Chronic pain

Chronic pain 150 150 Affordable Capstone Projects Written from Scratch

Read each article and provide a typed summary (approximately 2 pages double spaced definitely no more than two full pages altogether) of the major concepts and your opinion of each article. Please provide appropriate in text citations for each article. Use the grammar and spell check functions. (10 pts each X 4 articles = 40 pts.) There are actually five articles total, but you only have to pick 4 to write the 4 paragraphs over.


The following article is taken from:



Steven Feinberg, MD: CWCE November 1992 & revised October 1999



Providing cost-effective, yet optimal health care to injured individuals is often a daunting task. The many players involved—the patient, family members, health care providers and medical device suppliers, employers, insurance company representatives, rehabilitation nurse case managers, vocational consultants, attorneys, judges and others—all bring their own perceptions and agendas to the playing field.


Ideally, all parties are first interested in preventing and avoiding injuries. Work injuries do occur despite the best of prevention programs, and when this happens the various parties have different wants and needs following the injury and the subsequent medical care and disability.


The employee and family want to be provided appropriate quality health care while being treated with dignity and respect during illness. The injured worker would like to know that the employer is concerned and that there is a job to return to.


Most important, as well, is the need for communication. The injured worker needs to be informed in regard to medical, legal and return to work issues. This will limit misunderstandings but also decreases the associated anxiety related to no information or even misinformation.


The great majority of injured workers want to return to gainful employment and a normal lifestyle including their usual and customary activities. Concern about income maintenance is often of major importance. Health concerns include physical fitness, sexual functioning, adequate sleep, and pain control.


The employer is trying to run a profitable business and needs a productive employee who can maintain work place production. There is an obvious need to contain medical costs. The employer also needs to be informed and to receive communication to effectively plan for the future.


The payer (insurance administrator) has legal obligations to fulfill along with payment for the provision of appropriate, effective medical care to the injured worker. At the same time, the payer is concerned about cost containment. Effective and timely communication is of paramount importance to claims people as well.


The various health care providers have a desire to provide appropriate medical care while minimizing paperwork and “hassles.” Timely and adequate reimbursement is always a major concern.


The patient’s (applicant) attorney should provide information and legal representation. Timely communication between the attorney and injured worker and from the insurance administrator and health care providers is critically important.




When an injury does occur, immediate recognition and a rapid response are of paramount importance. When treatment delays occur whether due to system inefficiencies or questions of causation, the situation often spins out of control with ramifications that lead to excessive costs to the payer and prolonged suffering for the injured worker. Even when the workers’ compensation system functions at its best, a few injured workers decompensate, become dysfunctional and are labeled “chronic pain” patients.


Chronic pain robs the injured worker of his or her ability to have a productive, meaningful and enjoyable life. It takes away hobbies, recreation, friends, and the ability to support his or her family through gainful employment. The individual with chronic pain is not comfortable while awake, and usually does not sleep well. Weight gain and sexual difficulties occur. Anger, depression, despair and irritability are common. Chronic pain is often accompanied by loss of hope and self-esteem. It saps the individual’s energy and the ability to think straight.


Despite what often appears to be insurmountable odds, it is possible for the individual to learn to manage pain and to regain a productive and healthy life.



Immediate injury or illness recognition and treatment are the first steps to effective case management. Significant problems develop when causation is questioned or when injury recognition or acknowledgment is deferred. Employers who encourage workers to not file claims to see if the problem just goes away or to prevent insurance surcharges only cause more problems for themselves in the long run.


Medical care is often more “art” than “science.” I would like to suggest a model of medical care that views the doctor as a “Physician-Healer.” This is a commonsense approach to practicing good medicine.


The physician-healer is compassionate, consistent and fair. The physician-healer is a patient advocate who provides firm medical care with a return to work orientation. Neither rushing the injured individual back to work to please the employer or insurance carrier nor keeping the individual out of work needlessly is part of good medical care.


Time spent with the patient involves issues of timeliness, quantity and quality. It is important to show respect for the patient by being on time and leaving a long enough appointment to address all issues and questions.


It is important for the physician to do a thorough history and physical examination. It is of critical importance that the physician not only asks about the injury, but also get a sense of the depth and breadth of the injured worker’s life.


