SELECT COMMITTEE ON
THE WORKERS' COMPENSATION ACT
Mr. Michael Baker
MR. CHAIRMAN: Ladies and gentlemen, I would like to call the meeting to order. I would like to particularly thank Dr. Jock Murray who is with us here this afternoon. Perhaps for the benefit of Dr. Murray, I would ask everyone to introduce themselves. I will start with the committee members and Mr. [Hyland] Fraser.
[The committee members introduced themselves.]
MR. CHAIRMAN: Then we will start with the staff at the table, here.
[The staff introduced themselves.]
MR. CHAIRMAN: Then I will start with our good panel of consultants over there.
[The committee consultants introduced themselves.]
MR. CHAIRMAN: Finally, for the benefit of this one, I think perhaps we will ask our workers' compensation folks to introduce themselves.
[The workers' compensation staff introduced themselves.]
MR. CHAIRMAN: Thank you very much. The purpose of our meeting here this afternoon, of course, is to hear from Dr. Murray about one subject which you have heard, obviously, a great deal about, which is chronic pain and the method of treating chronic pain. I know that some of the members have a question about diagnosing chronic pain and those kinds of things. So I guess I will turn the meeting over to Dr. Murray now to do his presentation as he thinks best. Go ahead.
DR. JOCK MURRAY: As you have already learned, chronic pain is a major issue. It is not just a major issue for Nova Scotia, it is major clinical issue and it is a major social issue in most countries. One of the difficulties, initially, is getting a grip on the concept of what chronic pain is all about. A number of years ago, the Workers' Compensation Board of Nova Scotia asked if I would summarize the current literature on chronic pain to give them some idea of what this was about and what the current state of thinking was, medically, about the issue of chronic pain. So there is a very long report that I did for workers' compensation that dealt with the literature and the research on this. What I will do is summarize some of the basic ideas.
The first is a point about what chronic pain isn't because this issue is, I think, one of the most vexing and confusing things for people about chronic pain. If I used the blackboard, as university teachers are used to doing, I can do that? This is the issue everyone understands about pain and that is, if you drop a can of peaches on your foot, you get pain and what people understand is that the nerve impulses go up to the brain on the opposite side and it is perceived by the person as pain. Everybody understands that. That is acute pain. The reason I point this out is that the difficulty in understanding chronic pain is that everyone tends to think about acute pain. So they see it in this kind of a term and, in fact, when discussions about chronic pain occur, most people want to return to this concept.
Now this is a physiological, protective response. You drop something on your foot. You do a number of things that are protective: withdraw the foot, you may limp on the foot so that the tissues that have been damaged don't get damaged further, and you do things that are protective. This is localized and it is protective and it is related to local tissue damage. The tissue damage can be a cut or a burn or a bang or whatever and that makes sense and everybody understands that because everybody has experienced it. That is acute pain. The difficulty is understanding chronic pain.
One of things that people can't understand is that things can modify this. What most people would understand, for instance, is that if something painful happened, what your psychological state was can alter your response. How you perceive it may alter it. That is why football players will often continue to play with a broken limb and soldiers will continue to go forward and will tell you that they didn't even feel the pain of the shrapnel or the bullet wound until later. The mind can, in fact, have a great control over this and everyone recognizes that. So a minor gastric upset can make the child feel that they are so sick that they can't go to school. It is more about the psychology of the particular event.
We also know that some people are very stoic. They will put up with anything and they will have a painful condition and they will smile and they will carry on. You ask them how they are and they say they are fine, they do their work and they carry on. Other people seem to be disabled by minor events and they have difficulty through their life dealing with a lot of the normal stresses of day-to-day life. Everybody understands that until we get to talking about it in an individual person and nobody wants to talk about that issue. They don't
want to talk about other things than this. They want to talk about something that is causing the pain and therefore it has to be removed because there is something locally causing the problem. So this acute pain and what we almost always find is that with chronic pain, people are thinking about this. So we mentioned that it is a local thing related to tissue damage and it is protective.
But what about chronic pain? What we will find here is that with chronic pain - I will put that up so everybody can read it - unlike acute pain, chronic pain is not protective. It doesn't respond to things that acute pain responds to. If you have burned your foot or you have broken a bone, we can give you narcotics and analgesics and acute pain responds to it. Chronic pain does not respond to these things. You often cannot find a definable, local cause. That is why people keep getting X-rayed and investigated for chronic pain and often there is no explainable, pathological cause. There are, in chronic pain situations, complex physical, emotional, psychological and social factors. The question is usually whether people want to talk about those particular issues, even though intellectually everybody knows that those things are involved and how well perceived pain is. Everyone knows about people who put up with pain and carry on and people who cannot manage to do that. So these things are recognized by people.
Then there is the question of how one defines chronic pain. The way it is defined is somewhat arbitrary because at what point does acute pain, if it persists, become chronic? If you have an injury at this point and it is expected that that would be over and healed at this point, at what point do you say the person, who is continuing to have pain long past the point of healing, when do you define them as having chronic pain? Arbitrarily, it is said to be six months following the time it would have been expected to have disappeared. That is somewhat arbitrary but it is the point that has been accepted as a definition.
If there is no injury and you develop pain, there is no injury associated, but you just develop pain, it then becomes chronic pain that has persisted for six months. So those are the arbitrary definitions of what chronic pain is. There is, I think in many people, this concept of developing an injury, there is a transition phase and that is when the person is adapting to their pain and their other phenomena. Then there is a learned phase in which they continue to carry out that activity, whether or not pain is still there. The best example of that is the person who has had low back pain, later on may walk around like this, and sit down gently, but if you ask them, they may not have any pain. They are avoiding something that they know might occur. They have learned certain things. They now carry out a series of actions, whether they have pain or not. They have learned what to do, to move slowly, not to bend; even though they may act as if they have pain, they are doing it to avoid what might be painful. That is a learned phenomenon. That is the current definition that is used everywhere.
In many of these issues, by the way, there is what is called the International Committee for the Study of Pain. That committee is acknowledged internationally and they are the ones who set down definitions for what these various syndromes are or what the time
is, what the name should be, and that can be referred to because they do publish reports on the nature of chronic pain. Yes, you have a question?
MR. HYLAND FRASER: You showed on the diagram there, if something hits your foot, about the pain sensor in your brain. In chronic pain, is it the same sensor in your brain, or is it somewhere else, where it is being relayed to, or is it all over the place, or what?
DR. MURRAY: That is a very interesting question. What often happens in chronic pain is that this is now gone, but if a year later the person is still complaining of pain, what usually has happened is that there is a reverberating reflex back and forth through their nervous system, and it involves broader areas of the brain, and there is now a reflex concept that just keeps going. The brain has what is called plasticity, so that initially when something happens, the brain and the brain connections can change so that they now respond differently. It is believed that in chronic pain, there is now a reverberating circuitry that is abnormal.
MR. HYLAND FRASER: What would happen now if they dropped something on the other toe, does it ever straighten out after a second injury, an acute injury?
DR. MURRAY: No. It is not related, no. There are lots of things that can suppress this, because once you have this ongoing pain phenomenon, there are things that can aggravate it and there are things that can improve it. One of the things that you can do if you have this, that will improve it, is to mentally suppress it. Just say, I am going to ignore it, I am going to carry on anyway, and they do, and you can suppress this.
Other things can suppress it. If this person is complaining about the pain and something else dramatic is happening in the world around them, they will forget and will not feel the pain until they return mentally to thinking about it. If they are driving around as I was just recently trying to find a parking spot, the stress will increase the pain. Then they not only will be upset about getting parking, they will complain that their pain is worse. Everyone, I think, recognizes that when you are under stress, if you have a painful condition, the stress increases the pain.
There are a lot of factors that can modify the pain. A lot of them are related to things that occur in a person's life. We all can experience that. There are a number of principles that one can look at. One is that chronic pain is multi-causal in nature. If I am complaining about my back, I don't want to talk about the fact that it is multi-causal, I just want to tell you it is my back. I don't want to talk to you about the fact that some of it may have to do with my emotional state, how stressed I am, what my home life is like, what my job is like, whether I get satisfaction from my job, whether I can communicate with the people around me, or whatever. Even though those things will modify my pain and may continue it, I want to talk about my back.
The next point is not only personal and subjective, and everybody is aware of that. You can see people who have terrible, painful conditions who don't appear to pay much attention to it and carry on, and others who don't manage that. Then the question is, what is the difference? I mention again that acute and chronic pain are different, and they have to be seen as different, because the big confusion is always thinking of chronic pain as acute pain that has gone on for a long time. People think about it as if it were acute pain and they try to treat it with things that work in acute pain but which do not work in chronic pain.
The other thing that has been found over and over again, but is difficult to convince people of, is that when an injury or chronic pain is developed and there is no pathological change that can be found, and the person probably can't be damaged by continuing, the person does better and the problem does better if they get back to normal function as fast as they can, despite the pain. That is a principle that is difficult because not only do people with chronic pain have difficulty with it, so do physicians and so do our grandmothers, and so does everyone else who has always believed that what you really should do is rest.
What we are finding over and over again, in every study that has been done on chronic pain, on chronic low back pain and many other pain syndromes, the worst thing you can do is rest and be inactive. If you have a back problem, the old idea of putting you to bed for two weeks, of putting you on boards and all the rest of it makes the problem worse. The people who get up and get going despite the fact that they have pain do better. That has been shown over and over again by studies.
The difficulty is, once you can establish that there is no danger of being mobile and active, getting back to normal activities makes the problem worse and also, in a high percentage of patients, prevents the problem of chronic pain.
Injury prevention and early appropriate management are much more effective than dealing with chronic pain after it develops and workers' compensation in every country knows that if you intervene very early, you can often not only get the person back and active but the problem of chronic pain is minimized, the percentage of people with chronic pain is minimized, but that the longer they are kept off and inactive, the less likely they are to go back to work. The figures that are present in every compensation board in the world will show that by six months, the likelihood of getting back is pretty poor, by a year, it is disastrous, and by two years, it is almost impossible. The longer you are off, the less likely it will occur. That issue of the timing is an extremely important one.
