Patients as Experts: The Evidence for Managing Musculoskeletal Disorders and Pain

Brian Gifford, Ph.D.
Treatment for arm pain

The workforce burden of musculoskeletal disorders and pain

In 2018, one in four working age Americans sought care for musculoskeletal disorders (MSK) such as back pain and arthritis. MSK disorders account for one in five short-term disability (STD) claims each year, with each new incident resulting in an average of $9,000 in wage replacement costs (including costs for the 8% of MSK claims that enter the long-term disability system), for a total annual cost of about $6.3B to disability insurers and self-insured employers. Considering that most disability policies pay only about 62% of an employee’s wages and the average MSK leave lasts about two and a half months, an employee who requires time off the job to recover from an MSK condition or treatment stands to lose about 8% of their annual income.

The risks of one of the most common treatments for MSK and painful conditions—prescription opioids and other pain-relieving medicines—have become abundantly clear in the last few years. Each year in 2015 through 2017, one in three U.S. employees had a prescription for pain medicines, and approximately one in 20 exhibited patterns of prescription abuse or dependence. This not only poses a risk to employees’ health, but impacts the workplace as well. For example, problematic use of prescription pain relievers is associated with 43% more sick days absences than non-problematic use, and 233% more sick day absences when compared to employees with no prescription pain relievers.

The science and practice of patient-centered MSK care

The Center for Workplace Health and Performance (CWHP), with co-authors from the National Association of Worksite Health Centers (NAWHC) and the Integrated Benefits Institute (IBI), and with sponsorship from the Patient-Centered Outcomes Research Institute (PCORI), has released a report with insights employers can use to help their employees manage MSK disorders and other pain conditions—for the benefit of their own quality of life, and for their ability to contribute fully on the job. This collaboration of non-profit organizations drew guidance from both the science and practice of MSK and pain care: a review of 15 PCORI-sponsored scientific studies on MSK and pain, and a CWHP/NAWHC virtual symposium focused on best practices from the experiences of worksite health experts. Taken together, the guidance suggests that both patients and their employers can benefit from patient-centered approaches that incorporate the patient’s perspective, goals, and preferences into the design and delivery of their own care.

Pain studies focus on a variety of therapies and patient outcomes

Three themes emerged from the review of studies. First, studies that focused on patients with MSK and other painful conditions went beyond pharmaceutical interventions. They also examined approaches such as physical therapy, education, and targeting mental health/psychosocial factors. Second, pain management was a less common focus than patients’ quality of life and their ability to cope with and function through pain. Third, the studies emphasized the therapeutic value of incorporating patients’ perspectives into the care delivery process. For example, patients were better able to achieve their own self-care and mobility goals when these were explicitly shared with providers prior to the commencement of treatment, and when patients were incorporated as part of a care team with other medical specialists.

The review also identified several approaches to effective care, depending on the nature of the outcome. For example, a clinical intervention such as opioid monitoring and dose-lowering could help reduce overdoses (a care delivery outcome), while educational interventions such as pain coping skills and primary care group therapy focused on patient activation could impact care delivery, patient engagement, functional ability, and patient well-being. Therapeutic approaches (e.g., exercise training, physical therapy) and interventions applied to providers (e.g., collaborative care models) also showed effectiveness.

Worksite health experts emphasize personalized, collaborative care for pain

A symposium on best practices in treating MSK and pain patients in worksite health centers included presentations from practitioners representing employers such as Textron and Cisco, third-party providers for clients such as LinkedIn and Facebook, and the non-profit Foundation for Chiropractic Progress. What came through clearly from the sessions on preventing pain and MSK conditions, managing and treating pain, and integrating providers into collaborative practice was that a personalized care approach may give employers the best opportunity to preserve and restore employees’ productivity. For example, it was noted that employees of different generations not only have different health needs, but also different preferences for their engagement with onsite care. The value of training to help employees understand the etiology of injury and illness was described, but so was engaging with employees to align accommodations and treatments with their capabilities, needs and preferences. Multi-phased and interdisciplinary care approaches similarly emphasized the collaborative role of the patient, alongside physicians, chiropractors, physical and massage therapists, and mental health professionals.

Benefits professionals as part of a patient-centered care team

Taken together, evidence from both science and practice reinforce the clinical and business value of a patient-centered, collaborative approach to MSK and pain care. While the symposium focused on best practices in worksite health settings, every employer stands to benefit when access to high quality care promotes employees’ functional ability, engagement, and well-being. Benefits professionals—both in corporate HR roles and serving clients as external advisors or benefits administrators—can help employers ensure that the design of their health benefits encourages patient engagement and prioritizes collaborative approaches to care management, injury rehabilitation, and return-to-work (RTW) from disability leaves. This could encompass guidance such as helping employers identify “Centers of Excellence” that practice collaborative approaches or assessing unintended consequences of plan design changes that disrupt established provider networks. Specialists with expertise in managing disability claimants’ RTW—which often includes coordinating the skills of occupational nurses, vocational rehabilitation experts and HR specialists and identifying at-risk employees—may be especially well-positioned to act in the role of patient advocates, facilitating case management to ensure that employees remain engaged members of their care team.