It is important for the physician-healer to have the ability to rapidly recognize problem cases (Red Flags). It is important to determine motivating factors and what the patient wants.


Consider the following: How does a person with a problem become a patient with an illness? Recognizing what is motivating the injured worker and the associated illness behaviors will lead to better and more cost-effective medical care.


Realizing that the actual injury may be only partly accounting for the injured worker’s complaints may prevent injury extension, iatrogenic illness and unnecessary and costly tests and procedures.


The physician-healer needs to be cognizant and recognize the difference between organic and non-organic disability factors. It is important to recognize the rare malingerer who is perpetrating a fraud from the legitimate injured worker who has symptom magnification or exaggeration, whether conscious or unconscious.


Understanding the difference between acute and chronic pain is essential since treatment approaches are different for each. In fact, the treatment of the chronic pain patient with an acute pain protocol often results in inappropriate care and increasing disability.


The physician-healer understands the importance of communicating with the injured worker, family members, other health care providers, the employer, insurance carrier, rehabilitation nurse, attorneys and others.


Medications can include the early limited use of muscle relaxants and narcotics, but these drugs should not be used for prolonged periods of time, if at all. Judicious use of acetaminophen, aspirin and non-steroidal anti-inflammatory medication can be helpful. Antidepressants can also be useful, particularly with various pain conditions.


Tests and Procedures are commonly performed, but the physician should consider whether such services would make a difference. Too many tests and procedures are performed, and often the results are used to justify unnecessary further tests, procedures or surgeries. Physicians should treat the patient not the test results! An abnormal test result may not be relevant to the complaint.


In summary, the physician-healer or “ideal” medical provider is a patient advocate who is also concerned about cost-effectiveness and resource consumption. Just as it is important to know how to treat, it is also important to know when to stop. Nothing can replace good judgment. There is no end to the number of potential treatments and procedures, but will they make a lasting difference and affect the outcome?


Caring and concern is important but often the physician enables and supports illness perception and behavior by excessive attention and unnecessary medical care. Medical care should always be directed towards the injured worker taking responsibility for his or her own health, rehabilitation and well being. The health care practitioner can only effectively serve as a teacher or guide if this endeavor is going to be successful.


Physical and Occupational Therapy services are often prolonged and excessive. The physician should avoid ordering modality oriented, “shake-and-bake” therapy. Formal therapy occurs only a few hours a week and this necessitates that the therapist serves as an educator to the injured worker (student) so that treatment continues and is incorporated into everyday activities.


The therapist should emphasize therapeutic, active, patient directed therapy with appropriate time frames for treatment. The injured worker should begin an early stretching, strengthening and conditioning program emphasizing return to work (modified or full duty). Utilization of a work capacity center for a functional capacity evaluation, work hardening program, and a vocational evaluation may be useful. The injured worker may additionally benefit from a fitness center program and a self-directed exercise program.


Only an educated patient can be an active participant in rehabilitation. Passivity equates with lack of responsibility for getting well and returning to work. Make sure the injured worker understands the workers’ compensation system.


Successful treatment of the injured worker with resolution of symptoms will be for naught if the cause of the injury is not addressed by ergonomic modification and task simplification at the job site and consideration of causative factors away from work.


Return to work issues are different for each of the parties involved. The employee’s issues may include dislike of the job, co-workers or supervisor. The injured worker may be fearful of re-injury or be desirous of retraining and vocational rehabilitation. Identifying these issues will help clarify what may appear to be subjective complaints in excess of objective findings.


Employer and co-worker issues concerning the injured worker’s return to work are important. When the employer does not want the individual back or when co-workers are critical of modified duty, the injured worker often feels demeaned and unwanted. This can only lead to problems.


A job description or analysis can be very helpful to clearly delineate work demands. Determining the injured worker’s functional capacity, both physical and emotional can help determine true work abilities.


Getting the injured worker back to the job as soon as possible is of great importance. Time away from work not only means reduced income and the associated problems, but also engenders feeling of decreased self worth and doubt. It is a known fact that the likelihood of an injured worker returning to work decreases with time away from the job. Early return to modified work with fewer hours or with less strenuous job duties can be an effective means of reinserting the injured worker into the work place.


Vocational rehabilitation should start as soon as possible once it has been determined that the injured worker will be unable to meet the demands of his or her former usual and customary job duties. This should occur regardless of whether the injured worker has been deemed permanent and stationary. The employer should consider return to permanent modified duties or alternative job functions, and if this is not feasible, then alternatives should be pursued.