Those are just some of the basic things that have been shown over and over again. There are some other questions that I was asked to address and attempted to do this. These were questions that were asked of me by the WCB. One is, is chronic pain syndrome an entity? Is chronic pain in people from various reasons, somebody fell on their leg, somebody hurt their neck, somebody got a whiplash, somebody developed an acute back problem, after a while the ongoing chronic pain tends to look the same in these individuals. What was
evolved is a concept with the term chronic pain syndrome. It didn't matter how it had started, it is now known as chronic pain syndrome.
There was debate about this, should you not say this person is a whiplash, this person is a low back pain problem, or is there a thing after a while that this is just chronic pain syndrome, various ideologies? I think there is something in that, but the group that does not agree with me are much more influential, and that is the International Committee for the Study of Pain. They originally did use the term chronic pain syndrome but recently have suggested that it's probably not a useful term, to lump everything and call it a syndrome and not think about the other specific issues. So the term chronic pain syndrome has been discouraged as a term. That's why the reference is usually to chronic pain and not the so-called chronic pain syndrome. I think there are some advantages to it but that's a small point.
[2:00 p.m.]
Is it related to the severity of the injury? The odd thing is that it's not. Whether a person develops chronic pain from an injury is not related. Many people who have very severe injuries don't develop chronic pain. Many people who have very minor injuries do develop chronic pain. So the odd thing is that the degree of the injury is not the issue. If it were, then you would see this rate of chronic pain would be related to the most severe injuries down to, minimal injuries would not have chronic pain. In fact, there is no relationship. Many people with chronic pain, in fact, do not remember any injury in the initiation of their chronic pain.
Is it related to jobs? Well, that has been a difficult one because to some extent it might be. There are some jobs in which a person is prone to develop some injuries and a certain small percentage of those might continue with chronic pain, but it is not as clearly related to jobs as one might think. Jobs in which there is a lot of lifting don't necessarily have more low back pain associated with them. If the job has certain characteristics, however, it will have an increased incidence. If the job is one that tends to have little satisfaction, if it is a job in which the worker feels they have no control over things, if it is a job in which there are few rewards, the incidence of chronic pain is higher. There are some jobs in which you almost never see chronic pain. You will almost never see chronic pain in a physician. You'll almost never see chronic pain in a professional. One might suggest that while the reason is that they don't do anything that is physical and that might be so, but there is a difference again, and this has been done over and over, there is a relationship to the amount of satisfaction a person gets from the work that they do. That's just related to this multi-factorial thing. It is just one of the issues that tends to be a modifying factor.
Are there predisposing conditions? That is controversial. In other words, there are people who have written and have done research that suggest that one can show that certain individuals seemed to be more likely that they would develop chronic pain. Others don't believe that is so and because it is controversial and it is not clear, I think you just have to
leave that as being uncertain. It is not clear that certain individuals are prone to this before they develop the problem.
What about secondary gain and that's a major issue that may be raised. I have, I think, some strong feelings about this and I think there is a fair amount of data on this. The first thing that has to be understood is that people with chronic pain are not faking. They're not making this up. They are not putting on an act, telling you they have pain when they don't. They have pain and they are suffering. The question is, what are the many factors that are continuing this process after healing should have occurred and that, as we've mentioned, is multiple factors.
It is true that if you induce a secondary gain phenomenon, it can be one of the things that encourages the phenomenon to continue. It doesn't cause it. In other words, people can just as often have chronic pain when there is no compensation. Many of the people that I see with chronic pain, there is no lawsuit. There is no compensation. There was no injury. They're not gaining anything from the chronic pain.
I think that some people have the sensation that people are faking, that they're malingering, and that they're only doing it to get money. I don't think that's correct. However, it can be a factor on why the process might be continued and that is that the rewards are for continuing the process. It has been noticed, for instance, that one of the ways to get rid of chronic pain is to reverse all the rewards. If there are no rewards, the problem doesn't necessarily disappear but the person begins to adapt to their life and get on with things. Rewards tend not to allow people to get on with things.
There is a treatment program, for instance, in Seattle, that takes the issue and says, you've got chronic pain? Well, we know from all the investigation, or whatever, there is no ongoing process there that's of danger. Now, what we're going to do is we're going to get you back to normal functioning, normal life, and back to your job despite the fact that you have pain. We've shown that there's no pathological process going on here. We don't want to talk about your pain anymore. We don't want to hear about your pain anymore. We want to hear about how well you're doing. So when we come back to talk to you tomorrow, we would like to hear about what you've done that was more than the day before; how far you walked, how well you did, how many more hours you spent working, whatever. We want to talk to you about that. If you want to talk about pain, we'll walk away. They settle all the other issues. Now the rewards are for getting better.
The attention, the care, all the aspects are rewards for getting better, not rewards for staying sick, and most of our system has rewards for staying ill. I'm a physician and we tend to do that. If a person is ill, the more they complain, the more time we spend with them, the more attention they'll get, the more tests they'll get, the more care they get, the reward system tends to be for staying ill, not for getting better and that has become a real issue in the management of chronic pain.
A couple of other things and then we can talk about some of this issue. Just a couple of other points, because people raised them, is there a usual sensitivity to pain? In other words, does everybody in this room have the same pain threshold and do the people with chronic pain have low or high pain thresholds? The interesting paradox is that people who have chronic pain, who seem to be disabled by their pain and can't function, can actually be shown to have very high thresholds to pain. So if you test them for pain, they're not overly sensitive to pain. They're overly sensitive to their chronic pain problem but not to pain itself. So that's an interesting aspect. So when people are tested for their response to pain, people with chronic pain will often tolerate the pain longer than others.
Are there normal recovery times? Well, there probably are. If you get people who get an injury, get a disc, break a bone, or whatever, there is a normal expected healing time and most people would heal within a certain time. The tissues would have healed. The pain would have disappeared and within some limitations one can define what the normal expected recovery is and usually what is put as the recovery time is long after that. So that's when you begin to get concerned when a person who should have recovered is not. That's when you must intervene, not a year later.
The other problem with chronic pain is what medical evidence is necessary. Chronic pain is one of those situations that only exists if a person tells you they have pain. If they don't tell you they have pain, it doesn't exist. It's like insomnia. If people don't complain about sleeping poorly, they don't have a sleep problem. It only exists if the person complains about it. If you have pain and you don't complain, it is really not an issue. So, how then does one prove that a person who says they have chronic pain and can't function, what's the evidence for it? The difficulty is there is no evidence. There is no evidence that one can say, well, we've done this test and what we show is that you don't have chronic pain. So that's one of the major issues. Otherwise, it would be very easy.
What is the relationship to compensation? There is some general relationship to compensation. The amount of chronic pain is higher in the countries that provide compensation for it; it is low in countries that don't. Now, that may be a statistical error. If you don't have a compensation system, people don't come forward. So how relevant that is - but we do know that if you suddenly compensate for an injury, it will suddenly appear and become common. That may be because before people didn't come forward because it wasn't compensated. So it is hard to judge that but that issue is there. You can find, if you look at different parts of the world for compensation, there is a relationship to compensation in that country and the extent of both the problems and chronic pain. So that has been a long-argued relationship because it does appear to occur.
The other question was, can you apportion cause between injury and other causes? In other words, we know there might be social, psychological and other factors and then there's the injury. Can you decide that it is 40 per cent injury and 60 per cent the other? Well, that has actually been done and it is done in many systems and I don't believe you can
logically do it because I don't know on what basis you would decide that it is 60/40 per cent, not 40/60 per cent, but it is done a lot.
There is this issue, the so-called hysterical pain. I put that up merely to get rid of it. I don't think that is an issue. I don't think that there is a made-up phenomenon that is realistic. It is possible for you to come into my office and tell me you have terrible pain when you don't and you know you don't and you just made it up but I think that that's so rare that you can forget about it. So the idea that people are malingering or hysterically complaining of pain is not the issue. One of the major issues is separating suffering from pain. All of the individuals that we deal with in this situation are suffering. Whether the suffering is always pain is a different issue. They are always suffering but whether it is what we are thinking of in terms of pain isn't always certain.
Patient selection, and I talk about the funnel because I think there is a perception and there's something here too - I don't know whether you're interviewing people who have chronic pain, or whatever, but anyway . . .
MR. CHAIRMAN: They're interviewing us.
DR. MURRAY: Okay. Well, there is something else to recognize and this occurs in all aspects of life and it certainly occurs to the Workers' Compensation Board. There is a concept of a funnel. If you want to go out in society, there's a lot of chronic pain. There are housewives with arthritis. There are people who have problems with untractable migraine, disc problems and degenerative arthritis. There are all kinds. If you go out into the population and interview a large number of people, you'll find a significant percentage of people in the population have chronic pain, pain that is recurrent or long-standing, and what you'll find is many of those people just put up with it and manage it. It is part of their life. They understand it. They accept it and they go on.
The people who appear to the Workers' Compensation Board are a segment of that and they look different. One of the reasons they look different is they relate the problem to their workplace. So that's different and there are other issues. The people who may have great distress who come here are another segment of that group. So there is a funnel phenomenon and trying to identify that everybody - and I've had this argument with the Workers' Compensation Board, they see a certain kind of chronic pain. What they don't see is that big phenomenon of chronic pain that occurs in the population and there is a tendency to think that that's what chronic pain is all about. There is a bigger issue and there are other people. There are people who never complain but the Workers' Compensation Board will never see a person who never complains. Why would they be there?
So, the funnel is the idea that the process becomes more and more selective and so the people don't necessarily represent the total body of people with chronic pain. There are a lot of housewives who go through their life taking care of their kids, managing their house
and their families, doing their work, going out to work and whatever, despite the fact that they have pain but they're never included in this discussion. There are studies that looked at general populations to see what the differences are.
I mentioned the issue of suffering. I think that's an important one. You can always wonder about the severity of someone's pain problem but you can't necessarily dismiss the fact that those individuals are suffering.
