Rehabilitation of the Injured Worker with Pain

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Rehabilitation of the Injured Worker with Pain

• Sridhar V. Vasudevan, M.D.
• Clinical Professor of P.M. R.
• Medical College of Wisconsin Milwaukee, WI

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Educational Objectives

• Understand the concepts of injury and the role of
  the physician in rehabilitation of the injured
  worker with pain
• Recognize the complexity of the pain process
• List the stages of disability in workers
  compensation injury system
• Identify the frequent problems in the evaluation
  management of work injuries
• Discuss the strategies useful in effective and
  efficient rehabilitation of the injured worker

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DEFINITIONS

• INJURY
• WORKER
• RESIDUALS OF INJURY
• ACUTE PAIN
• CHRONIC PAIN
• CONCEPTS OF DISABILITY
• REHABILITATION
• LIMITATION / RESTRICTION
• CONCEPTS OF DISABILITY

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Definitions / Concepts

• INJURY
• A mental or physical harm to an employee caused
  by accident or disease.
• It includes damage to or destruction of
  artificial members (hearing aids, eye glasses )

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Definitions / Concepts

• WORKER
• Employee covered by the workers compensation laws
  of the State of Wisconsin. (Wis. Chapter 102 )
• At the time of the injury, the employee should be
  performing services OUT OF and INCIDENTAL TO the
  employment
• The injury is not intentionally self inflicted

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Definitions / Concepts

• RESIDUALS OF INJURY
• Pain
• Weakness
• Decreased range of motion- Stiffness
• Deformity
• Amputation
• Decreased endurance
• (All leading to Disability from Work )

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Definitions / Concepts

• ACUTE PAIN
• A warning of a physical condition needing
  correction
• Is biologically meaningful, useful, time limited
• An UNPLEASANT Sensory AND Emotional EXPERIENCE
  which is primarily associated with tissue damage
  or described in terms of such damage or both (
  I.A.S.P. )

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Definitions / Concepts

• CHRONIC PAIN
• A condition that lasts beyond its healing period
  ( 3 to 6 months ) and is associated with
  significant lifestyle alterations including
  loss of employment, decreased physical, social,
  and recreational activities, psychological
  changes and disability
• Frequently associated with Ds that include Drug
  misuse, Depression, Deconditioning, Disuse,
  Dysfunction Disability that exceeds
  identifiable objective pathology

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Definitions / Concepts

• CHRONIC PAIN
• Persistent or recurrent acute pain of sufficient
  duration and intensity to adversely effect the
  function of the person (WMS)
• NOCIOCEPTION Tissue injury
• PAIN Unpleasant sensory experience
• SUFFERING Emotional consequence of pain
• anxiety, fear, depression
• PAIN BEHAVIOR What a person says, does, or does
  not do, that indicates pain

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CONCEPTS OF DISABILITY

• PATHOLOGY
• Is the change occurring from injury and the
  response of the body
• Altered Anatomy and / or Physiology
• Example Lumbar strain, Disc herniation with
  radiculopathy, rotator cuff tendinitis

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CONCEPTS OF DISABILITY

• IMPAIRMENT
• The anatomic, physiologic, psychologic
  abnormalities or loss that are medically
  determinable by objective means
• May be temporary or permanent
• Examples Decreased range of motion, decreased
  sensation / strength, absent reflexes, abnormal
  MRI / EMG, depression, decreased cognition

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CONCEPTS OF DISABILITY

• LIMITATION OF FUNCTION
• Those functions that could be POTENTIALLY limited
  due to the impairment (s)
• Example Inability to do overhead work, Inability
  to lift over 20 lbs. avoid twisting

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CONCEPT OF DISABILITY

• DISABILITY
• Task-specific inability to perform specific
  function that may be related to the role of the
  patient
• Example Inability to perform heavy construction
  job

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REHABILITATION

• A treatment PROCESS concerned with the medical,
  physical, psychological, social, emotional, and
  vocational aspects of the individual.
• It focuses on maximizing FUNCTION and assisting
  in the assumption of USUAL ROLES, in individuals
  with impairments that compromise function

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DEFINITION / CONCEPTS

• LIMITATION
• Activities that CANT be done due to
• Anatomic loss- amputation, contracture
• Functional loss-vision, hearing, sensory loss
• Subjective symptoms- pain, fatigue, dizziness
• Motivation- secondary gain, FEAR, stress
  avoidance

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DEFINITION / CONCEPTS

• RESTRICTION
• Activities that SHOULD NOT be done as they
  may
• Delay healing
• Aggravate condition
• Accelerate course of disease
• Precipitate symptoms
• Provide safety threat to employee and co-workers