It is important to make realistic vocational plans. Functionally, vocational rehabilitation is a chancy proposition under the best of circumstances, particularly in a difficult job market. The individual’s abilities and goals are of the greatest importance as poor planning leads to wasted resources and decreased perception of self worth with associated increased disability.


THE DILEMMA: Injured Workers Who Become Dysfunctional Chronic Pain Patients 

One of the greatest challenges to the workers’ compensation system is the evaluation, treatment and permanent disability rating of injured workers with chronic pain. Many patients with a chronic pain problem are functional, working and in some ways are “invisible” as they do not display outward manifestations of discomfort. Too often though, and after great expense, the injured worker with chronic pain remains dysfunctional and unemployed while continuing to consume resources with no end in sight.



The effective evaluation of dysfunctional patients with chronic pain requires the physician to be thoroughly familiar with the physiologic characteristics of pain as well as the social and psychological factors that influence an individual’s response to a work injury.



“Pain” is a general term that can mean many different things. It can be thought of as a signal that something is wrong and it is also used to describe an individual’s response to that signal. The International Association for the Study of Pain (IASP) defines it as “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”


The concept of pain can best be understood if it is divided into its component parts: Nociception is the activation of pain fibers by an injury thus initiating a signal that aversive events are occurring. Pain is the perception of this signal by the nervous system. Suffering is the emotional response accompanying pain and can also be defined as a state of severe distress associated with events that threaten the well-being or intactness of the person. Pain Behaviors are things (limping, grimacing, moaning, etc.) some people do when they suffer or are in pain. Pain behaviors often present as misdirected activities connected in superficial appearance to discomfort but (often unconsciously) directed at ends other than pain relief such as sympathy and time out from activities that are viewed as unpleasant (e.g., work) by the injured individual.


It is important to view nociception and pain separately as a signal system, while suffering and pain behaviors should be viewed as a set of responses that blend past experience and anticipation with perceived stimuli. Two people with identical injuries may display widely differing perceptions and responses to the same pain “signal.”



Disability is a legal or social judgment regarding loss of function based in part on a medical opinion. Depending on the particular rating system, disability is determined by a combination of measurable objective impairments (like an absent reflex or a paralyzed limb) as well as subjective factors (e.g., complaints of pain).


Consider the following question. For the injured worker with chronic pain; when, and how much, do suffering and associated pain behavior, apart from objective findings, warrant a person’s designation as disabled or requiring assistance? In other words, how much weight should be placed on subjective factors? The answer to this question will vary according to the rating system used and the judgment or bias of the individual determining disability.



Acute pain is a physiologic response to tissue damage and a warning from the body’s alarm system that signals damage or danger. It helps locate the source of the problem. It thus has biologic value to the individual.


Chronic pain is a common problem with many definitions and is difficult to diagnosis and perplexing to treat. It is a subjective personal experience that cannot be measured or quantified and can only be evaluated through observation of a behavioral reaction (i.e., what the patient demonstrates to us). Chronic pain may originate from a genuine physical source but in a subtle and progressive manner it begins to “out-shout” the original disease. It becomes the disease. It has no biologic value to the individual.



The cost of chronic pain to society exceeds seventy-five billion dollars yearly in medical costs and lost work productivity. The personal cost in terms of lifestyle alterations to the injured worker and family members is considerable and cannot be adequately measured.



Internal factors include the individuals past pain experiences, ethnic and cultural background, and the presence of secondary gain or rewards for illness behavior. The premorbid psychological make-up of the injured worker as well as the social situation (past and present) at work and at home is also of importance. The following factors are common in patients who are dysfunctional with chronic pain: a history of childhood emotional, physical or sexual abuse, substance abuse (alcohol, tobacco, drugs, etc.) and ongoing marital discord and/or work place related problems.


External factors include the fact that physicians and significant others often inadvertently support pain complaints and behavior. Physicians receive little training in chronic pain management and their education actually teaches mismanagement. Physicians are trained to ask about and pay attention to pain complaints that can reinforce pain behavior. Continued tests and medications for increasing complaints support the injured worker’s perception of being dysfunctional. Illness behavior is rewarded by attention from others (family, friends, co-workers, etc.), and time out from unpleasant tasks such as work, being productive, competition, and for some people, sex. There can also be financial (disability payments) and educational (vocational rehabilitation) rewards for illness behavior.