I made some recommendations to the Workers' Compensation Board and they are not different than a previous report. This is the Spitzer report which was done in Quebec, a large number of experts from various disciplines and they were looking at the issue of chronic pain. What they found is that people with chronic pain should return to work if there are no objective findings and the only thing that was required to define and diagnose a person in most cases was a good history of physical examination. They didn't need all kinds of investigations and consultations. That was their recommendation. Having pain was insufficient cause to stop you from going back to work. Now, simple as those recommendations sound, they are very difficult for people to accept, the fact that you should carry on despite the fact that you have pain. Then if you fail on that approach to get you back to normal activity and work, then there should be a standardized approach, a standardized package that not only tries to get you over this issue but also, again, attempts to get you back to normal activities and back to work.
I am not going to go through all the treatment things that have been tried in these because most of them have not been very successful because they concentrated on a specific thing. It is like saying: we will treat chronic pain with acupuncture, we will treat chronic pain with physiotherapy, we will treat chronic pain with whatever - a single approach has almost always failed.
The two most important recommendations. If you are developing chronic low back pain, the most important thing that can be done to minimize your proceeding into a chronic pain situation is, increase your activity, improve your function, the goal is to get you back to work. The programs that have taken that approach have been successful as long as they were initiated early enough; you can't initiate it successfully in someone who has had the problem for the last five years.
That is why my recommendation to the Workers' Compensation Board was an early intervention program. When the person is at the point where they should have healed and the problem should be better, that is when you intervene. You don't wait six months, you don't wait another year. You intervene really early and the problem has often been the person has been off for a very long time and them someone decides they now have to do something about it. It is too late. So, early intervention and that is not terribly original, that has been recommended in every study that has been done on chronic pain.
So this is what I recommended to the workers' compensation. Recognize the complex factors that are involved. You know the worst thing you can do with a person with chronic pain is keep giving them one more myelogram, one more MRI of their back, send them to two more consultants, whatever, always looking for that thing that if you just found it and removed it, the problem would go away. It is not as simple as that. It is a complex issue with strong social, psychological, physical and other factors.
Educate the professionals. I am the first to admit that some of the worst people managing this problem are physicians and the reason is physicians still think of acute pain. So they assess it like acute pain and they treat it with manoeuvres that work in acute pain and when it goes on and on, they regard it as acute pain that is lasting a long time rather than a different phenomenon, which is chronic pain. Even though the things don't work, they keep being used. Well, we will do another MRI even though the last one was negative and we will send you to another orthopaedic surgeon and we will do another CAT scan and another, always looking for this acute phenomenon. Also, the physiotherapists and others have to recognize the nature of chronic pain as opposed to acute pain.
So, the first thing I thought they should do is have an educational program for the professionals who are dealing with this and have them recognize the characteristics of chronic pain early so you can intervene early. Educate the employers because the employers aren't very helpful in many of these situations because they say, I don't want the guy back until he is fine. That is not helpful when we are encouraging people to get back despite their problems. So we would like some modification of times and schedules and work and whatever, to help this person get back into a normal environment. So we have to educate the employers.
We also have to educate the employees because in fact the people that they work with are often not very supportive either and they don't want people who can't function 100 per cent because it means they have to work harder. So very often, getting the person back into a modified program that gets them back to normal, the fellow employee is often one of the difficulties because they are not sensitive or encouraging to the person who cannot function fully.
There is a lot of education here and the approach has to be a rehabilitation approach. The rehabilitation approach is, increase your function, return to normal activities, despite the problem. The measure is that increased function, return to work, return to normal existence, those are the measures. It is not, give enough drugs until the pain is gone.
The other issue, and we mentioned early intervention, is the multi-disciplinary team. If you really want to make a difference, then you have to have the team approach that involves the physician and the physiotherapist and, depending on what professionals are appropriate at the time, involves the patient in that process and very often involves the family in the process.
I think I will stop there and that is the summary of the recommendations I gave to workers' compensation. Prevention is the most important thing, a rehabilitation philosophy. Use expected recovery times, then you will know that this person, there is a signal that says, this should have healed and have been pain free at a month and it is now four months and this person is still hobbling around, still having pain, still not back to work. You need to have a sign that there is something happening. So expected recovery times are useful. Educate the professionals, educate the employers; use practice guidelines, that is a general approach that can be used in the different situations that occur. They are guidelines. They are not rules. If we have a situation with a person with an acute back injury, what is the guideline for how we are going to manage that process?
Develop management handbook and use a multi-disciplinary approach and I also felt that they should simplify the workers' compensation approach because it just makes it worse if things just drag on and on. It is a long-standing process. By the time you get that resolved, you are now into the year and one-half problem that I talked about. Now, trying to get people back to normal function is not only difficult, it is often impossible. So have a very simplified approach.
Anyway, that is the gist of the two years that I spent on this for the workers' compensation.
MR. CHAIRMAN: Dr. Murray, I know there are going to be a lot of questions from other members and I have a long list but I am going to ask you, just because it is based on some of the evidence we heard, there is a term we have heard, fibromyalgia. Would you like to just comment on fibromyalgia?
DR. MURRAY: It is a controversial condition. I am not sure why it is controversial. Anyway, it probably shows you that I am in one camp on this thinking. Fibromyalgia is a chronic pain disorder characterized by certain features. The features are surprisingly similar in all of the people who have it. It is this, if I can annoy my friend again. What you find is that these people complain of widespread pain and they have, when they are examined, tender points. The tender points are in very characteristic places: back of the neck, right there, the trapezius at the top of the shoulders, over the costochondral junctions of their chest, between their shoulder blades, in the lower back area, over their hips. Some, if they are really bad, have it around the knee and in the elbows and they have it in the temporomandibular joints. You examine them and patients get surprised that I can go to them with my finger because the points are always the same in everybody.
They have widespread pain, tender points, they all have fatigue, they all have sleep disorder, and they may have some other features. They may have migraine headaches, cold hands and feet, they may have irritable bowel syndrome, they may have a number of those kinds of features, not all of them have that, all of them have that. And that is fibromyalgia.
The reason it is controversial is some people say, this is a psychological syndrome and it doesn't really exist. My point is, I am not defining what it is due to, but if every patient comes in and has that syndrome, then it is something. If it is something and it is so characteristic, then if you say it is not fibromyalgia, then give it another name, because it is something. They all have the same features and they all look the same.
MR. LUC ERJAVEC: Is it caused by a traumatic incident or does it just appear?
DR. MURRAY: It can be. I saw one this morning. This is the other business of the funnel. Everybody who comes to workers' compensation, it has been caused by an injury. If you go out into the population, you will find this is a very common syndrome, however, in the general population, most of those people didn't have an injury. Most fibromyalgia people do not have an injury they relate it to, but if you do get an injury and develop this problem, then you say it is an injury-related phenomenon. Injury can do it.
Here is how it does it, and did it with the patient I saw this morning. They get a whiplash, get hit from behind in their car, snap their head. Afterwards, they have pain in their neck, pain in their head, and after that, they have a number of features including this, and if you examine them a month later, they have the tenderness back here and over the shoulder blades. Then six months later, they are still having this, now they are getting it over their chest and in their shoulder blades. A year later, you examine them, they have their low back, their hips, and whatever. There is a spreading phenomenon.
One of the characteristics that often occurs, and it is very interesting, you get the person who has a low back problem and then see them a year later, and what they have is this. Or see the person who has the neck problem, starts in the neck, see them a year later, and what they have is this. And they all begin to look the same. You examine them and they all have these tender points, they all have pain, they all have trouble sleeping, they all have chronic fatigue.
Then the issue is, what is that? Because it is 40 per cent of a rheumatologist's practice. It is a common problem. What is it? Well, we are not really sure what the ideology of this is, because, as I point out, many of the people don't have an injury to start, it just develops. A high percentage of people with migraine eventually develop this process. What is it all due to? I am not sure, but it is a syndrome, there is no question about that.
MR. CHAIRMAN: The difficult question that I wrestle with is because we have a system, for better or worse, that compensates people for loss of earnings as a result of injury, and this is a problem that I am wrestling with, if in some people it is caused by an injury and it is a recognizable syndrome, and they are not getting better, I guess the next logical question is, do they deserve compensation? I mean, that is not a question for you as such, but I just want your general view. Is there a treatment for that or are these people doomed, for lack of a better way of putting it, to suffer the symptoms you have outlined?
DR. MURRAY: My personal experience, and again we are getting away from the idea of just the compensation, because most of the people I see with this are not compensation problems.
MR. CHAIRMAN: The treatment would be generic.
[2:30 p.m.]
DR. MURRAY: Yes. The treatment is generic. What we know, and I wrote a whole section on fibromyalgia in this report, is that most things fail. Most drugs fail. Most procedures fail. There are a couple of things that do make some difference. The first thing is to reassure people that they don't have some terrible disease that is going to kill them, it is just going to make them very uncomfortable. It is complicated by the fact that it is not just pain they have to put up with, it is the fact that they are tired all the time, and they can't sleep at night. That is always present.
What makes a difference? There is a long list of things that have been tested and don't make any long-term difference. There are things, if you have fibromyalgia, I can make you feel better today. I can massage your muscles, I can put ice on it, I can give you a hot bath, we can do all kinds of things and you will feel better today, but you will still have the problem tomorrow. Those things work to make the person more comfortable at the time. They are all physical, related to reducing muscle tone.
The things that make a difference long term, as far as I am currently aware, is one medication a tricyclic antidepressant taken at night, which is useful in any chronic pain. Taking a tricyclic antidepressant in low dose at night reduces the discomfort in these patients, doesn't take it away, it is not a pain pill, but it is also useful if you have cancer pain or if you have bone pain or whatever, using a tricyclic antidepressant at night often reduces chronic pain.
The other thing that improves this situation is a regular exercise program. People who get into a regular exercise program and exercise despite the fact that their muscles hurt notice that their fibromyalgia does reduce. It gets better, they feel more comfortable. They get in a regular exercise program and all the symptoms begin to reduce, not necessary go away, they will always sort of be prone to it. The problem is, people don't want to exercise when they are both fatigued and their muscles hurt. It is a very hard thing to get people to get into a regular exercise program when they have this. Those are the only two things that I know of that have been shown to make any difference.
