Returning Patients to Work
This study investigated what nonphysical factors were associated with patients not returning to work after soft-tissue injury. As the authors state, “Nonphysical factors, the nature of which may be social, economical, or psychological, may also influence the success of work hardening and may act as barriers to successful work return.”
One hundred patients were involved in this study. The mean injury duration of the participants was 13 months; the mean time absent from work was 7.5 months. Many of these patients had undergone surgery for their injuries -- 20% of cervical spine patients, and 35% of low back patients. Fifty-one percent of the participants were using medications. Eighty-eight per cent of the patients had a diagnosis related to the spine.
The patients attended a “work hardening: program daily for 7.5 hours and for an average of 17.3 days. The average treatment lasted 4.3 weeks. The program consisted of “physical therapy conditioning, work simulation, and a psychological education group.” At the end of the intervention, 50% had returned to work. The author reports that there were three non-physical factors associated with returning to work:
1. Having a high school education. Less educated patients were less likely to return to work. This could be due to the fact that, “most heavy labor and blue collar jobs are performed by the less educated persons and that these jobs may be more difficult to return to than lighter jobs.”
2. Absence of “pain behaviors.” These were defined as “overt behaviors that are not in proportion to physical findings, such as facial grimacing, emotional lability, positive Waddell’s signs, constant holding of the injured area, and antalgic limping.” Unfortunately, the studies criteria for low back pain “physical findings” was reduced to :simple and severe,” and the criteria for these was evidence of “radiographically-determined injury to the disc or bony structures.” If there were no radiological findings, the injury was classified as “simple.” Thus, if a patient was not considered to have a real injury, but behaved as if he or she did have pain, these were determined as “pain behaviors!” The patients with pain behaviors were less likely to return to work than those without and were less likely to complete the program, but this could be related to the fact that “Work hardening tends to further aggravate pain…” That these patients were in real pain, despite signs on radiologic exams, seems to not be considered in this paper.
3. Absence of attorney representation. Those patients that retained an attorney were less likely to return to work, showed more pain behaviors, and were more likely to be discharged from the programs for lack of compliance. The study did not provide data regarding attorney representation and severity of injury, or length of time off work.