Chronic Pain

Often, after work injuries, people are left with chronic pain.  In some states, the workers’ compensation case ends once the claimant has reached maximum medical improvement, (or MMI).  In layman’s terms, MMI means that you have gotten as good as you are going to get. If you have chronic pain, you may have already reached MMI but continue to need more treatment.  In those states where the workers’ compensation case ends at MMI, it can be an expensive prospect for injured workers’ needing continuing treatment. Thankfully, Virginia is not one of those states.   In Virginia, the medical treatment is covered as long as the treatment is related to the work injury.

Most people with chronic pain are treated by doctors who specialize in pain management.  For your information, pain management is actually a subspecialty of medicine that falls under various specialties.  According to the American Board of Medical Specialties, your pain management doctor can be a family doctor, an emergency room doctor, a physiatrist, an anesthesiologist, a neurologist or a radiologist.

The subspecialty means that, in addition to the training the doctor received in their actual specialty, the doctor has additional training in the evaluation, diagnosis, and treatment of all different types of pain.

The types of treatment used for chronic pain can also vary.  Chronic pain can be treated with medication.  The medications can then be over the counter, which means purchased without a prescription, or available only with a prescription.  The medications can be administered orally and/or topical. Oral medications are medicines that are swallowed, such as pills or syrups.  Topical medications are medicines applied to the skin, such as ointments, creams, or patches. Sometimes the topical medications are placed directly on the painful area, but not always.  For example, fentanyl patches are sometimes placed at a location very different from the painful area.

Pain management also does not necessarily always mean medication.  There are other methods of pain relief. The doctor can prescribe a Transcutaneous Electro-Nerve Stimulator, or TENS unit.  A TENS unit is a device that uses pads (or electrodes) placed on your skin and attach to a device that will provide a very mild electrical current to the pad to stimulate the painful area.  According to the website WebMD, one of the theories as to how this works is that “stimulating nerves closes a ‘gate’ mechanism in the spinal cord, and that can help eliminate the sensation of pain.”  Another theory is that stimulating the nerves helps the body produce endorphins or natural pain killers.

Doctors can also prescribe acupuncture.  Acupuncture is a traditional Chinese treatment used for pain in which thin needles are placed at specific points in the body.  Scientists say the treatment can stimulate your body’s natural pain killers and may boost blood flow and change brain activity.

There are also a variety of injections that doctors can try.  I have included a list of some that I have seen in medical records.

Peripheral Joint Injections

Your peripheral joint is any joint that is not your spine, such as a shoulder, a knee, an elbow, etc.  In a peripheral joint injection, the doctor inserts a needle directly into the problem joint to inject the medication.

Trigger Point Injections

A trigger point is a knot of muscle that forms when the muscle does not relax.  These can sometimes be felt under the skin. In a trigger point injection, the doctor inserts a needle filled with anesthetic, saline, or a corticosteroid, into the trigger point to make the muscle relax.

Epidural Steroid Injections

Epidural steroid injection is an injection performed in the back or neck in an attempt to place some anti-inflammatory steroid with or without a local anesthetic into the epidural space close to the inflamed area that is causing the pain. On the Mayo Clinic website, Dr. Richard Rho explained, “Epidural steroid injections contain drugs that mimic the effects of the hormones cortisone and hydrocortisone. When injected near irritated nerves in your spine, these drugs may temporarily reduce inflammation and help relieve pain.”

Facet Joint Injections

Facet joints (also called Zygapophysial joints) are located on both sides of the back of the spine where two vertebrae meet. These joints contain cartilage between the bones and are surrounded by a sac filled with fluid. Facet joint injections are injections of a medication into the joint while you are awake, (but under a local anesthetic) and the doctor will issue an x-ray guidance which is called fluoroscopy.

Medial Branch Blocks

Medial branch nerves supply the facet joints.   A medial branch block is similar to a facet joint injection, except the medicine is injected onto the nerve rather than the joint.

Radiofrequency Ablations

Radiofrequency ablation (RFA), also called radiofrequency neurotomy, is when a needle is inserted in the nerves, then an active electrode is inserted through the needle which sends a small amount of electrical current to the target nerve.  This creates a heat lesion. This resulting lesion prevents the nerve from sending pain signals to the brain. Once the RFA lesion is created, the pain-transmitting ability of the nerve fibers is lost and pain signals from the source do not reach the brain. The effects of RFA can last for months, or even years.  The nerve will regenerate, but the pain may not return.

Sympathetic Block

The sympathetic nervous system refers to the nerves that spread out from your spine to your body to help control several body functions that you have no control over. A Sympathetic block is used to treat pain thought to come from these nerves, such as complex regional pain syndrome or peripheral neuropathy. The way these injections are performed is similar to the facet joint injections or medial branch blocks.

Spinal Cord Stimulation

According to Dr. Brian Anderson and Dr. Kevin Cockroft, who wrote an explanation of spinal cord stimulation for the American Association of Neurological Surgeons, spinal cord stimulation is a relatively new technology that can help manage chronic pain.  A spinal cord stimulator is similar to a TENS unit, in that it is a device consisting of a wire or “electrode” that is connected to a battery controlled control unit called a “generator.”  The electrode releases a very mild electrical pulse that the injured worker cannot feel that masks the pain signal to prevent the signal from reaching the brain. The difference is that, while the electrode of a TENS unit is placed on the skin and the unit is held in your hand, in a spinal cord stimulator, the electrode is surgically placed in a space over the spinal cord and the unit is placed surgically at the waist.

Because of the relative permanence of a spinal cord stimulator, there are several stages to getting one.  First, doctors usually order psychiatric or psychological testing before starting the procedure to ensure that the injured worker understands what will happen.  Then, once the psychiatric approval is given, the pain management doctor will perform a trial. The trial is when one or two wires are surgically placed into the outside the spinal cord, but the wires are connected to a generator that remains outside the body.  This is usually kept in place for about a week and can be adjusted if necessary, to allow the doctor and the injured worker to determine how well the device will control the pain.

According to Drs. Anderson and Cockroft, trials are considered successful if they can remove half of a patient’s pain.  If the trial is successful, the injured worker can then have the spinal cord stimulator permanently placed. This means that the electrode is placed on the back in the space behind the spinal cord as it is with a trial, the wire is run under the skin to the generator, which is placed under the skin at waist level. At this point, adjustments may be made as needed with a remote control.  The generator can have a rechargeable battery that will need to be recharged every few days and replaced roughly around every 10-15 years. The generator can also have a non-rechargeable battery, in which case the batter would need to be replaced around every 3-5 years.

Speak with an Experienced Virginia Workers’ Compensation Attorney

Not all treatment recommended by your doctor will be immediately approved by the workers’ compensation insurance company.   If your doctor has recommended a treatment that is not being approved by your workers’ compensation carrier, you should contact an experienced  Virginia Workers Compensation Attorney with experience handling workers’ compensation matters to assist you in getting this treatment approved.  Call us at (804) 755-7755 or contact us through our online form.