MR. CHAIRMAN: Thank you. I am going to turn it over to some other people because I don't want to use up all the time but another question I had, and I will give you an example of the problem, a lady appeared in Sydney who was a personal care worker, had hurt herself, an arm injury. She can't go back to work because her employer says, well, you might
drop a patient. Therefore, she is not going to be able to return to that workplace. She has pain. Would I be correct in surmising that from the point of view of treating her chronic pain, that she would be better off if she went back to the workplace, even if, arguably the workers' compensation system paid her entire salary just for the routine of getting up in the morning, going out the door, going there and doing whatever she can do without dropping patients?
DR. MURRAY: Yes. One of things that I have become aware of and this is not a surprise to anybody, to look at people who are kept off work for chronic pain, their life situation is almost always a tragic story. One of the ways that you can improve it is getting them back to a normal existence with normal relationships with people, with satisfaction from doing their job, despite the fact that they have a problem. I can tell you, if you think it is kind to keep people off work, then look at the family situations that develop in most of those situations. They are very miserable, unhappy people. The idea that it is kind to do that is misguided.
MR. CHAIRMAN: Again, a question. You indicated that generally analgesics and painkillers don't help. So, if you have someone who is diagnosed as having chronic pain but is getting relief from, for example, morphine injections, then I take it that wouldn't meet your definition of chronic pain?
DR. MURRAY: No. That is a little different. You can make anybody unmindful of things by giving them morphine, but what it doesn't do is take away their chronic pain. They will tell you they feel more comfortable because narcotics, in fact, will suppress the nervous system. There are people with chronic pain who say they have to drink all the time, or they take morphine or analgesics or whatever, but if you look at the situation, the situation is actually no better and it is often worse. They now have two problems; they have their original problem and they have the problem with the drugs they are taking.
The commonest story though isn't that of narcotics, the commonest story is to find people with chronic pain who are on a list of medications, and if you ask them, do they make any difference? They tell you, no. The question is then, why are you taking that stuff? There is a lot of it, because it is still based on the idea that there must be a medication that would help. So medications are used. They take sleeping pills that don't help them sleep, they take pain pills that don't help their pain. Often they are better off dealing with this kind of situation. Looking for the pill that will take this away, looking for the test that is going to find the thing that can be just removed or whatever, is always fruitless.
MR. CHAIRMAN: One last question, then I will ask if the members have questions. One thing that seems to be observable as a pattern is that people who have been injured, there is treatment, a process of treatment, and then at some point in time a physician employed by the board apparently looks at a chart and says, your condition should be healed by now. These people get notification, oftentimes a very short notification that their cheque is not coming
tomorrow or their cheque is not coming next week. That is my observation, I am not saying that it is true.
This is my personal, subjective observation from some of the evidence that we have heard, that there is a physician that reviews the case that says, you have had a low back injury and it should be healed after six months or three months or whatever the heck it is, and they get a call from their caseworker who says, no cheque. I call it the cold turkey method. What is your comment about the efficacy of dealing with that, as far as getting people back to work, getting on with their lives?
DR. MURRAY: I am not sure what to say about that. Unless you put it in a general context, if you developed a program that had earlier intervention, coupled with the concept that payment would occur for a certain expected length of time, plus some of these other things you mentioned, that they are going to assist the person to fit back into the workplace and are going to get employers who are more sensitive, if you coupled those things, then I think that would be part of a useful program. But if you don't have anything else in place, then it is a bit problematic. You just send them a note, that is a bit of a problem.
Most compensation boards do have a concept of normal healing times. I think Alberta has one that has been used most extensively. For any particular condition, there is time that they say, there is a problem if things are not healed by then.
MR. CHAIRMAN: I guess I don't have a problem with the ordinary healing time, I guess I have a problem with, I think that there is very little communication. It is my observation, based certainly on our cross-section of people that appeared, that there seems to be very little communication about that, that people find out sometimes on relatively short notice that they should have gotten better by now. Of course, they are very distressed and I think they then focus - and this is an observation - their entire lives on getting compensation back and not on getting better.
DR. MURRAY: Right. Again, not wanting to suggest that people are just making these up, but there are a lot of factors that tend to continue the process of chronic pain. If their lives are unhappy and they are concentrating now just on the idea of compensation, there are a lot of subconscious, psychological demands and they can't, in fact, get better.
MR. CHAIRMAN: I was just thinking that it is very hard to concentrate on getting better when you are worried about making the mortgage payment next month.
DR. MURRAY: Right. That is why there is the idea that in the chronic pain situation there are a lot of social, psychological, family and other issues. The real problem with that is that if you have pain in your back, you don't want me to talk to you about those things. That is the real issue. What you want to say is, it has nothing to do with that, it has nothing to do
with my marriage, it has nothing to do with my job; it has to do with my back, and stop talking to me about those things. That is one of the real tough issues in all of this.
MR. CHAIRMAN: Mr. Parker.
MR. CHARLES PARKER: Dr. Murray, I had a couple of questions for you. You mentioned earlier on that there is some relationship between the type of job that people do and whether they develop chronic pain. You mentioned also that in the general population there are certainly a lot of people with chronic pain, but maybe they don't complain about it, or you don't hear about it as much. Also the fact that when there is the possibility of maybe getting compensation or getting money for your injury, then people come forward. I am still unsure of the relationship between what people do for a living - and you mentioned doctors and maybe office workers and so on, don't seem to get chronic pain as much as labourers.
People we have heard from have certainly all been labourers or people who work in the woodlots or in a factory and most often it is a back injury, occasionally arm or leg injuries. Could you explain a bit more on the relationship there between . . .
DR. MURRAY: As I mentioned, there is some relationship but it is not as clear as one might think. It is a very difficult issue to select a profession or a job and say that woods workers are going to get a lot more chronic pain than office workers, because in fact what you will find is that there isn't a clear relationship to that kind of thing. There is a relationship to other factors. There is a relationship, for instance, not to what it is you actually do, it is how much satisfaction you get from doing it and whether you feel you are in control.
MR. PARKER: Then an office worker who is unhappy and not in control of their job is more likely? I guess we haven't been hearing from those people. It is usually labour people that we have heard from, at a physical job.
DR. MURRAY: But if you look at workers' compensation claims, there is wide range of occupations and office workers are a high rate. There is another issue - some of them are interesting examples - in groups that in fact you know that pain and injury is likely, some of them never get it. One of the examples that was used by a world expert on chronic pain who came here to give a talk was high-performance jet pilots. When they do their practice and when they get ejected from aircraft, they almost always get fractures. They fracture their lower back and if you X-ray their back, you will see they have cracks and fractures and whatever. They never miss a day. They don't stay off, no matter what happens to their back, and they never miss anything and they never develop chronic pain.
MR. PARKER: Maybe their job satisfaction, is that a factor?
DR. MURRAY: You can't stop those people from going to work. They love it, all they want to do is fly.
MR. PARKER: What about politicians? (Laughter)
DR. MURRAY: Are you asking, do they get it or are they chronic pain? (Laughter)
I don't want to overemphasize that point. What I am saying is that there is a multiple group of factors of which those things are part of it, but that is not the only thing. You can find someone who has a lot of job satisfaction and still gets chronic pain. There are lots of other factors, but if you look at the group, what you will find is that those things in fact do have some relevance, because people are always looking for the underlying reason. The odd thing is that the extent of the injury itself, or the amount of change or lack of change on X-rays and whatever isn't the measure which one would expect it would be.
MR. PARKER: It is just hard to define sometimes why some people have it and others don't, I guess.
DR. MURRAY: Yes. That we are all different is not surprising, and that we all cope with things differently and deal with issues differently. It is not that something is good or bad, it is just that if you and I have a different approach to things, there are some circumstances in which your approach might turn out to be the more positive one, and in other circumstances that mine is. It is just that they are different. People are different in how they respond and cope.
MR. PARKER: I had a second question, too. You mentioned in Seattle, there is a clinic that deals with chronic pain and they sort of look at a positive aspect of dealing with it. Is that an expensive clinic or would it be worthwhile to send people to it maybe from here?
DR. MURRAY: I think that what you find is that there are pain clinics everywhere and they all know the methods. In fact, some of the best pain research is done in Canada and some of the best-known world experts on pain are in Canada.
MR. PARKER: So should some of injured workers that are suffering from chronic pain, be sent to pain clinics elsewhere here in Canada?
DR. MURRAY: It depends entirely on the approach and how early you start. There is nothing magic about Seattle, they just take one approach which is, get rid of all the negative rewards and put positive rewards. That is their long-standing approach and that fellow who did that is one of the acknowledged experts in chronic pain. That is one approach. There are other approaches that are used because it is so multiple. They have just taken one approach to one of the issues. My feeling is that people should look at all of the various ideas. One of
them is to get rid of some of the rewards for staying ill, if you want people to get back to work.
MR. PARKER: So is it working for them? Are they having some success out there?
DR. MURRAY: This method has been going for 25 years. Now what they will then take is people early on. They have established that there is no ongoing damaging pathology here and then they take that different approach. Now, what was done here by workers' compensation that I think just got started, you may have heard something about, is their early intervention program took that plus other things as an early approach. They coupled this business of, we will get in there early, we will do things with a very positive, aggressive kind of approach but there is a limit to it. I think those two things coupled will, in the long run, do the best thing for a Nova Scotian person with chronic pain. The thing I think is a tragedy is the person is two years now and has had chronic pain, trying to get that life back on track is very difficult.
MR. PARKER: Okay, thank you.
MR. CHAIRMAN: Mr. [Hyland] Fraser.
MR. HYLAND FRASER: Dr. Murray, I have just a couple of things I want to get your comments on, I guess. The first thing, and I guess all of us recognize that most of the people who came before us are long-term sufferers. They have been injured from back in the 1980's, early 1990's and they kind of feel, in their own mind, they are caught up in the system. They can't get paid. They were paid a PMI early on which they can't live or they can't work. Based on what you said earlier, are those people pretty well down the garbage can as far as ever getting their lives back if it is chronic pain that is the problem, because they are 8, 10, 12 years away and really no hope for them, to speak of?
