Workers' comp payers are spending a bundle on imaging tests and procedures to deal with injured workers' low back pain. But the situation isn't getting any better. In fact, experts say that despite much more aggressive treatment – and a 10-fold increase in costs! – outcomes have not improved at all, and disability rates among working age Americans are higher than they have ever been.

What's the problem? Aren't MRIs, CT scans and the like supposed to identify the problem and lead clinicians to treatments that get injured workers better and back to work? Apparently, not necessarily.

Two physicians and a workers' comp risk control strategist put together a white paper for insurance brokerage Lockton. They concluded that a lot of physicians, including many in workers' comp, rely waaaay too heavily on imaging tests to find the cause of back pain and perform major procedures on people who may have only needed some good physical therapy; or more time to recover; or some relief from life stresses – maybe just a few squats and a good night's sleep. A slight oversimplification, perhaps; but the idea is that a lot of people who end up with spine fusions and other surgeries are probably suffering from issues that a scalpel can’t fix – and might just make worse.

To better understand this whole issue, I went to Dr. Jennifer Christian – long-time disability expert, president of Webility Corporation and one of the three authors. (The other two were Keith Rosenblum of Lockton, and Dr. David B. Ross, a Johns Hopkins/Harvard-trained neurologist who's president of a company looking at new technologies to help determine the true source of a person's pain.)

Dr. Christian was kind enough to give me a crash course on pain – for the layman. The way she explains it, pain is basically all in your head – an experience in the brain. No brain; no pain.

The pain "experience" in the brain is comprised of several elements.  

The first is what you might expect to be the source of the pain – a specific place in the body. You step on a nail – it hurts. Christian calls it the "sharp owie."

This first layer of pain experience is called nociception. Basically, a nerve cell responds to certain kinds of tissue events by sending alert signals through the spinal cord to the brain. It's the brain’s reaction to those signals – not the actual stepping on the nail – that causes the experience of pain.

The next layer is the part of the brain that interprets the meaning of signals. An essential function of the brain is deciding what's important and what's not; what you should pay attention to and what you can ignore. Dr. Christian says these are “gates” in the brain. 

If you just whacked your arm on something, your brain interprets the incoming signals as potentially dangerous and decides to pay full attention, alerting other parts of the brain to pay attention in case protective action is necessary. But your brain can downplay or even completely ignore signals of the exact same intensity, depending on its understanding of the situation. For example, it won't worry about continuing signals from sore muscles you overused while playing tennis a few days ago.

The third layer of the pain experience is a bit more dicey and less well-studied – but important for people with chronic pain. It involves a primitive automatic and unconscious ability of the brain to learn and remember. Think conditioned reflexes: Pavlov’s dog. If something caused a lot of pain in the past, the brain may recognize that same situation and recreate a "hurt sensation" – even though there's no nocioceptive signal coming from the body. Some people’s brains seem to get stuck in a groove, continually producing a pain experience without any incoming information. This vicious cycle can be set up by chronic opioid use; the brain is rewarded for creating pain experiences by getting more opioids.    

The final layer is "pain" caused by emotions, thoughts and memories. The body is another channel through which human emotions are communicated. You're nervous, your stomach hurts; you’re embarrassed, you blush.   

The pain experience is due to all these layers of brain processing. The trick is to figure out how much of a contribution each of the various layers has made. Then you can address the cause and relieve the pain. 

Sometimes it’s simply a "sharp owie" and may require surgery, or time to heal. Sometimes it's just a sore muscle and requires PT, exercise and reconditioning. Sometimes the brain is magnifying a modest nociceptive signal because of worry or fear due to health illiteracy, false beliefs, external stressors or lack of trust. Or, there may be pent-up emotions from current or past experiences that manifest as physical sensations without tissue injury; or magnifying a recent injurious event. In other words, the mind, brain and body work together to create the experience of pain – all the time, in every case.

To illustrate this, Dr. Christian directed me to the website of Dr. David Hanscom, a spine fusion surgeon in Seattle. Initially enthusiastic about the procedure in the mid-1980s, he started to notice that many people didn't do well afterwards. So he postponed operating on people with obvious mental health complications until they resolved their depression, anxiety and life stresses. He developed a conservative care regimen that focuses on getting more sleep, exercise, body awareness, improving mood, dealing with life predicaments, focusing on the future, etc. He found many of these patients decided they didn’t need surgery. Now he's expanded the program to include all surgical candidates – even those with obvious structural problems and no known psychosocial risk factors except chronic pain. He says that a natural response to chronic pain is anger and anxiety, which heightens the resting state of the nervous system. His new theory is that calming the nervous system might be enough to change the way the brain’s “gates” are working and diminish the pain experience.   

So what does this mean for workers' comp payers? Well, you're very likely wasting lots of money on diagnostics and treatments that are making little if any difference in the injured worker's recovery. But you don't necessarily have to.

In addition to programs such as that run by Dr. Hanscom, there are emerging innovative tests being applied to patients with chronic pain.

One of the study authors – Dr. David Ross – is president of a company that has created a testing methodology that, along with behavioral medicine assessment, can definitively identify which source or sources is creating a worker's pain. The company says the tests have enabled more workers to be referred for physical therapy, cognitive behavioral therapy or other treatments instead of surgery – and opioids.