensation and Other Acts, Livingstone, Edinburgh, 1912. Mealy, K., Brennan, H. and Fenelon, G.C.C., Early mobilisation of acute whiplash injuries, Br. Med. J., 292 (1986) 656-657. Melzack, R., Katz, J. and Jeans, M.E., The role of compensation in chronic pain: analysis using a new method of scoring the McGill Pain Questionnaire, Pain, 23 (1985) 101-112. Mendelson, G., Persistent work disability following settlement of compensation claims, Law Inst. J., 55 (1981) 342-345. Mendelson, G., Not ‘cured by a verdict’: effect of legal settlement on compensation claimants, Med. J. Aust., 2 (1982) 132-134.
Mendelson, G., Chronic pain and compensation: a review, J. Pain Sympt. Manag., 1 (1986) 135-144. Mendelson, G., Psychiatric Aspects of Personal Injury Claims, Charles C. Thomas, Springfield, 1988. Miller, H., Accident neurosis, Br. Med. J., l(1961) 919-925; 992-998. Ontario Workers’ Compensation Appeals Tribunal, Decision no. 91.5, Res. Publ. Dept., WCAT, Toronto, 1987. Osterweis, M., Kleinman, A. and Mechanic, D. (Eds.1, Pain and Disability. Clinical, Behavioral, and Public Policy Perspectives, National Academy Press, Washington, D.C., 1987. Petroni, F., Significant others and illness behaviour: a much neglected sick role contingency, Sot. Quart. 10 (1969) 32-41. Priestley v. Fowler, 3 (1837) M.&W. 1030-1033. Slot, G., Pain in its medico-legal aspect, Trans. Med. Legal Sot., 22 (1927) 74-91. Sprehe, D.J., Workers’ compensation: a psychiatric follow-up study, Int. J. Law Psychiat., 7 (1984) 165-178. Tait, R.C., Chibnall, J.T. and Richardson, W.D., Litigation and employment status: effects on patients with chronic pain, Pain, 43 (1990) 37-46. Tarsh, M.J. and Royston, C., A follow-up study of accident neurosis, Br. J. Psychiat., 146 (1985) 18-25. Weinstein, M.R., The illness process: psychosocial hazards of disability programs, JAMA, 204 (1968) 117-123. Wiesel, S.W., Feffer, H. L. and Rothman, R.H., Industrial low-back pain: a prospective evaluation of a standardized diagnostic and treatment protocol, Spine, 9 (1984) 199-203.
121 Publishers
B.V. All rights reserved
0304-3959/92/$05.00
PAIN 01894
Guest Editorial Compensation
and chronic pain
George Mendelson Department of Psychological Medicine, Monash University, Clayton, Victoria 3168 (Australia) and Pain Management Centre, Caulfield General Medical Centre, Caulfield, Victoria 3162 (Australia) (Received
1 February
The first reported case of an employee seeking compensation from an employer for a work injury reached the High Court in England during 1837. The plaintiff employee had been travelling in the employer’s van which “broke down, and the plaintiff was thrown with violence to the ground, and his thigh was thereby fractured.” The lower court entered a verdict of f 100 in favour of the plaintiff. On appeal, however, the judgment was reversed, Lord Abinger C.B. noting that “if the master be liable to the servant in this action, the principle of that liability will be found to carry us to an alarming extent” (Priestley v. Fowler 1837). It was not until 1897 that the Workmen’s Compensation Act introduced a statutory scheme in Great Britain which provided income support for injured workers on a no fuuft basis (Bartrip and Burman 1983). Similar legislation was subsequently passed during the early part of this century in the United States (Larson 19.52). In discussing the effects of the introduction of workers’ compensation laws, Collie stated that “fraud is a product of the age, of the Workmen’s Compensation Act, of Trade Unions and allied Clubs. There are no malingerers in countries where there is no Workmen’s Compensation Act” (Collie 1932, p. 1). Several publications appeared during the early decades of this century on the subject of the detection of malingering among compensation claimants (Collie 1912, 1913, 1932; McKendrick 1912; Jones and Llewellyn 1917). One of the areas of concern discussed by the authors was pain (Slot 1927). Thus, according to Collie, “In dealing with a back injury, it is necessary to make up one’s mind on two points. First, is the pain real, psychic or assumed; second, is it due to disease or accident? In the vast majority of cases, alleged pain in the back is mental and not physical. The idea of a tender spot or of pain takes possession of the patient,
Correspondence to: Dr. George Melbourne, Victoria 3004, Australia.