DR. MURRAY: I don't know. I think just the statistics on the person, the further you are out with the problem of getting back that in every jurisdiction, with every method tried, the likelihood has been poor. The question is then, but why did this all occur? You see one of the attitudes that most workers' compensation systems have taken, said they are responsible for the injury and the expected problems after it. All of this other stuff isn't their responsibility. Well, that may sound a little tough but somehow there has to be some resolution to it. Personally, I don't know what the appropriate thing to do in that circumstance is.
In fact, in my discussions with workers' compensation, I made one request and that is that workers' compensation is a complex issue and they have policies and whatever. I am not involved in their policies. They wanted me to do a medical survey of the current thinking about chronic pain. I will do that. Don't ask me to get involved in your policies. There are other experts and people who know much more about policies than I do. My simple thing was
simplify your policies but I am not an expert on workers' compensation policy. There are experts. My issue is only to tell you what the medical thinking is and what the current thinking is in the literature.
MR. HYLAND FRASER: One of the other things we heard, and these would be workers who were injured a few years ago, after the expected time of recovery, if it was a broken leg or a broken arm or torn ligaments or whatever it was, they were put into what is called a work hardening program. Is that part and parcel of trying to get them back to work?
DR. MURRAY: Yes.
MR. HYLAND FRASER: One of the complaints that we heard regularly is that people are asked to go back to work when they felt they weren't ready. If a normal recovery time were six weeks, WCB put them in the work hardening program and said that is it, you can go back to work and they really dug their heels in and said, you know, I was just sent back to work too early. Now I don't know what percentage, maybe there is a big percentage of the workers this works for and maybe we only hear of the small percentage. I don't know but is that a psychological problem, a barrier, that we are going to have to get over, over the next number of years in trying to overcome, I guess, what you are saying?
DR. MURRAY: The attitude against the work hardening program?
MR. HYLAND FRASER: Yes.
DR. MURRAY: I think so and I think that the evidence is that if you just have work hardening alone, then although the results are better than doing nothing, they are not as good as they could be and the work hardening philosophy, coupled with other aspects of a program is one of the things to do. Again, getting back to the workers' compensation early intervention program, the concepts of work hardening are part of that.
One of the reasons, it is not just psychological so much as getting back to this business, the idea that I am going to hurt myself if I start doing things that hurt. That is the thing that one has to get over. Even though it does hurt, you are not hurting yourself to do it. That doesn't make any sense to our grandmothers or to my education as a physician or whatever. That is a different concept now. We believe, you have pain, don't do anything. Avoid doing it. You've got pain, rest. You've got pain, stay off work, stay home from school. What we didn't realize, we were doing terrible things when we did that. It is logical but in fact the results are poor. You've got pain, carry on, and it works.
MR. HYLAND FRASER: Just one other question. I am not a biologist or anything, or understand how the body works but endorphins, or whatever they are called that make you feel good, is there any way that has been generated, or anything, for people who have chronic pain to increase whatever that is that makes you feel good?
DR. MURRAY: That is a very good question because we know that endorphins and other neurochemicals are involved in a lot of this process and it is one of the reasons, if you produce endorphins, that you may not experience the pain. It is endorphins that cause the football player to keep going and the soldier to keep going forward when they have got terrible injuries. The problem is, how do you do that on a chronic basis? There actually are medications that increase endorphins. In fact, morphine and those drugs, are just modified endorphins. So endorphins are the body's own morphine. The difficulty is getting anything that from a practical point of view increases endorphins so much that it would suppress this phenomenon. We are not successful at doing that. A lot of the research in pain and understanding pain and getting at how you could manage it better, including in firbromyalgia, is related to that issue of trying to understand better the manipulation of endorphins.
MR. HYLAND FRASER: Thank you, Mr. Chairman. I will pass, now, to someone else.
MR. CHAIRMAN: I just want to follow up on a question that Mr. [Hyland] Fraser had asked you. We have heard from a number of individuals who view work hardening as the equivalent of a chamber of horrors. Let's be blunt. That is their view of it. Some of them have reinjured themselves and I think they have some reason to believe that they did actually injure themselves there. Obviously, that is a problem with selection. I take it you would agree that people who are subject to, where the therapy they are going to get is going to cause a more serious injury, should obviously be weeded out more effectively.
DR. MURRAY: Also the gradation of how quickly you can do this because some people you can do it quickly and other people you do it slowly.
MR. CHAIRMAN: That was exactly where I was headed because there was one lady who weighed 110 pounds and they were having her doing bench-pressing or something like that, fairly early on when she got there and, of course, she was constantly going every day at the end of the day to the VG Outpatients - at the time it was the VG Outpatients - for treatment for pain and difficulty and so forth. I guess I was wondering, given the fact that certainly there's a significant number of workers that we see appearing who have a very negative experience to work hardening, how do you best make it more effective, you know, I guess my question is, it's quite clear from what you've said that you feel the literature and experience, that those programs help?
DR. MURRAY: They do.
MR. CHAIRMAN: But how do you make sure that it is individualized enough that you don't, (a) put people into the program that do do themselves injury and, (b) that you make sure that the thing is not, you know, four weeks and you're supposed to be all right. So that means in week one you've got to do this, this and this and, week two, you do this, this and this and, week three, before you graduate and you're better.
DR. MURRAY: It probably does require, though, some allowance on both sides, so some rigidity is required in the concept of work hardening. The other aspect that is sometimes missing is the commitment of the worker and that's an important component. If it's just you forcing this person to go on the scale and they say, no, it's going to make me worse and I'm scared of it, if they're not committed to this and they're not positive about it, it is probably not going to work. So one of the things about work hardening is getting the commitment of the worker to do this. Another component that is usually missing is getting the commitment of the employer and the other employees to go along with this process.
So I guess my feeling is that if you don't have the commitment of the person who says I know I have pain but I really want to get back and whatever, and they'll commit to the process and so you have commitment on both sides, your likelihood of success is pretty good. If the person is not for it in the first place, putting a rigid system in, which they're just going to object to, you're not going to get too far with that one because they'll find every reason to show what you're doing is harming them - another part of the reward system.
MR. CHAIRMAN: Mr. DeWolfe.
MR. JAMES DEWOLFE: Dr. Murray, one of your overheads indicated that chronic pain involves complex physical, social and psychological factors and it didn't say usually involves, it said involves. So, am I to take it that that is always the case in your mind?
DR. MURRAY: Yes.
MR. DEWOLFE: Surely, that's not the case.
DR. MURRAY: It is and the reason it is is simple. It is not that one can say, well, you know, those are the reasons the person has it, but once you have had chronic pain for any length of time, it always has these factors involved, no matter what. If you've had pain for the last two months, severe pain, for any reason whatsoever, I can tell you that it has psychological effects on you. It will have psychological effects in the people that you deal with and the people around you and it has other - psychological aspects are always present in the presence of pain. It is part of the concept of pain and so they're always present. The question is how much do they modify what's going on but if I've had pain for the last two months, there is always a psychological factor in my pain in my relationship to it. Those things are always present.
They may, in fact, be things, however, that are positive. My psychological aspect of my pain might be to say I am a dour Pictou County Scot and we don't get sick so we're going to keep damn well going and that's the psychology that's involved. (Interruption)
One of the most interesting aspects, this happened to me, in terms of an aspect of pain, and I've told people this story before. It probably shows how clumsy I am but I was in my workshop doing something and I dropped something on my foot. A couple of days later I was in my kitchen and my kids were there and my wife was there and I dropped something on my foot. The thing that interested me is the difference. What do you think the difference was when I dropped it on my foot when people were around?
[3:00 p.m.]
AN HON. MEMBER: The adjectives used. (Laughter)
MR. MURRAY: Exactly. Number one, when I was alone, I didn't use any adjectives and I didn't make any sound and I didn't do anything much but when people were around, there was an aspect at communication and there was saying things, hopping around and doing a display that shows them how much pain I'm getting. That's part of the psychology but when I'm by myself, there's no sense doing that. There's no one to communicate to.
MR. DEWOLFE: Dr. Murray, it has been my observation on this tour that many patients are misdiagnosed, they are put in the chronic pain category and even last night one case was brought to our attention where a gentleman went on his own to Moncton where they had more sophisticated equipment that, in fact, detected a disc, or a couple of discs that were injured, and he was in the chronic pain category. Of course, that report was sent to the Workers' Compensation Board and essentially trashed because it was suggested that it's just one doctor's word against another's. I guess as a physician yourself you wouldn't be party to that sort of attitude. I would think that, you know, if there's better equipment and specialists that perhaps have better training on today's (Interruption) methods in Moncton that might be better than what they would have in Truro, that you would look at that situation and compare, would you not?
DR. MURRAY: Partly. You're assuming then that the presence of the disc is the cause of the problem?
MR. DEWOLFE: I'm assuming that that would be correct, yes.
DR. MURRAY: And if that were so, then removing them should make the problem go away. If you removed the discs and they still had a chronic pain problem, then - one of the difficulties is if we X-ray everybody in this room, a significant percentage of people in this room are going to show degenerative changes in their X-rays and some of you will have discs of which you have no complaints and some of you may have some complaints and you've got discs. The question is what's the relationship to anything. It's common in the population and if you find it, if you have a person with chronic pain and you X-ray their back and they've got degenerative disc disease, is that the cause because by age 70 everybody has it. By age 60 about 60 per cent of people have it. So those changes are common on X-rays of anybody.
So then the problem is, if you find it, is that the cause? You see, that's one of the killers. When you get a problem and you do an X-ray and you find it, you will assume that's the cause. My only question is you would have to be pretty certain that what you found on the X-ray is actually the cause of the problem.
MR. DEWOLFE: But it could very well be?