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STAGES OF DISABILITY

• TEMPORARY TOTAL DISABILITY ( TTD )
• TEMPORARY PARTIAL DISABILITY
• PERMANENT PARTIAL DISABILITY (PPD)
• PERMANENT TOTAL DISABILITY

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TEMPORARY TOTAL DISABILITY

• Period of time where employee is under ACTIVE
  treatment and unable to provide restricted work
• 2/3 rd. of wages provided- based on statutes

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TEMPORARY PARTIAL DISABILITY

• Where the employee is able to resume part time or
  limited duty work
• Still in active treatment
• Paid to the TTD amount

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PERMANENT PARTIAL DISABILITY

• Once Healing period/ Maximum Medical Improvement
  (MMI) is reached.
• Further treatment would not improve or change
  condition substantially and the condition is not
  progressive
• SCHEDULED limbs, eyes, ear
• NONSCHEDULED spine, torso, head

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PERMANENT TOTAL DISABILITY

• Injured worker is PERMANENTLY and totally
  disabled from being able to return to ANY work.

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STEPS IN THE REHABILITATION OF THE INJURED WORKER

• Accurate Diagnosis- causation?
• Prompt, proper, timely treatment- that is
  appropriate and reasonable
• Ongoing assessment of medical status and ability
  to work- Stage of disability
• Assessment of residual capacities, limitations,
  and restrictions-Temporary OR Permanent

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STEPS IN THE REHABILITATION OF THE INJURED WORKER

• Returning employee back to work, outlining
  capabilities and restrictions
• Determining end of healing if there are any
  permanent restrictions
• Maximum medical improvement PPD
• Acceptance of the employee by the employer -same
  job, different job same employer, training
  placement with same employer, or outplacement

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PROBLEMS

• The diagnosis
• The treatment
• The employee
• The employer
• Job/work factors
• Other factors

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PROBLEMS The Diagnosis

• Limited in scope- DDD, facet arthritis, LBP
• Lack of recognition of ergonomic factors-
  individual and job related
• Failure to recognize and accept soft tissue
  etiologies (myofascial pain syndrome, RSI)
• Inability to accept psychosocial implication of
  injury- anxiety, stress, depression
• Failure to recognize that chronic pain needs a
  multidisciplinary rehabilitation treatment

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PROBLEMS The Treatment

• Not Comprehensive-prevention of flareup,
  transition from rest to work
• Pharmacological, surgical, rest, interventional
  treatment- with side effects
• Not individually designed-patients variable
• Differences among treating physicians based on
  speciality and personal and professional bias

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PROBLEMS The Treatment

• Failure to address the psychosocial factors
  early- anger, fear, anxiety, finances
• Treatment often delayed due to legal conflicts of
  claims- denial, IME, hearing
• Inability to accept chronic pain treatment
  early by patient, physician and payors
• Controversies- Opoioid vs Non-opoioids, surgery
  vs conservative, pain relief vs improvement in
  function, litigation vs none

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PROBLEMS THE EMPLOYEE

• Failing to consider variables related to work
  DOT Physical demands
• Environmental factors Cold, drafts, repetition,
  speed
• Ergonomic factors Individual and job site
  factors
• Previous education training Formal education
  (GED, Special Skills)
• Intelligence ability to learn (level of
  education)

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PROBLEMS The Employee

• Work experience interest Frequent job changes
• Attitude towards work, self, supervisor,
  coworkers Work ethic, performance issues
• Age Relation to physical mental adaptations

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PROBLEMS The Employee

• Assessment of Dis(Abilities) Limitations
• Inconsistency amoung physicians based on
  background bias
• Need to recognize differences between impairment
  disability
• Recognizing difficulty in the current inability
  to objectively assess and predict abilities
• Functional Capacity Evaluation?
• Lack of recognition of different states of
  illness/disability, temporary/permanent

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PROBLEMS The Employee

• Other Factors Exaggeration inconsistencies
  due to adversarial legal system - Waddell Signs
• Differences inconsistencies in determining
  disability amongst the medical system
• Differences in treating doctors, as well as IME
  physician(s)
• Fear of aggravation, fear of inadequate
  compensation - Hurt vs Harm

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PROBLEMS The Employer

• Acceptability of employee to employer - Fear of
  claims of re-injury
• Ability to make job site modifications Costs of
  changes. Precedent setting
• Concern regarding increased insurance rates
  Work Comp Rates
• Poetentail of reduced profitability per work
  station Productivity decrease
• Economic Efficiency of settlement separation
  vs. continued employment with restrictions Cost
  effective?