Chronic pain patients tend to present with similar features. They report persistent (3 to 6 months) pain, which may be consistent with or significantly out of proportion to physical findings. They demonstrate progressive deterioration in ability to function at home, socially, and at work. Many chronic pain patients show progressive increase in request and usage of medications or invasive medical procedures. They demonstrate mood disturbance with a predominance of depression and anxiety and exhibit significant anger and hostility.


Chronic pain patients also commonly present with non-organic physical findings including superficial and non-anatomic tenderness, “give away” weakness, a sensory loss that does not conform to any known nerve distribution and various pain behaviors such as grimacing, limping, moaning, and frequent position changes.



Chronic pain patient characteristics can include suffering, loss of hope and self esteem, pain behavior, significant lifestyle alterations and losses, drug dependency, multiple medical and surgical interventions, difficulty sleeping, decreased sexual interest and participation, inactivity, somatic preoccupation, weight gain and physical deconditioning. Patients often wear the “Badge” Of Chronic Pain. They dramatize their complaints and use devices such as braces and canes to justify illness and recognition as being sick and disabled. These individuals present with posture and gait abnormalities, they display facial grimacing and they rest excessively.



In the natural history of chronic pain everyone loses! The patient sees multiple specialists and undergoes numerous tests and procedures, and possibly unsuccessful surgeries are performed. The physician, payer, employer, and attorney become frustrated and often question the patient’s motivation. Terms such as malingerer, symptom magnifier, elaboration, exaggeration, embellishment along with somatoform disorder and functional overlay are utilized in medical reports. After significant resources have been expended, the patient is told that “There is nothing more that can be done for you. You will have to learn to live with it.” By this time the patient is desperate: “The PAIN is real! It’s not all in my head.”



This includes reducing the misuse of medications and invasive medical procedures, maximizing and maintaining physical activity and returning to productive activity at home, socially and/or at work. Also important is increasing the patient’s ability to manage pain and related problems while reducing subjective pain intensity. Goals should include reducing or eliminating the use of health care services for primary pain complaints and minimizing treatment costs without sacrificing quality of care. The program should providing useful information to the patient and professionals involved in the case to resolve any medical-legal issues and allow case settlement.


A strong emphasis needs to be placed on increasing the patient’s level of function and ability to manage pain and related problems, even if no reduction of subjective pain intensity is feasible.


The clinical evaluation needs to be tailored to each chronic pain patient and performed by health care professionals with specialized training in pain medicine and rehabilitation. The initial clinical evaluation needs to be performed by a physician and psychologist. At the onset of treatment an evaluation needs to be accomplished to assess the individual’s emotional, physical and functional abilities. If return to work is a goal, a vocational evaluation component should be included.


Continued reassessment should be ongoing throughout the treatment process to continually update decisions and revise the treatment plan accordingly to achieve as many of the treatment goals as possible.



Choosing which patients and in what setting they should be offered treatment is critical. Treatment should be offered only to those patients who exhibit a reasonable chance of showing significant improvement. Factors that should exclude patients from treatment in a chronic pain program include the inability to understand and carry out instructions, aggressive and/or violent behavior, imminent suicidality, unwillingness to participate or uncooperative behavior. Individuals with unrealistic expectations such as a total cure are poor candidates for treatment. Patients who have medically unstable conditions such as high blood pressure or heart failure may not be able to participate in treatment.



Treatment modalities that should be available include medication management, physical and occupational therapy, behavioral-psychological therapy, vocational and disability management and adjunctive treatment modalities such as nerve blocks and trigger point injections.


Medication management includes a trial or continuance of non-steroidal anti-inflammatory and/or anti-depressant medications. There continues to be much controversy regarding the use of narcotic medication for CPS patients. Their use should be limited and if used there should be clear evidence that they do not impair the patient and produce significant and sustained improvement in function. Patients with a primary alcohol or other substance abuse problem should be treated for this separately prior to active participation in a pain rehabilitation program.