DR. MURRAY: It could be and then it is very simple. If you have a disc, it produces a very characteristic problem and removing it makes the problem go away. That's why a lot of surgeons, you take a number of these individuals who have the chronic pain kind of situation, they've got an abnormal looking X-ray, and you take them to those surgeons, they often will not operate on the individuals because they know the results are poor. In other words, taking out those discs that you found, it doesn't make the problem better.
MR. CHAIRMAN: Mr. Fage.
MR. ERNEST FAGE: Thank you, Dr. Murray. Dr. Murray, most of the discussion so far, and I apologize for coming in late, appears to me to deal with occupational health and safety and not the issues confronting us with workers' compensation. Chronic pain certainly is a term that has a huge lack of understanding I should say, but the people we were seeing in my estimation, and I really am new at this, was their fixation to win a judgement against the WCB and there was no doubt in my mind that they in their mind were suffering from pain, fixated with pain, but our decision here is not an occupational health and safety recommendation. We have to bring recommendations back regarding workers' compensation and the one recommendation we had the opportunity to bring back with these people who are long serving, that's who was in front of us, 2,400 cases in the backlog and approximately by varying estimates 1,200 of them have been there pre-1990.
We know, quite honestly, that if they've had chronic pain for six or eight years, the opportunity to reverse that, and many experts have already told us that that's pretty close to nil. So the only option we really have is do we pay them money? Will that make their pain go away?
DR. MURRAY: Will it make it go away?
MR. FAGE: No. But those are the options left to us as a committee and a group, the road we are heading down with this, looking at WCB legislation. What you have imparted to us is extremely important for occupational health and safety, for prevention, for many other good reasons. But our definition here today needs to deal with, I guess the one burning question I would have, if we decided that these people who are injured workers have fixated and decided and can only see that if they win against the WCB and receive a payment, then their pain goes away, because that is all they are seeing.
Quite honestly, those people have put their lives on hold for anywhere from 8 to 20 years to win that judgement against the WCB. In their mind, it appears to be clearly evident, the ultimate goal and the satisfaction, all those things related to their pain will be to win a judgement against the WCB, and by winning that, basically you have a cheque. Will that cheque, doctor, do away with any of that chronic pain?
DR. MURRAY: I don't think so. I don't know. I have no idea of the nature of the testimony or whatever that you have seen, so I don't know about that. I do know that there is a misconception that if you pay people that the problem will go away. That is based on the idea that the only reason the people continue their chronic problem is to get money. There are people who do believe that that is so, and they talk about the green poultice. You take dollar bills and make a poultice of it and put it on their lower back and it makes the pain go away.
I think that that is not either fair or correct. The reason that I think that is so is that if you take a group of people who have a claim and they have a chronic problem and their lives have been ruined and whatever, and you give them compensation or give them whatever, and then you go back and talk to them five years later, their lives aren't back together again. They are still tragic stories. If the idea is that you are suddenly going to make their problems better, I don't think that is correct.
There is very strong literature that suggests that most of the people are in fact malingering. I don't believe that is so, so I don't believe that if you just give them the money that the problem gets better.
MR. FAGE: I don't believe they are malingering either, but those people are so focused and their struggle has been so epic and long. The ultimate relief, the ultimate joy, the ultimate glory is winning that WCB case. We are talking about chronic pain, how to alleviate it. We are talking this afternoon, prevention, quick intervention. This is not what we are dealing with.
DR. MURRAY: I don't know, because it is back to the Chairman's point about, if you are fixated on this issue, you can't get about the rest of your life. That is an issue. You can't put this behind you, or put up with it, or cope with it if you are fixated on it. But I am not sure what you do about it. I hope no one is going to ask me what I think you guys should do about all this, because I really don't know. My issue is to try and explain what we currently understand, and we don't understand everything about chronic pain, but at least I can give you some idea about what we currently understand, it is this complex, difficult problem. It is a difficult problem in every society.
MR. FAGE: Thank you for being so candid.
MR. CHAIRMAN: Doctor, if you can give us the solution to this problem, that would be very nifty. We will just stop right here, and stop asking questions. Mr. Erjavec and then Mr. Neville.
MR. ERJAVEC: As we said earlier, a lot of the people that we have heard from over the course of the last few weeks, a lot of them have been 40 or 50 years old, hurt two, three, four, five years ago and have had chronic pain for a long time. They are convinced that they will never go to work again because of their chronic pain. In your opinion, is someone who has chronic pain disabled?
DR. MURRAY: That is difficult. The reason is that again, the difficulty of what disabled is. I am not sure how you answer it when two people can have the pain, or large numbers of people can have pain, and some carry on and some don't. The person who carries on and copes, they are not disabled, but the person who can't is disabled.
The reason I know it is a difficult issue is my major role is in treating chronic disease. I have MS patients, we have 2,000 people with MS. Those who ask for disability pensions to quit work and whatever, it has more to do with the nature of the person rather than their disability. The need in the individual to feel that they are now disabled and they can't carry on is not related to the amount of physical disability they have. It is one of the difficult issues. Then, is the person who says, I can't cope, I can't manage, and whatever, are they now disabled when there is another person in a wheelchair who has never missed a day's work? How you define who is disabled, I don't know. I find it really difficult.
One of the most difficult issues of being a physician, Dr. Lamplugh will understand this, is making this decision of saying when a person is disabled, because it is such an individual phenomenon and it is not necessarily related to the nature of the underlying pathology. It is related more to the nature of the person. I am not sure how you do that. That is why Canada Pension and others have such rigid guidelines for what they define as disability.
MR. ERJAVEC: Let's say it is an ideal world and just pretend the person doesn't have the mortgage due next week and has to pay for food, whatever, is giving them a cheque and saying you will have chronic pain forever, is that basically the worst thing you could do for them? Like, stay home, you have chronic pain.
DR. MURRAY: I think so. If the question is, the person who develops chronic pain, you say, look, you have pain, you are always going to have pain, stay home, rest, don't do anything, don't go back to work, whatever, that is the worst thing you can do. Then their lives tend to become tragic lives because of the nature of that. There is a phenomenon of what your lifestyle then becomes as a non-working, non-productive, disabled person, in your eyes and in other people's eyes. It is almost never a positive thing; it is often that the lives of many of these people are tragic. But I don't have simple answers for how you deal with all of that.
MR. FAGE: Luc, can I interject? That's exactly what I was talking about and what I was hoping maybe would come out of it too, when you look at some people who have finally got closure, regardless of the size of the settlement, have decided to move on. They got a settlement out of the WCB, then they become unfixated with beating the WCB in a claim settlement and they actually become somewhat productive in their lives, because the fixation and all those sort of pressures that were there to win that WCB case are not there. Now they can refocus on getting on with their life, and the other tragic part is it seems like they are caught right in that focal eye window point. Once they win, then do they do those things you are talking about?
DR. MURRAY: It is not quite so simple though, because the person who wins the disability, the large payment then has a motivation to stay that way, otherwise they look like they were faking. If you suddenly got it, and then you said, okay, I am going to get on with my life, and you jump up and start jogging and going to work, whatever, people will say that you were faking. There is some motivation to remain with the disability lifestyle.
This is extremely complex, and the one thing that I have tried very hard to do is not try to be judgemental or insensitive or unkind to people who truly are suffering. The questions are very difficult. One of the difficult ones for you and for workers' compensation is responsibility. Who is responsible? That is one of the issues. The other issue is, well, okay, we will accept certain situations, so then, what is the most productive thing to do? Then the third is probably, what can we afford to do? One of the frustrating things about disability is that you can never pay anyone enough. If you think you are going to make people happy by writing them a cheque, what you will always find is that the cheque was never enough.
MR. CHAIRMAN: Mr. Neville.
MR. JAMES NEVILLE: Dr. Murray, when you are speaking about the treatment of chronic pain, you left out the words, nerve block.
DR. MURRAY: Yes, and you know why, it doesn't work. The reason it doesn't work is that nerve block works for acute pain. If it did work, it would be great, because then everybody who has chronic pain, just go around and block the nerves and then the pain would be gone. What you will find is that lots of people who have chronic pain have had all kinds of nerve blocks. When you block the pain, it can block the sensation related to that nerve, but if you have this central reverberating problem going on, blocking a nerve doesn't function. That is why, if nerve blocks worked, most of these people would be back at work. In general, nerve blocks are not successful in chronic pain.
MR. NEVILLE: One more question, Doctor, can you separate chronic pain, arthritis, pre-existing conditions, can you separate them?
DR. MURRAY: To some extent. One of the things is that, in the concept of chronic pain, you exclude those others conditions. The person who has ongoing pain from rheumatoid arthritis is excluded from this discussion of chronic pain. They have a recognizable condition that is an ongoing condition that produces pain.
Two of the patients I saw this morning have intractable migraine headaches. That is not included in the discussion of chronic pain. The person who has a non-healed fracture of their hip, or has a vascular necrosis of their hip, or whatever, and as a result has ongoing pain, that is excluded from this discussion. You take those conditions that are characterized by chronic pain and exclude those, these are chronic pain for which there is no underlying pathology that demonstrates the cause.
MR. CHAIRMAN: I am just going to follow Mr. Neville, on your question. That seems to be a problem. It is probably a training problem, but we do seem to see, occasionally, where some people will see a medical report that this person has chronic pain, and they will misapply it, for lack of a better way of putting it. What the medical report, if you read it in its entirety, may be saying is that the person has chronic pain as a result of a pathological condition. An example would be someone who has a back injury and they have tissue damage to nerves in the neck or back or spine, and they have ongoing pain based on that.
DR. MURRAY: Based on that. That is different.
MR. CHAIRMAN: That is right. But unfortunately, I think in the medical reports, of course the physicians use chronic pain, ongoing pain, those kinds of phrases, and it is sort of like a red flag to a bull, because the person who is trying to separate - because of course, how you treat that person and how you compensate that person, that is the system we are dealing with - is going to be very different based on the causation. I take it that it is your view that it is very important that you get people in the right stream?