Mendelson,
33 Queens
Road,
1991, accepted
9 April 1991)
and has the same effect and requires the same treatment as obsessions in regard to other parts of the body” (Collie 1932, p. 221). Until 1970 the predominant theme in the professional literature dealing with the medico-legal aspects of compensation was concern about the putative clinical entities of ‘accident neurosis’ (Miller 1961) or ‘compensation neurosis.’ In an oft-quoted aphorism, Foster Kennedy defined ‘compensation neurosis’ as “a state of mind, born out of fear, kept alive by avarice, stimulated by lawyers, and cured by a verdict” (Kennedy 1946). In 1970 two articles published in Australia drew attention to the adverse emotional effects of the compensation process (Balla and Moraitis 1970; Ellard 1970) and reported that, contrary to the viewpoint forcefully espoused by Henry Miller (19611, patients do not all improve and return to work after the finalization of the compensation claim. The finding that patients continue to experience symptoms and require treatment following the finalization of litigation has now been supported by other studies (Hohl 1974; Enccl and Johnston 1978; Kelly and Smith 1981; Mendelson 1981; Sprehe 1984; Tarsh and Royston 1985); significantly, there have been no published reports to confirm Miller’s findings. Miller’s results may have been due to the biased nature of his sample, which consisted of 50 litigants selected out of several thousand on the basis of their ‘gross neurotic symptoms’ noted during examination. Patients in receipt of compensation benefits or involved in litigation form a significant proportion of those attending pain clinics; Carron et al. (198.5) reported that 49% of patients with chronic low back pain attending a pain clinic in the United States were in receipt of pain-related benefits. Studies which have examined the relationship between chronic pain and compensation have used three methodological approaches: (1) comparison of the pain characteristics of patients who are receiving compensation with those of patients who are not involved in
122
litigation or compensation; (2) comparison of the treatment response of patients in receipt of compensation with those who do not receive pain-contingent benefits; and (3) examination of the duration and characteristics of chronic pain patients under different systems of compensation (Melzack et al. 1985; Mendelson 1986). Comparisons of the pain described by litigants or compensation beneficiaries with that described by non-litigants do not support the oft-repeated assertion that patients claiming compensation describe their pain experience as more severe than a comparable group not in receipt of pain-related benefits. While several studies have shown that pain patients in receipt of compensation have a worse response to treatment, other studies have demonstrated that specific management programmes are effective in helping such patients return to work and in preventing chronicity (Wiesel et al. 1984; Deyo et al. 1986; Fordyce et al. 1986; Mealy et al. 1986). Once a pattern of pain behaviour and disability is established, it may become entrenched as a result of factors within the environment, including the family and the social milieu (Weinstein 1968; Petroni 1969; Hyman 1971; Cole and Lejeune 1972) and resistant to change. It has been shown that the system of compensation does have an important effect on the presentation of pain complaints and their duration, and this has been recognised in the recommendation by the Committee on Pain, Disability, and Chronic Illness Behavior of the Institute of Medicine that neither ‘chronic pain alone’ nor ‘chronic pain syndrome’ be included among the conditions which “allow a presumption of disability” by the Social Security Administration (Osterweis et al. 1987). The article by Guest and Drummond in this issue examines the effects of compensation on pain severity and emotional state of patients with chronic back pain. The authors have compared a group of compensation recipients with a group who had settled their compensation claims, a study design not previously reported. The finding that there was no significant difference in the measures of pain severity when the two groups were compared is in keeping with the results of other studies. Similarly, the finding that compensation recipients showed more marked anxiety and depression has been previously reported; the importance of the study by Guest and Drummond is that they have confirmed these findings using a different methodology. Their results are also of interest in that they showed that following the settlement of claims patients continued to experience pain at a significant level of severity, again demonstrating that patients are “not cured by a verdict” (Mendelson 1982). The presence of emotional distress among patients with chronic pain in receipt of compensation is impor-
tant to recognise in clinical practice; Leavitt (IYYO)has shown that such patients with psychological disturbance were more likely to have a longer period of disability, irrespective of whether they were in receipt of compensation payments. The effects of compensation on chronic pain patients and illness behaviour is mediated by a complex interaction of not only biological, psychological and social factors but also influenced by economic factors and the legal characteristics of the particular compensation system (Dworkin et al. 1985; Jamison et al. 1988; Mendelson 1988; Tait et al. 1990). The judicial system is paying increasing attention to recent advances in the understanding of mechanisms which determine the experience of pain (Ontario Workers’ Compensation Appeals Tribunal 1987), and there is a continuing need for both descriptive and empirical studies of patients with chronic pain who are within the compensation system so as to further our knowledge of this important and complex problem.
