By Nicole Matoushek, MPH, PT, CSHE, CEES
Returning an injured worker back to the workplace either to their original position or to an alternative one within appropriate restrictions is the ultimate goal of worker rehabilitation. It is important to return the injured worker back to the workplace promptly, in order to maximize therapy outcomes, enhance the patient's coping skills and functional capacity, and return the patient to a normal activity level.
Active clinical management and the prompt return to work will reduce the incidence of chronic pain syndrome behaviors, minimize impairment, and promote the healthful adjustment to or modification of the worker's lifestyle to reach the best possible outcomes both vocationally and psychosocially.
BARRIERS TO RETURN There are various barriers to the clinical management, functional outcomes, and the return to work of the injured worker. These barriers can affect both progress in therapy and return to work. They are classified in terms of subjective, objective, and external influencing factors. Subjective influencing factors include depression, disease conviction, lack of motivation, malingering, and pain focus. Objective influencing factors include clinical complications, co-morbidity, pain limitations, and clinical outliers. External influencing factors that can adversely affect the progress of therapy and return to work of the injured worker include attorney involvement, work or ergonomic issues, and physician re-referrals without medical necessity.
Successful therapy outcomes, patient progress, and return to work can be maximized with the implementation of active clinical management strategies. These strategies for treating the injured worker include providing active clinical management for all objective, subjective, and external influencing factors; keeping the worker motivated; developing patient responsibility and independence from the need for further therapy; providing active, goal-directed treatments; modifying the treatment plan of care based on medical necessity; providing work-specific goals; identifying candidates for further work injury management programs such as ergonomic services, or return to work programs; and providing effective communication to the physician, employer, and referral source.
Return to work may be particularly challenging with individuals suffering from chronic pain. Chronic pain patients are defined as individuals out of work with pain lasting more than 6 months. While representing a small percentage (3% to 10%) of all work injuries, these individuals account for an estimated 80% to 90% of the total dollars spent in the workers' compensation system.1 This dollar amount includes both direct and indirect costs. Direct costs include medical and legal fees, while indirect costs include administrative and training costs, indemnity, as well as lost efficiency.
DEFINING PAIN Pain by definition is a subjective personal experience of discomfort known only to the individual. Because of its subjective nature, quantifying this experience is highly problematic. There are no diagnostic tests that actually measure pain. Thus, an individual's expression of pain is ultimately a manifestation of complex nociceptive stimuli and the brain's processing of that stimuli. In addition, particularly in the case of chronic pain, psychosocial factors can significantly affect the interpretation or motivation of these signals and the manifestation of pain behaviors.
There is a distinction between chronic pain and chronic pain syndrome. Chronic pain is the brain's interpretation of nociceptive stimuli from the body. Chronic pain syndrome is the individual's behavioral response to pain. This behavioral response is affected not only by the pain stimuli received by the brain from the body, but also by the individual's emotional state, personality factors, and social factors. Chronic pain syndrome includes all changes that an individual experiences when chronic pain enters their life. These changes can include loss of activity tolerance, physical deconditioning, alterations in mood and behavior, changes in interpersonal relationships, and loss of social and recreational pursuits. In addition, there may be vocational adjustments, such as loss of a job, diminished productivity, impaired work motivation, or the change of a job or profession. Factors that may increase the risk for chronicity and disability can include previous work injury, total work lost over the last 12 months, poor physical fitness, self-rated poor health, heavy smoking, psychological distress and depressive symptoms, low job satisfaction, and personal problems. It is important to minimize the development of these chronic pain syndrome behaviors and assist the worker with chronic pain to adjust to or modify their lifestyle to reach the best possible outcomes both vocationally and psychosocially. The prompt return to work of an injured worker is an important part of this adjustment.
MINIMIZING IMPAIRMENT In order to minimize individual impairment, it is essential to address return to work concerns immediately with an injured worker. Impairment following an injury may include diminished functional capacity, reduced strength, limited range of motion, loss in activity tolerance, or the use of assistive devices. Impairments can mean restrictions at the workplace. In order to minimize impairment and maximize the successful vocational and psychosocial outcomes, prompt return to work should be a primary goal. To ensure a prompt but safe return to work, appropriate job restrictions should be made. These restrictions can be temporary or permanent. They should be based on what the employee cannot do. They should be specific and should match the essential or primary job functions.
Returning an injured worker back to the workplace either to their original position or to an alternative position within appropriate restrictions is the ultimate goal of occupational medicine and worker rehabilitation. In some cases accommodations may be used to assist the worker in this transition. Other tools to achieve this goal, particularly where there is no accommodation opportunity, include additional medical intervention such as pain management, physical reconditioning, or work hardening.
BENEFITS OF PROMPT RETURN The prompt return to work of an injured worker will also facilitate good coping skills and promote the healthful adjustment to or modification of the worker's lifestyle. The changes that enter the individual's life following an injury can affect interpersonal relationships, financial status, recreational or leisure activities, and vocational situation, and can even cause mood and behavior disturbances. Depression is probably the most commonly encountered emotional disturbance experienced by injured individuals. It is usually part of the worker's response to loss that they may have incurred in their personal life. Other emotional disturbances can include irritability, anger and resentment, fear or anxiety, or changes in personality. These emotional disturbances affect the well-being of the individual. The prompt return of the worker to the workplace will promote the healthful adjustment to or modification of a new lifestyle and minimize emotional or personality disturbances, thus promoting general well-being.
The prompt return to work will reduce the incidence of chronic pain syndrome behaviors, minimize impairment, and promote the healthful adjustment to or modification of the worker's lifestyle to reach the best possible outcomes both vocationally and psychosocially. Successful therapy outcomes, patient progress, and return to work can be maximized with the implementation of active clinical management strategies. These strategies for treating the injured worker include providing active clinical management for all objective, subjective, and external influencing factors; keeping the worker motivated; developing patient responsibility and independence from the need for further therapy; providing active, goal-directed therapy; modifying the treatment plan of care based on medical necessity; providing work-specific goals; identifying candidates for further work injury management programs such as ergonomic services, or return to work programs; and providing effective communication to the physician, employer, and referral source. It is important to return the injured worker back to the workplace promptly to maximize their coping skills and functional capacity to return to a normal activity level.
Nicole Matoushek, MPH, PT, CSHE, CEES, has 12 years of experience in physical therapy practice, ergonomics, clinical management, and consulting in the field of worker