DR. MURRAY: Yes. In fact, in the report that I mentioned, that category of people, we state that is excluded here. I saw a patient this morning who has had for many years intractable facial pain from trigeminal neuralgia that is a different issue. That is trigeminal neuralgia, it causes continual facial pain, but that is not the discussion about chronic pain. The person with chronic pain, that's different.
MR. CHAIRMAN: Thank you. Next is Ms. Godin.
MS. ROSEMARY GODIN: Sorry I was late coming in as well. I just wanted to comment on something that Mr. Fage said, he kept using the word, winning, that people want to win. I have been looking at it as they just want to be validated, their injury to be validated. I know that some people who spoke before us said that they felt like they were being called liars by the WCB and you've addressed that issue this afternoon earlier.
I wanted to ask about pain clinics. Early on you were talking about one in Seattle but do we have pain clinics?
DR. MURRAY: There's a pain clinic at the VG.
MS. GODIN: Is that the only one in Nova Scotia?
DR. MURRAY: Yes, as far as I know.
MS. GODIN: Since you didn't make reference to that I assume it doesn't have the same philosophies or the same style as the place in Seattle?
DR. MURRAY: No. In fact, here they have not only pain experts but one of the people in the pain clinic here is the editor of the Canadian Journal on Pain and Pain Management but what you'll notice is it is again this funnel phenomenon. If you go to the pain clinic, what you will notice is that there's a big array of conditions and problems and whatever that are being treated by the pain clinic, one of which is this group of chronic pain. So the management of these other conditions is different depending on the process itself. It is not geared only to the problem of chronic pain.
I don't have any information on this, but I suspect that if you look, that they have a success rate with chronic pain that's probably equivalent to any other pain clinic. There is no pain clinic anywhere that's going to get 80 per cent of the people with chronic pain over their problem and back to work. The question then is what are the best results that one can get and what are the approaches that are valid? One of the things we know is that there is no magic. The real magic is starting early in the process to try and prevent this long-standing problem. Now, your issue is one that's even more difficult. What do you do when it is years later?
MS. GODIN: So, I guess my question is, where - and early intervention I'm sure sounds good to everybody - in Mr. Erjavec's ideal world, would we expand our pain clinics? Is that what would be best for Nova Scotians to get this early intervention or how would, where would they go to do . . .
DR. MURRAY: No. The Workers' Compensation Board has a very effective early intervention program. One of the problems that this court case that has generated all of this has done is to almost inactivate that early intervention program and the reason is if you're going to give people big cheques for having chronic pain, who wants to go into an early intervention program? The early intervention program has also a very strict cut-off about things. Do you think those people feel justified if others have no limitation and - to me, one of the serious questions here is how much this opening up the process is going to negatively impact on a new program that has not only been having good results but is being looked at now by other jurisdictions as a model.
MS. GODIN: So early intervention is not a medical problem, health system problem in this province, it is a legislative problem?
DR. MURRAY: Yes.
MS. GODIN: In relation to the WCB?
DR. MURRAY: It is interesting that you raise the issue of legislation. One of the things that needs to get done, of course, is some of the legislation has to be changed to make things more effective but there has been . . .
MS. GODIN: But the medical services are there?
DR. MURRAY: . . . some difficulty getting the legislative changes that the Workers' Compensation Board wanted and that is problematic. The other thing though is that this program, the early intervention program by the Workers' Compensation Board, was just getting up and rolling. They were educating the physicians. They were doing a lot of educating of professionals around the province. They were getting people into the program. The results were surprisingly good, probably better than anywhere else, and then the process suddenly has switched focus. Now the focus is all on this other issue.
I don't know if you have had discussions with the Workers' Compensation Board, have you?
MR. CHAIRMAN: We've had some discussions and there are more to come.
DR. MURRAY: Well, ask them about the early intervention program because it is a very impressive program but I am sure you'll find that they're wondering about its viability given all the rest of this stuff.
MR. CHAIRMAN: Dr. Lamplugh.
DR. ANTHONY LAMPLUGH: Thank you, Mr. Chairman. Just by way of clarification, Dr. Murray, the people that have been seen by this committee over the last few weeks have nearly all been in the chronic pain category and they are people who have not been treated well within the system either by the way the Workers' Compensation Board handles appeals, upon appeals, upon appeals, or by the way the employers have not accepted them back to work if they aren't fully able to work. In addition to that, physicians didn't look upon the treatment in the same way many years ago. Just looking at the references that you put in your report, I noted that there were a few old ones, some in the 1980's, over 100, and from 1990 to 1994, over 180. So, in fact, the evidence and education on the matter is relatively recent?
DR. MURRAY: Yes.
DR. LAMPLUGH: So these people that were seen by the committee are all in trouble, suffering, as you so rightly described and one of the biggest problems that they had, as was mentioned by one of the MLAs, was the fact that nobody validated their problems.
DR. MURRAY: Yes.
DR. LAMPLUGH: While money would help to get people off welfare, for instance, as long as people don't expect money to reduce pain. I'm sure money will help the endorphins greatly? (Laughter)
DR. MURRAY: Also I again mention this, I had a nice gentleman in my office who had a very dramatic demonstration of crawling almost across the table, trying to get up on the examining table, and he was moaning. It was evident to me that this was a little more dramatic than what I expected and I asked him, why do you do that? He said, well, doc, I just wanted you to know that I had pain. He's not faking but he's trying to communicate to me that he is suffering and he has pain and he is in distress. So part of the display is to make sure that I understand that. It is like me, when I'm alone in my workshop, I don't do any of this stuff because I have no one to communicate with. The problem is thinking that he's faking when he's doing it. That's why - and this often happens - you see a person and they tell you that they have serious problems, or whatever, and you later see them and they don't appear to be doing that. They don't seem as disabled or whatever. Some of it is part of communication. It doesn't mean the problem is not there.
MR. CHAIRMAN: Mr. Hadley.
MR. DOUGLAS HADLEY: Thank you, Mr. Chairman. Dr. Murray, it is more so of a statement than a question perhaps but we had talked earlier about some people having symptoms of chronic pain but never expressing those or making them known. You had also mentioned about perhaps the best approach might not be to provide these people with a cheque, people who do have outward symptoms of chronic pain. I guess my question would be, is it safe to assume that if the committee decided to perhaps compensate for chronic pain, that we're going to see the incidence of cases of people that we had not heard from before coming forward saying, well, since you're cutting cheques perhaps for such individuals, I have been feeling pain even though I have not said something all these years?
DR. MURRAY: Of course, I think that's right. You will see that and you have no way to judge it either. So that is true and I think that must have been one of the initial concerns that people had, is that people who didn't complain before, who were getting on with their lives and whatever, will now come forward and say, well, I've got pain too and without being unfair, that may be right. I don't know what's right. I didn't say that I don't think you should
give people cheques. What I said was I don't know what the answer to all this is. I know that you can't reconstruct their lives and make the problems go away by doing it.
There is an issue though that you have raised that is important and it is one of the reasons it's best done early. There is an issue of closure, saying it's over now, you know, it's closed. You didn't make anything better. You didn't cure anything, whatever, but at least it is over and that is one aspect that might occur, that it's just closure to the issue. There is no reason to continue the crusade, or whatever, and so maybe people will get on with their lives, I don't know. I don't know what the answer is and I don't know how you decide the responsibility. I mean is the Workers' Compensation Board responsible for everything?
[3:30 p.m.]
MR. HADLEY: Thank you, Dr. Murray.
MR. CHAIRMAN: I guess I have one question following up on what you talked about, early intervention, and the fact that there was the employer side and the fellow employee side. Then you mentioned the family at one point. Would you think there would be any benefit if the workers' compensation system met with the families of people who had been diagnosed as having a pain problem, I'll put it that way, to see if family strategies to deal with that would assist in the recovery of the individual?
DR. MURRAY: I think if it is part of, for instance, in an early intervention program, incorporating the family and the family discussion, that is very important.
MR. CHAIRMAN: Because I just perceive that, for example, and many of the families that we're seeing, of course, you know, money is a problem. Money is a problem for everyone but often times they're people with more marginal incomes and, you know, maybe paying the spouse's salary for a day and the cost of the spouse's travel to Halifax to meet with somebody and to dialogue about the problem, would you think that was an unreasonable expenditure if it was part of a whole early intervention program?
DR. MURRAY: I don't think so but I think if you get more information about the early intervention program, you will find that they incorporate those things. They have used social workers. They do interviews. They look into the family dynamics and a number of other issues. Whether they actually have the family members attend, or whatever, I'm not sure but what you'll find is that that's the approach. It is a very broad approach and not one that just deals with an issue of pain. It is an issue of all of these things that impinge on the concept of pain.
MR. CHAIRMAN: Mr. Fage.
MR. FAGE: It is just that I don't think that's actually what is occurring out there because when you look at the new guidelines with social assistance, you can spend $714 a month for your basic single unit and you can spend some of it on transportation to Halifax, or if it is a family unit, a couple of bucks more. Those people already spend the maximum trying to live, to have an apartment, those type of things. Any function of somebody outside of the metropolitan area coming in that has no other source of income, it has to come from WCB. Tying it into another social program that doesn't interact with WCB in any functional way, I don't see the reality in any of the areas I deal with and anybody that is accessing funds to come to Halifax, or to a clinic down here, through the family benefits, has to take that off their food budget if that ever occurs. That money has to be generated out of WCB funds rather than some social policy that really doesn't exist, doctor, I don't see it out there.
DR. MURRAY: No, although I know that with this new program, the costs of the program and the support of the individual is part of the intervention. What they do then is put a limit on it though. It lasts for a certain length of time.
MR. CHAIRMAN: Just to follow up on Mr. Fage's comment, I think one thing that's an observable fact is that there does seem to be some kind of a communication breakdown with many of the people that we see. Many of these people seem to do better with face to face contact than contact even over the telephone, for example.
DR. MURRAY: Yes, right.
MR. CHAIRMAN: And that's an observation that many of these people, to suggest that a social worker calls you up and talks to you over the telephone, it's not . . .
DR. MURRAY: No.