References Balla, J.I. and Moraitis,
S., Knights in armour: a follow-up study of injuries after legal settlement, Med. J. Aust., 2 (1970) 355-361. Bartrip, P.W.J. and Burman, S.B., The Wounded Soldiers of Industry. Industrial Compensation Policy 1833-1897, Clarendon Press, Oxford, 1983. Carron, H., DeGood, D.E. and Tait, R., A comparison of low back patients in the United States and New Zealand: psychosocial and economic factors affecting severity of disability, Pain, 21 (19851 77-89. Cole. S. and Lejeune, R., Illness and the legitimation of failure, Am. Sot. Rev., 37 (1972) 347-356. Collie, J., Medico-Legal Examinations and the Workmen’s Compensation Act, 1906, Bailliere, Tindall and Cox, London, 1912. Collie, J., Malingering and Feigned Sickness, Edward Arnold, London, 1913. Collie, J., Fraud in Medico-Legal Practice, 2nd edn.. Edward Arnold, London, 1932. Deyo, R.A., Diehl, A.K. and Rosenthal, M., How many days of bed rest for acute low back pain? A randomized clinical trial, N. Engl. J. Med., 315 (1986) 1064-1070. Dworkin, R.H., Handlin, D.S., Richlin, D.M., Brand, L. and Vannucci, C., Unravelling the effects of compensation, litigation and employment on treatment response in chronic pain, Pain. 23 (1985) 49-59. Ellard, J., Psychological reactions to compensable injury, Med. J. Aust., 2 (1970) 349-355. Encel, S. and Johnston, C.E., Compensation and Rehabilitation. A Survey of Workers’ Compensation Cases Involving Back Injuries and Lump Sum Settlements, New South Wales University Press, Sydney, 1978. Fordyce, W.E., Brockway, J A., Bergman, J.A. and Spengler, D., Acute back pain: a control-group comparison of behavioral vs. traditional management methods. J. Behav. Med., 9 (19861 127140. Hohl, M., Soft-tissue injuries of the neck in automobile accidents: factors influencing prognosis, J. Bone Joint Surg., 56-A (19741 1675-1682.
123 Hyman, M.D., Disability and patients’ perceptions of preferential treatment: some preliminary findings, J. Chron. Dis., 24 (1971) 329-342. Jamison, R.N., Matt, D.A. and Parris, W.C.V., Effects of time-limited vs. unlimited compensation on pain behavior and treatment outcome in low back pain patients, J. Psychosom. Res., 32 (1988) 277-283. 16 Jones, A. B. and Llewellyn, L.J., Malingering or the Simulation of Disease, Wm. Heinemann, London, 1917. Kelly, R. and Smith, B.N., Post-traumatic syndrome: another myth discredited, J. Roy. Sot. Med., 74 (1981) 275-277. Kennedy, F., The mind of the injured worker: its effect on disability periods, Compens. Med., 1 (1946) 19-24. Larson, A., The nature and origin of workmen’s compensation, Cornell Law Quart., 37 (1952) 206-234. Leavitt, F., The role of psychological disturbance in extending disability time among compensable back injured industrial workers, J. Psychosom. Res., 34 (1990) 447-453. McKendrick, A., Malingering and Its Detection Under the Workmen’s Compensation and Other Acts, Livingstone, Edinburgh, 1912. Mealy, K., Brennan, H. and Fenelon, G.C.C., Early mobilisation of acute whiplash injuries, Br. Med. J., 292 (1986) 656-657. Melzack, R., Katz, J. and Jeans, M.E., The role of compensation in chronic pain: analysis using a new method of scoring the McGill Pain Questionnaire, Pain, 23 (1985) 101-112. Mendelson, G., Persistent work disability following settlement of compensation claims, Law Inst. J., 55 (1981) 342-345. Mendelson, G., Not ‘cured by a verdict’: effect of legal settlement on compensation claimants, Med. J. Aust., 2 (1982) 132-134.
Mendelson, G., Chronic pain and compensation: a review, J. Pain Sympt. Manag., 1 (1986) 135-144. Mendelson, G., Psychiatric Aspects of Personal Injury Claims, Charles C. Thomas, Springfield, 1988. Miller, H., Accident neurosis, Br. Med. J., l(1961) 919-925; 992-998. Ontario Workers’ Compensation Appeals Tribunal, Decision no. 91.5, Res. Publ. Dept., WCAT, Toronto, 1987. Osterweis, M., Kleinman, A. and Mechanic, D. (Eds.1, Pain and Disability. Clinical, Behavioral, and Public Policy Perspectives, National Academy Press, Washington, D.C., 1987. Petroni, F., Significant others and illness behaviour: a much neglected sick role contingency, Sot. Quart. 10 (1969) 32-41. Priestley v. Fowler, 3 (1837) M.&W. 1030-1033. Slot, G., Pain in its medico-legal aspect, Trans. Med. Legal Sot., 22 (1927) 74-91. Sprehe, D.J., Workers’ compensation: a psychiatric follow-up study, Int. J. Law Psychiat., 7 (1984) 165-178. Tait, R.C., Chibnall, J.T. and Richardson, W.D., Litigation and employment status: effects on patients with chronic pain, Pain, 43 (1990) 37-46. Tarsh, M.J. and Royston, C., A follow-up study of accident neurosis, Br. J. Psychiat., 146 (1985) 18-25. Weinstein, M.R., The illness process: psychosocial hazards of disability programs, JAMA, 204 (1968) 117-123. Wiesel, S.W., Feffer, H. L. and Rothman, R.H., Industrial low-back pain: a prospective evaluation of a standardized diagnostic and treatment protocol, Spine, 9 (1984) 199-203.