Physical and occupational therapy should be active with limited, if any, passive “shake and bake” modalities. The goal of intervention is aimed at reactivation of the injured worker’s ability to function. This is an educational model where the patient learns improved posture and body mechanics while increasing general fitness, coordination and flexibility.


Behavioral-psychology therapy is aimed at teaching individuals pain management skills. The modalities generally include cognitive restructuring of perceived pain and disability, reduction of anxiety and depression, with relaxation and self-hypnosis used to reduce muscle tension. Treatment may also include biofeedback, marital/family therapy, and group therapy.


Vocational issues need to be addressed conly while the patient progresses from multidisciplinary pain treatment to a smooth transition towards gainful employment.


Adjunctive treatment modalities can include a variety of nerve blocks, trigger point injections and more invasive procedures such as spinal cord stimulators or implanted narcotic spinal pumps. Much controversy swirls around use of such procedures and the efficacy of such treatments is too lengthy and controversial to discuss in this article. Expensive procedures show low to moderate long-term effectiveness.


Follow-up is a critical component of treatment to reduce recidivism or “back-sliding.” Patient support groups can be beneficial and are strongly recommended to help move injured workers towards a normal life.



The medical care of these dysfunctional injured workers is difficult and costly. The individual may be well ensconced in the role of a dysfunctional chronic pain patient and be unwilling to give up the “benefits” of being ill. Even with treatment, relapse and recurrence rates are high with “successfully” treated patients often slipping back into prior patterns of dysfunction. Despite these negatives, many dysfunctional injured workers with chronic pain can be treated successfully, particularly with early intervention using a functional restoration model.


A multidisciplinary team best provides evaluation and treatment with leadership provided by a physician with expertise in chronic pain management. A rehabilitation nurse should be assigned to the case to provide case management.


Treatment goals for the dysfunctional patient should include detoxification from drugs, reduced cure seeking, pain control, an increased activity level, reaching a P&S status and return to work.


Functional restoration program components can include exercise and conditioning, medication reduction, vocational and psychological services, dietary counseling, didactic lectures, and work readiness activities. The program should concentrate on the injured worker taking responsibility for the rehabilitation program and return to work effort.


Payers are often wary about recommendations concerning psychological services in fear of invoking a “psychiatric” claim with associated prolonged treatment and no end in sight. It is important to realize though that emotional dysfunction is part and parcel of a chronic pain syndrome and that physical treatment alone without a psychological component will likely be unproductive. Psychological services should be limited and focused on the pain problem and increasing function.


Physician involvement includes being there for the patient for reassurance and guidance through the difficult process of learning to manage chronic pain and returning to a functional existence. Complaints of increased discomfort are not unusual once a pain program starts as the patient is already deconditioned and likely will experience the normal aches and pains of getting back in shape. The physician will reexamine the patient and reassure the injured worker that this is the “good” pain that comes with taking back your life and becoming healthy again.


If the individual is a qualified injured worker, then vocational rehabilitation efforts should be started early during the medical treatment phase. It requires the cooperative efforts of all concerned. It is important to identify and deal directly with problems such as pain behavior, lack of job seeking skills, poor self-concept, unrealistic goals, return to work fears, and lack of “motivation.” The constant focus should be not whether the injured worker is going back to work, but when!


A functional restoration program is ideally accomplished on an outpatient, part time basis lasting two to three months, but for injured workers with significant psychosocial issues, a full time program lasting approximately four to six weeks is more effective.


Functional restoration programs are much more cost effective than traditional chronic pain treatment that tend to focus on pain relief rather than increased function. Chronic pain programs that emphasize the use of narcotics and procedures such as nerve blocks, may provide temporary benefit, but without achieving increased function and self sufficiency, the injured is unlikely to maintain any long-term pain relief or improvement.


Treatment should not go on indefinitely. Continuation of a functional restoration program can only be justified if the injured worker is making steady gains toward return to increased function and return to gainful employment.


A physician with chronic pain management experience best manages future medical care for the chronic pain patient. De-emphasis on medications, procedures, therapy and somatic preoccupation is important. The treating physician best serves the chronic pain patient with reassurance and encouragement to stay active and to keep working.



All parties in the workers’ compensation system potentially contribute to the creation or prevention of dysfunctional injured workers. Prevention is the most effective method of keeping down costs while also avoiding human suffering. Prevention starts out with caring and concerned employers hiring and supporting appropriate employees. Risk management and loss prevention programs make sense and should be encouraged. Ergonomic changes are best accomplished as part of a prevention program rather than after an injury has occurred.


