Rethinking Pain: From Damage to Perception

For much of modern medical history, pain was viewed through a simple lens: the greater the injury or tissue damage, the more pain a person should feel. This biomedical model dominated clinical reasoning, where pain was assumed to be a direct consequence of structural harm – a broken bone, a herniated disc, or an inflamed joint. In this framework, healing the tissue meant eliminating the pain.

Over the last several decades, groundbreaking research in neuroscience and psychology has dramatically reshaped this understanding. Thanks to the work of experts in the pain science community, we now know that pain is not just a symptom of injury – it is an output of the brain, influenced by biological, psychological, and social factors. This shift from a “tissue-based” to a “brain-based” understanding of pain has profound implications for how we assess, treat, and support individuals experiencing persistent or work-related pain.

This contemporary model of pain emphasizes that pain can occur even without physical damage – and that pain can persist long after tissue healing has occurred. Fear, beliefs, past experiences, stress, and even the work environment can amplify or sustain pain responses.1 Recognizing this complexity, healthcare providers are moving away from treating only the body and toward addressing the whole person – through what is known as the biopsychosocial model of care.

Understanding this paradigm shift is especially crucial in the world of workers’ compensation, where pain is one of the most common — and costly—reasons for delayed recovery and extended disability. By applying modern pain science in this space, clinicians and employers have an opportunity to not only improve outcomes but also reduce costs, foster trust, and support injured workers on a more meaningful and sustainable path to recovery. We dive deeper into some of the science, provide insight into how employers and therapists can apply this biopsychosocial approach, and what the literature tells us about the benefits of employing this strategy.

Contemporary Pain Science

At the heart of contemporary pain science is the idea that pain is an output of the brain, not a direct input from injured tissues. While tissue damage can certainly contribute to pain, research by neuroscientists have shown that the brain assesses multiple inputs – biological, psychological, and social – before deciding whether to generate a pain response. While new to our understanding of pain, this has been seen clinically for years.

For example, it’s known that pain can occur even in the absence of physical injury, as seen in cases of phantom limb pain. In this instance, there is no limb present to send biological information to the brain, yet the injured individual can experience extreme pain. This can also be seen in cases of chronic low back pain, where there is no identifiable structural cause.

One of the key concepts in modern pain science is central sensitization, a state in which the nervous system becomes hypersensitive and overreacts to normal stimuli. This means that non-threatening inputs, like light touch, normal joint movement, or even stress2, can produce significant pain responses. As you may imagine, once a patient has become centrally sensitized, their prognosis is negatively impacted. So, what can be done to reduce the probability of central sensitization? The answer lies in a biopsychosocial approach to patient care.

Applying the Biopsychosocial Approach in the Real World

Translating pain science into clinical and workplace practice begins with adopting a biopsychosocial framework. Clinically, this means not only assessing for tissue impairments but also screening for psychological barriers (like fear of re-injury, depression, or catastrophizing) and social factors (like job dissatisfaction, lack of support, or legal pressures).

There are a variety of standardized tools available for therapists, physicians, and employers to gain valuable insight into how an injured worker is perceiving their injury. These tools can help stakeholders quickly identify patients at risk for prolonged disability based on these non-physical factors and intervene in evidence-based ways to improve the chance of a favorable outcome. For example, consider how a therapist can influence the following factors:

  • Biological: Implementing manual therapy to desensitize structures, encourage improved joint mobility, and increased tolerance to exercise/activity through graded exposure.
  • Psychological: Use cognitive-behavioral strategies or pain neuroscience education to address unhelpful beliefs, educate on expected outcomes, and place imaging findings into the appropriate context.
  • Social: Coordinate care with employers to modify work tasks and support return-to-work goals.

In the workplace, employers and case managers can also apply a biopsychosocial model by avoiding overly medicalized messaging, maintaining open communication with injured workers, supporting injured workers through the recovery process, viewing their employees as assets vs. liabilities, and emphasizing functional recovery rather than symptom elimination. Each of these approaches have been shown to improve outcomes and reduce costs.2,3,4,5

Research: Outcomes and Benefits

The literature supports that a biopsychosocial approach in the workers’ comp setting is both outcomes-driven and cost-effective. A 2022 study4 by Pedersen et al. examined workplace injuries within the context of strong vs. weak job relations. This was defined as strong job relations having a low risk of losing their job after an injury and that injured employees had influence around return-to-work job planning.

This study revealed that those employees with a strong job relationship had a higher return to work rate and spent more weeks working during their rehabilitation. A particularly important finding was that additional care (defined as multidisciplinary interventions) did not make a difference when compared to the basic intervention group who had strong job relations.

So, what is the take home message for employers? Implementing a strategy that is employee first, taking into consideration the employees psychological and social factors, yielded a better outcome with fewer medical interventions.

Conclusion

Adopting a contemporary biopsychosocial approach, grounded in modern pain science, offers a clear path to better outcomes, lower costs, and more efficient care delivery within the workers’ compensation space. Each stakeholder involved in an injured workers’ rehabilitative process has the opportunity to positively or negatively impact the overall progression of that injury. By considering all elements factoring into an injured workers’ pain experience, stakeholders (clinical and non-clinical) can intervene in ways that benefit all.

To learn more about how Upstream Rehabilitation and our family of brands can assist with Workers’ Compensation and how physical therapy plays an effective role in helping injured workers return to work, contact our Workers’ Compensation team today!

 

References:

  1. Butler D, Moseley L. Explain Pain. Second Edition – April 2013.
  2. Grant GM, O’Donnell ML, Spittal MJ, Creamer M, Studdert DM. Relationship between stressfulness of claiming for injury compensation and long-term recovery: a prospective cohort study. JAMA Psychiatry. 2014 Apr;71(4):446-53. doi: 10.1001/jamapsychiatry.2013.4023. PMID: 24522841.
  3. https://www.texasmutual.com/blog/posts/2018/12/the-key-to-compassion-what-your-employee-is-really-thinking-when-they-are-injured-on-the-job
  4. https://www.crawco.com/resources/how-empathetic-claim-management-helps-avoid-large-jury-awards-and-nuclear-verdicts
  5. Hallden J. The original intent of workers’ compensation: a team approach. Work. 2014;48(3):435-9. doi: 10.3233/WOR-141909. PMID: 24962304
  6. Pedersen, K.K.W., Langagergaard, V., Jensen, O.K., et al. Two-Year Follow-up On Return to Work in a Randomised Controlled Trial Comparing Brief and Multidisciplinary Interventions in Employees on Sick Leave Due to Low Back Pain. J Occup Rehabilitation (2022)
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