MR. CHAIRMAN: These people don't react well to that kind of thing and maybe it is the people we're seeing that don't react well. I'm not saying there aren't people who react well to that. I'm simply saying . . .
DR. MURRAY: Yes, but in this program it is all face to face and it is all done as a program. So it is not done in that fashion.
MR. CHAIRMAN: Mr. MacDonald. I know Mr. Delefes has a question but Mr. MacDonald was first and I forgot, I'm sorry.
MR. CHARLES MACDONALD: I was trying to get early intervention there.
MR. CHAIRMAN: Early intervention for Mr. MacDonald.
MR. CHARLES MACDONALD: I guess in early intervention, doctor, and I look at it a bit different. In the group that goes on to have long-term problems, it is roughly 10 per cent of what is coming through the system, if I understand it right on figures, numbers, but is it possible not to intercede very early on with that group. Some of them I find that the diagnosis has been wrong or they have to go to a specialist six months later or nine months later. By the time they get there, most of the problem is already in place. Can we not look at that group of 10 per cent or 20 per cent, whatever it may be? Surely we know the ones that will go on to have long-term care problems with their injuries, whether it be back related or broken limbs or ligaments that are badly torn, that sort of thing. Is there a process whereby they can be looked at or treated differently in the system?
DR. MURRAY: You can organize anything. You point out a very important problem and that is that the system sometimes does create this problem. One of the reasons is just the one you mentioned. The person should have recovered in two months and it is now four months. So then a consultant is asked and that takes three months. The consultant orders an MRI and that takes two months. Then they are a little uncertain so they ask another consultant. At that point you are already too late. So it is true, it doesn't take a rocket scientist to organize that system better but that is not an easy thing to do either. That is why, again, the attempt with the early intervention was to put all of the this stuff in operation very quickly and get it done, rather than this ongoing problem. So you point out a really serious issue.
MR. CHAIRMAN: Mr. Delefes.
MR. PETER DELEFES: You sort of partially answered this, doctor. You mentioned the early intervention process, it is sort of a holistic approach where different elements are brought to bear including sort of a counselling, psychological component. As you mentioned, as their problem evolves, there is an increasing psychological, emotional component. I am sure you wear different hats in your office and one is that of a counsellor/therapist. Is there anything that can be done in a therapeutic way, a psychological way, counselling way, once their problem has evolved considerably or gone five or six months into the problem? Is there any hope for counselling therapy at that point?
DR. MURRAY: It is very important. The person doing the counselling is important, too. For instance, if you had the problem, one of the things that is important to counselling is first to explain to you what the problem is and what it isn't, to reassure you about some of these things and how we are going to do it. Now, for that to be effective, you have to have trust in the fact that I know what I am talking about. So who does the counselling is also important. It is the credibility of the person giving the information.
A lot of what I do in neurology is counselling people about things that they are very frightened about. It is doing a careful examination, assessing them and then explaining to them what this issue is about and how they can manage it, not prescribing medication very often
or doing anything, it is showing them what this is about, how to understand it and how to deal with it and how to cope and manage; also, how to deal with a normal life, despite the fact that you've got the problem. So I think that aspect of the whole thing is more important. Where we often fail is to think that there are magic bullets, that maybe there is a drug, that if we just write a prescription, that would solve the problem. It almost never does. You get a lot more out of this system, early on, talking to people, explaining the situation, advising what they can and cannot do, what the rate of improvement should be, what not to be afraid of, what you don't need to have in terms of investigation and whatever. You get a lot more out of that than you do out of one more pill.
MR. CHAIRMAN: A couple more questions, Dr. Murray. The apportionment issue, and I think you made it clear but I just what to make sure I understood correctly. Your view is that it is practically impossible to apportion causation to people who have chronic pain. So that, for example, and I am talking about people who are in the system now, seven years ago, they may have been mistreated for whatever reason but seven years ago they had an injury, they have developed chronic pain. Am I correct that your view is to try to develop a formula that says it is 70 per cent caused by your workplace and 30 per cent caused by other factors, aging, or whatever, is practically impossible.
DR. MURRAY: All I know is I couldn't do it.
MR. CHAIRMAN: Okay, that is the first question. The second question, I just wondered how it fit into the chronic pain issue, was the environmental illness factor. We have seen a number of people who have come from the QE II who have been suffering from, the diagnosis at least of some physicians, environmental illness. How does that fit into the chronic pain issue, the environmental illness pain?
DR. MURRAY: That is interesting. There is an overlap. I am not sure how to understand the overlap but if you look at the issue of, if you took populations of people with chronic pain, and for example people with fibromyalgia or whatever, and people with chronic fatigue syndrome and people with environmental illness, you find there is a big overlap in the groups, that a significant percentage of the people with chronic fatigue have fibromyalgia. A significant number of those people feel that they have environmental illness. So there is a big overlap between these various conditions. I don't know how to understand that, I just know that is what is seen. Now you also have the controversial issue that nobody is sure what most of those syndromes are about.
MR. CHAIRMAN: Mr. [Hyland] Fraser.
MR. HYLAND FRASER: Mr. Chairman, I guess before I ask my question, we are going to have to excuse ourselves because we are going to Guysborough, both Mr. Charles MacDonald and myself to fill in on the Community Services Committee but just one question before we go. On our tour, and it was referred to earlier, a lot of people who came before us
are working people, maybe not as highly educated as others. You said in some of these, job satisfaction is not there and it is difficult to go back to work. I know a couple of comments I heard, I am not sure if they came to us in the official presentations but in the holistic approach to trying to solve some of these problems, people were suspicious of psychologists and other people and they said, you know, WCB thinks it is in our head now, the pain is down here, there is nothing wrong with my head. I don't know how you get over that because that is a tough part of trying to . . .
DR. MURRAY: A tough part. Remember when I started and indicated that everyone intellectually knows that these factors are components, nobody wants to talk about any of those. So it is not surprising that people who have chronic pain do not want to talk about the psychological aspects of chronic pain because there is the inference that that means it is all in my mind and they don't want to accept that. The only thing people want to talk about is the thing in my back that is producing my problem, not the other issues. That is understandable but it also makes it very difficult to address the issue. Then people keep searching for the thing in the back. The rejection of psychologists who can be very helpful is a very common thing because of what people think it means. It is like if you think I should see a psychiatrist, it means that I am crazy and if you think I should see a psychologist when I have pain, you think I am making it up. It is the image.
MR. CHAIRMAN: I understand that Mr. [Charles] MacDonald and Mr. [Hyland] Fraser have to go. We will let them know how the report turns out. (Laughter) No, just kidding. Mr. Erjavec.
MR. ERJAVEC: Just one quick question, following up sort of what the chairman was talking about with apportioning, is it work, is it whatnot. One of the programs that the WCB is floating is this new marked life disruption and saying is it low, medium, high. From what I am getting from you, that could be a real can of worms, trying to peg someone in a box to say chronic pain is having this level of impact on your life or should have this level impact on your life.
DR. MURRAY: Well, the marked life disruption issue is one way of trying to get at some of that. It is saying, well how much has this disrupted the person's life. To some extent, you could make that determination. What you do with it, I am not sure but it is one way. If the demand is to assess what responsibility there is here and what disruption there has been in the person's life and how much pain has been a problem, that is one way of trying to get at it but it is a very difficult measurement.
MR. ERJAVEC: Is it a useful way or are they throwing good money after the bad sort of deal?
DR. MURRAY: If the requirement is to have a measure, it is a reasonable measure but everybody can understand how difficult that will be. That is why one of the simplest measures that has been used is to say, you break your wrist, right, at work, there is a certain amount of time that is expected that you would be off and healing, whatever. You are compensated for that and when that is over, it is over. That is the simplest process. Then there is no apportioning of anything.
MR. ERJAVEC: The simplest and best or just simplest?
DR. MURRAY: It has some advantages. You would have to say, yes, but is it fair. What if six months later I still have a problem, is that fair? I am not sure but one of the things it does, it does have closure, it does not encourage a chronic problem, there are no rewards for continuing after. So there are a lot of positive things but in all of these things, one of the issues is always the question of fairness and that is where it gets difficult because fair to who? Fair to workers? Fair to employers? Fair to the workers' compensation system? Fair to the taxpayers of Nova Scotia? Fair to the individuals and their families? That is where it gets difficult. I don't know the answer to those things but I am glad we have a committee like this that can solve it. (Laughter)
MR. CHAIRMAN: Because we will know what it is, right?
DR. MURRAY: Right.
MR. CHAIRMAN: Dr. Murray, I think I have one last question and it has to do with - how should I describe it? - the idea of how to make the system work practically. I think I understood what you have had to say about the people who have six or eight year old chronic pain and the fact that there is not a lot that can be done. I am talking about looking from the front-end side, from here forward, to obviously minimize the disruption in people's lives and be as effective as possible. Are there any suggestions that you would have for the existing program that WCB has that would help to make it more efficacious, to improve it, for lack of a word?
DR. MURRAY: Yes, I think so. I made some general recommendations here and some specific things have followed through at the workers' compensation. Now they did follow through on a number of them, including having this early intervention program with a multi-disciplinary approach. My feeling is that that is probably the most important thing that you could do. It is understandable, there is a limit, there is a very active early process and the results - and you can ask them, because they know better than I do, I was not involved after that. I just made the recommendations and they went on. My vague information is that the program was surprisingly successful in a sense that they probably had better results than any other program like it anywhere. So other areas were then looking at this program as being a leader in the process. So my feeling is that they actually are doing the things that they are supposed to be doing.
MR. CHAIRMAN: Are there any other questions from the members or consultants? Thank you very much, Dr. Murray. You have been here longer than I think you were originally booked for. I appreciate your forbearance with us. I appreciate all your help. Thank you very much.
DR. MURRAY: My pleasure. You have a difficult task and I wish you well.
MR. CHAIRMAN: If the members could stay, we are going to continue our deliberations but we can stretch our legs maybe for a five minute break. I am starting to get cold hands and cold feet. Does that mean I am developing fibromyalgia?
[3:50 p.m. The committee adjourned.]