Once a worker is injured, immediate recognition and appropriate treatment are essential to injury resolution. Complicated or possible problem cases should be identified early, a rehabilitation nurse case manager assigned and referrals made to specialists capable of providing fair, compassionate and cost-effective care. Critical in this whole process is an educated and informed injured worker.


When it becomes obvious that traditional treatment approaches are ineffective, early referral to a functional restoration and/or chronic pain program is recommended.


Admittedly, evaluation and treatment of injured workers with chronic pain are difficult and often unrewarding. Such efforts can prove worthwhile though in appropriate selected patients, while meeting our legal, moral and ethical obligation and duty to assist the injured worker with returning to a meaningful life and gainful employment.


Medical care whether for acute illness or chronic disease is not inexpensive. Health care practitioners should be prepared to offer clear and concise treatment plans and time frames for treatment. Chronic pain rehabilitation efforts should have a definite endpoint and return to work focus. The answer for these individuals is not more doctors, procedures and surgery but rather case closure with an allowance for appropriate conservative future medical care.


Ideally, a well-coordinated, appropriate and rapid response to injury with early recognition and directed treatment of problem cases may avoid the dilemma we often find ourselves in with a dysfunctional injured worker with chronic pain.

Published/Copyright 2000 CWCE Magazine For The Workplace Community.


hereThe following article comes from:;f=25;t=001644;p=0


Title: Keeping the Injured Worker Motivated in Therapy

Author: Nicole Matoushek PT, MPH, CSHE, CEE


Worker Rehabilitation
Worker Rehabilitation is a specialized field of rehabilitation that focuses on treating patients with work-related injuries. Rehabilitation professionals have treated injured workers for decades. In recent years, however, there has been an increase in the involvement and focus of the clinical management of injured workers. Rehabilitation professionals are now, closely involved with the clinical management of the injured worker from the acute stage in the rehabilitation process through return to work. This involvement in specialized return to work programs and the determination of the readiness of return to work has created a niche to effectively and safely assist in the return of an injured worker to gainful employment.


The Goal
The primary goal of worker rehabilitation is to address the injury and to return an injured worker back to the workplace to his, or her, original position or to an alternative position with appropriate restrictions. In some cases, accommodations may be required to facilitate the worker in this transition. Other clinical methods may be needed to achieve this goal, particularly where there is no accommodation opportunity. These clinical methods include; additional medical intervention such as pain management, functional capacity evaluation testing, physical reconditioning, or work hardening. In most cases, prompt return to work results in the best clinical outcomes.


The Benefits
The benefits of prompt return to work of an injured worker go beyond early case closure and clinical outcomes. The prompt return to work of an injured worker facilitates good coping skills and promotes the healthful adjustment to or modification of the worker’s lifestyle and minimizes emotional or personality disturbances thus promoting general well being.


The Challenges
The injured worker seeking rehabilitation following a work-related injury may present with emotions or feelings that could potentially adversely affect the progression of the functional restoration process. The injured worker may have feelings of skepticism, anger, fear, frustration or a lack of motivation. They may have emotions or fears about loss of function, inability to perform work duties, and financial concerns. The workers’ compensation patient may also be experiencing job changes, due to the need to perform job duties that are less fulfilling or challenging or may involve a lower pay. These emotions and feelings can adversely affect the progression and functional outcomes of the therapy or work injury program. Therefore finding ways to keep the injured worker motivated and focused on the task at hand: the rehabilitation of the injury and the safe and prompt return to work, becomes critical.


Keeping the Injured Worker Motivated
There are various methods to help to motivate an injured worker to progress with their rehabilitation and return to work. Once the rehabilitation professional identifies an individual with potential motivational challenges, the rehabilitation professional can develop a strategy to facilitate and improve the individual’s compliance and motivation to achieve rehabilitation goals. Respect for the injured worker is essential. To effectively motivate the injured worker, the individual must feel respected. This respect can be demonstrated if the rehabilitation professional has an appreciation for the mental, physical and emotional resources and states of the individual. Many of these individuals have not worked for extended periods of time; they may be physically deconditioned, may have chronic pain, or pain syndromes or may be having difficulty adjusting to functional impairment. While in other cases, the lack of motivation may not be completely clear or the individual may have ulterior motives. In all cases, there are various methods to motivate the injured worker and achieve success with the return to work objective. These methods are described below:


Methods to Motivate Injured Workers:
Rehabilitation Staff: Provide a rehabilitation staff that offers continued encouragement and positive feedback.