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PROBLEMS Job/Work Factors

• Job tiltles often not specific Vague, other
  duties as delegated
• Job description not reflective of actual job
• Restricted jobs desirable filled by seniority
  in union shops
• Reduced income with restricted work Major
  factor in manual labor jobs

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PROBLEMS JOB/Work Factors

• Reduced or discontinued benefits with trial
  work
• Restrictions not honored Fear of re-injury,
  fear of being fired
• Lack of availability of well paying restricted
  work With poor educational background

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PROBLEMS Other Factors

• Attitude of others spouse, parents Reinforce
  sick role, lack of empathy
• Attitude of co-workers Resentment with limited
  duty work
• Attitude of physicians, attorneys, other health
  care professionals payers Those supporting
  disability role
• Enable
• Those rejecting disability role antagonize
• Attitude of employer Reluctance to take back
  with history of previous injuries job site
  modifications

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PROBLEMS Other Factors

• Attitude of others spouse, parents
• Reinforce sick role, lack of empathy
• Attitude of co-workers
• Resentment with limited duty work
• Attitude of physicians, attorneys, other health
  care professionals, and payers
• Those supporting disability role enable
• Those rejecting disability role antagonize
• Attitude of employer
• Reluctance to take back with history of previous
  injuries
• Job site modifications

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SOLUTIONS

• Early appropriate diagnosis
• Comprehensive, early aggressive remobilization
• Medical System - Role

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SOLUTIONS EARLY APPROPRIATE DIAGNOSIS

• Utilize Consultants PMR, Occ-Med, Pain,
  Orthopedists, Neurosurgeons, Anesthesia and
  Psychology
• Recognize diversity of opinions
• Understand complexity of pain bio-psycho-social
• More comprehensive view of injury
• Mechanical
• Behavioral
• Environmental

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SOLUTIONS Comprehensive, early, aggressive
remobilization

• Avoid prolonged rest and passive therapy, 2-4
  weeks
• Early referral to rehabilitation programs and
  services
• Identify utilize pain centers that focus
  on rehabilitation to improve functions utilize
  active multidisciplinary treatment

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SOLUTIONS Comprehensive, early, aggressive
remobilization

• Recognize chronic pain as an entity early
  prevent chronicity, treat utilizing
  psychophysiologic approaches
• Recognize difference between
• Work hardening
• Pain rehabilitation

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SOLUTIONS Work Hardening Programs

• A highly structured, goal oriented,
  individualized interdisciplinary program which
  uses conditioning tasks that are graded, to
  progressively improve the biomedical,
  neuromuscular, cardiovascular, psychological
  functions of the injured worker with simulated or
  real work activities.

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SOLUTIONS Work Hardening Programs

• It provides a transition between acute care and
  return to work, addressing issues of safety,
  physical tolerance and work behavior (Iserhagen)

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SOLUTIONS Pain Rehabilitation Programs

• A program organized to reduce pain when possible,
  improve function, increase quality of life and
  decrease dependence on the health care system for
  individuals with chronic pain which interferes
  with physical, psychosocial, and vocational
  functioning through the provision of a
  co-ordinated, integrated, interdisciplinary team
  of professionals including nursing, physical
  occupational therapists, psychologists and
  physicians.

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SOLUTIONS Pain Rehabilitation Programs

• Addresses
• Pharmaceutical
• Interventional
• Cognitive-behavioral
• Physical rehabilitation
• Addresses the 4 approaches in combination to
  improve function and provide self-management

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SOLUTIONS Medical System

• Physicians need to recognize their important role
  in Workers system by
• Early diagnosis
• Proper, prompt treatment
• Returning worker to employment as medical
  stability occurs
• Become knowlegeable cooperative with system
• Supplying complete, timely, reports completing
  forms

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SOLUTIONS Role of Physician in Rehabilitation
of Injured Worker With Pain

• Causation Relationship of injury to diagnosis
• Medical diagnosis
• Objective findings, supportive of diagnosis

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SOLUTIONS Role of Physician in Rehabilitation
of Injured Worker With Pain

• Period of Temporary Total Disability
• Date Healing Plateau is reached
• Ability to return to work
• Restrictions, if any temporary or permanent

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SOLUTIONS Role of Physician in Rehabilitation
of Injured Worker With Pain

• Description of permanent impairments
  limitations
• Residual capabilities
• Suggestions for future treatment Medical
  maintainance, vocational
• Permanent Partial Disability, if any scheduled
  vs unscheduled

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SOLUTIONS Role of Physician in Rehabilitation
of Injured Worker with Pain

• Cooperation amongst physician, rehab teams,
  attorneys, case managers, insurance carriers,
  employers, vocational, counselors, DWD, and
  employee despite adversarial system
• Recommend Realistic Restrictions Capabilities
• Understand work environment

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SOLUTIONS Role of Physician in Rehabilitation
of Injured worker with Pain

• Recognize restrictions may affect future
  employability
• Recognize road blocks to recovery patient,
  family, employer, medical system,
  insurance/compensation system, legal process
• Assess end of healing and permanency
• If you cant, refer to appropriate physicians
  with interest experience in you community