Create an Environment that Fosters Return to Work: The physical environment of the facility should set the stage for recovery and functional restoration. The environment should offer and encourage physical activity, independence, functional activities, individual responsibility, appropriate behaviors and facilitate work-specific training.

Behavior Modification Techniques: When treating an injured worker who presents as difficult, unmotivated, does not put forth maximal effort or behaves inappropriately, the rehabilitation professional should confront the individual. However, the confrontation should be supportive and encouraging, not destructive or accusatory. These individuals should be educated about their behaviors, motivational levels and clinical inconsistencies. This provides an opportunity for the injured worker to modify their behavior and improve his or her performance.

Goal Setting: Treatment goals should be set weekly and should be discussed with the injured worker. The injured worker should be aware of the goals that are set for him or her, as well as the progress towards the rehabilitation goals. This establishes clear expectations, and facilitates compliance and progress. If the individual fails to progress towards the goals as expected, discharge from skilled rehabilitation may be appropriate. The reasons for the discharge will have been identified and communicated to the individual.

All of these methods can be helpful in skilled therapy, and can foster the successful clinical management and return to work of the injured worker.


(Original article, published in ADVANCE for PTs and ADVANCE for OTs, 2005)
Nicole Matoushek, MPH, PT, CSHE

ErgoRehab, Inc.



The following article comes from:


Quick Response in Workers’ Comp Cases (Often the single most important factor in reducing total costs.)



While the benefits of safety and loss prevention programs are mostly self-evident, they only represent half the battle in the war on workers’ compensation costs. Minimizing the severity of accidents that do occur is of equal importance.


The severity of a workers’ compensation injury is not determined solely by the nature and extent of the injury. Only the physical damage can be adequately assessed at that time. Too often employers focus on the immediate need to stop the (physical) bleeding by rushing the injured worker to the nearby emergency room, only to allow the emotional and financial “bleeding” to continue and clot at its own pace.

Obviously, getting the injured worker appropriate medical care as quickly as possible is the first step. But, quick response shouldn’t stop there. As soon as the situation at the site of the injury is under control, the real work begins.

The loss must be reported to your insurance carrier or claims administrator immediately. This “Timely Notification of Loss” is the key to getting quality claims service and managing loss costs.

The sooner the claims adjustor can begin “managing” the claim, the sooner he can get it resolved (either through return to work or settlement) and the less it will end up costing the employer. Proper claim management starts with contacting the injured employee, employer, and the treating physician to properly and fully understand the situation.

Immediate contact with the injured employee gives him reassurance that his claim will be handled quickly and fairly. It also allows the employee to get answers to questions or concerns he may have about how and when he will receive benefits, what to do with medical bills, etc.

By contacting the employer worksite as soon as the injury is reported, the adjustor can gain a better understanding of how the injury occurred and what the employee’s job requirements are.

Early intervention with treating physicians can help assure that appropriate quality medical care will be provided with the goal of returning the injured worker to the job when it is best to do so, either at a full or modified duty level.

Quick response to a workers’ compensation injury also allows for other “cost management” programs (such as work hardening, vocational rehab, etc.) to work in the most cost effective manner.

Overall, quick response and early intervention provides for efficient claims handling, reduced costs, and positive employee morale by demonstrating to injured employees that you are concerned about his/her welfare and are providing quality workers’ compensation benefits. Many studies have shown this to be true. Some business insurance studies show that for each day that passes between the date of injury and the date case management begins, the duration of the claim increases by 2 1/2 days. In other words, if it takes an average of two weeks before your claims adjustor can begin working on your workers’ comp cases, the cases will typically last more than a month longer than if immediate intervention is employed.

Establish and communicate to all management and supervisory employees mandatory policy and procedures on what to do when an on-the-job injury occurs, including a review of the importance and benefits of timely notification of loss to your insurance carrier or claims adjustor.

Workers’ Compensation Quick Response Checklist

  • Telephone or fax all first reports of injury to the carrier or adjustor immediately after the incident occurs. Don’t delay while waiting for medical reports, bills, etc.
  • Minimize the number of people in the loss reporting process. Provide for direct notification from the worksite to the adjustor rather than channeling the reports through a main office. Establish procedures for using back-up personnel to report losses when the person who is primarily responsible is unavailable to do so.
  • Work with your insurance company to assist in gathering subsequent information helpful in minimizing the loss. Help them understand the employee’s job requirements, how the accident happened, and what modified work you have available.
  • Stay in touch with your injured employees, reminding them they are a valuable part of your team, and asking them what you can do to help speed their recovery.
  • “Stop the Bleeding” in the emotional and financial aspects of the work-related injury; don’t just relieve the physical pain.



The following article comes from:

Maximizing Outcomes By Nicole Matoushek, MPH, PT, CSHE, CEES

October 2005

Returning injured workers to the job involves addressing a variety of needs

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.

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.

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.

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.

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


The following article is from:


Desperate workers can turn to violence

Strains of delays, pain from injuries dangerous mixture

By Bob Norberg
Press Democrat staff writer


In Santa Rosa a year ago, a man fired a shot through his apartment ceiling into the bedroom of a neighbor, narrowly missing people sleeping in bed. Another man was shot to death in the lobby of the Santa Rosa Police Department, where he had been acting erratically. Just recently a man shot himself, his wife and his daughter to death in their Santa Rosa home.

A year ago, a former Marine shot himself to death in the office of Peninsula Rep. Tom Lantos, where he had been seeking help in clearing up his dispute over his disability claim.

Three years ago, in Emeryville, a disabled worker came back to work, confronted a personnel analyst for the company in a dispute over his benefits and later followed her into the parking lot, where he shot her with a handgun.

Also three years ago, during a meeting with a workers compensation judge in Santa Monica, a woman pulled a pistol out of a purse and shot herself in the head. A year earlier in a Los Angeles workers compensation hearing room, a judge disarmed a disabled worker who was holding a small-caliber pistol to the head of an attorney representing the man’s former employer.

The common thread in these cases, according to police, attorneys and state officials, was all of the people were injured workers, with their cases entrenched in the workers compensation bureaucracy.

The obvious question is whether the violence was the result of a person having to deal with the injury and the system, or the result of personal demons that already were haunting the person, said Robert Baron, a Santa Rosa psychiatrist.

The answer, Baron said, probably is both. ”There are individuals who play out the psychological problems of a lifetime through their injury,” Baron said. ”It can get pretty drawn out for the claimant, and they snap. They can be just overwhelmed.”

According to a Press Democrat analysis of state computer data, disputed cases — about 20 percent of all workers comp claims — take an average three years to resolve, while the injured worker is left to deal with the disability and economic hurdles.

There is widespread agreement the situation can turn dangerous. ”Violence is a very serious problem,” said Chris Voight, spokesman for the Association of California State Attorneys and Administrative Law Judges. ”Judges and the lawyers who appear before the judges all see this. ”You have people who have been waiting for months or years for closure and they’re broke and they’re desperate. They’re very emotional about their illness and their economic situation. Threats are not at all uncommon and people are worried about it.” The problem is so serious that Voight’s association is renewing its call for metal detectors for all workers compensation courtrooms, where there presently are no security measures, not even bailiffs with sidearms.

Advocates for injured workers call for a different response. ”Wouldn’t you think they’d try to fix what’s causing the despair, instead of just locking themselves up tighter?” asks a frustrated Dorsey Hamilton, founder of Compensation Alert, a nonprofit group that helps injured workers. When an incident with a disabled worker does occur, it is likely to generate headlines. Even if the link to the disability never is mentioned, it often is obvious to the lawyers and families of the disabled person. ”It’s pretty common and you’re going to see a lot more of it,” said Don Galine, the attorney for Victor Francis, the former Marine who killed himself in Lantos’ office. ”We had one case where I was talking to the wife on the phone and the guy was shooting holes in the floor while we were talking. I was listening to the shooting. It is very common for people to become totally frustrated with the system. ”The death (of Francis) is definitely related to the workers comp system — they cut off all his benefits,” Galine said. ”He was so disillusioned and distraught. Here you had a hard-working guy, a veteran, and he couldn’t work and he was broke.”