October 2001

Motivation and the Variables Affecting Work-related Injury Outcomes

By Gregg J. Carb, D.C.

Two patients of similar age and body-type present with work-related complaints of upper back/lower neck pain gradually induced with prolonged sitting and deskwork.  Upon examination, the two have common postural faults of increased upper thoracic kyphosis and forward head carriage.  The active cervical ROM is slightly restricted at the end-points of movement due to pain, orthopedic tests generally reproduce the discomfort present on ROM testing, and palpatory findings are alike (lower cervical facet and upper thoracic costotransverse joint rigidity with regional cervicothoracic muscular hypertonus).  There is no neurological involvement.  Neither patient has concurrent health problems such as diabetes or chronic infection.  X-rays correlate with the postural analysis and demonstrate straightening of the cervical lordosis with mild degenerative spondylosis in the lower cervical spine. 

            Given a common history of injury, patient type, physical findings, and symptomatic complaints, you might expect a similar response from both patients to a comparable treatment plan.  This is not necessarily the case as other variables come into play that may significantly affect the patient outcome.  In my experience, the basis of the patient’s subjective response to care comes down to one major factor: motivation.  Many injuries involve psychological as well as physical damage to the body.  An injured employee’s state of mind will set his or her maximum willingness to perform any certain task or tolerate the various physical exam procedures.  In other words, the patient decides how much they will or will not do with their pain — which greatly impacts evaluation of the patient’s impairment/disability.

In the example of the two patients above, suppose patient A:

            1. Finds his job challenging and fulfilling

            2. Is well paid and spends accordingly

            3. Relates well to his manager and fellow co-workers

            4. Handles the pressures of the job well

            5. Returns at the end of the day to a satisfactory family life

            6. Makes an effort to stay healthy by getting some exercise and watching his diet

            7.  Has had no trouble reporting his injury and securing benefits

On the other hand, suppose patient B:

            1. Finds his job overly repetitive and a dead-end street

            2. Is a lower wage earner

            3. Is in conflict with his employer or a fellow employee

            4. Gets easily stressed out and overwhelmed

            5. Leaves work and goes to an empty home

            6. Is sedentary, over-weight and smokes

            7. Was scrutinized by the employer\claim adjuster when reporting the injury

            Although patient A and patient B may have similar physical injures and clinical findings, they will have very different motivations that inevitably affect treatment outcome.  Patient A will lose the sense of satisfaction and challenge he gets from his job if removed from it.  He enjoys the income that he earns and could not maintain his usual standard of living on disability pay for very long.  The encouragement and support he receives from his employer, fellow employees and at home will help in his recovery.  He wants to get better in order to continue his active lifestyle away from work.  He feels appreciative that the benefits and personnel are in place to cover the expense and administrative process of treating his injury.  In short, he is motivated to get the most effective treatment and give his best effort as a patient to fully recover, and has nothing to gain by getting or giving less.

            Patient B consciously or unconsciously wants to use his injury as a temporary or permanent reprieve from the dissatisfaction and anxiety of his job.  He can get by on disability pay for some time if necessary as it represents a greater percentage of his usual income.  He is relieved to escape from any unpleasant tasks through work restrictions or avoid contact with his boss or co-workers altogether through time off.  He is without encouragement to get well from anyone at home and has more free time to indulge in his poor health habits.  He feels abused by “the system” and wants to teach his employer and the insurance company a lesson by getting as much out his injury as he can.  In short, he is motivated to seek prolonged or ever-changing forms of treatment and give least effort as a patient, because there is much to gain by getting and giving less.

            Our hypothetical patients described above are polar opposites in the variables that make up their motivation to recover.  They don’t represent real-life patients that most often form a complex mixture of both positive and negative variables.  However, one very strong negative variable alone can over-shadow weaker positive ones and make an injury difficult to resolve.  Therefore, I believe it is important to screen patients in advance for variables that may affect treatment outcome, and respond appropriately as soon as becomes clear that a negative variable is significantly impeding recovery.  Advanced screening means asking specific questions on intake forms and during the history-taking portion of the evaluation.  Responding appropriately may include a carefully-worded discussion with the patient, referral to an EAP (employee assistance program), notice to the claims administrator with a close-ended treatment plan, or release of the patient with proper documentation.

            The literature provides the following insight into this subject.  Simon1 et al studied depression and work productivity, and the comparative costs of treatment versus non-treatment. They found information suggesting greater self-reported work impairment among depressed workers; a synchrony of change between depression and work impairment; reduced work impairment with successful treatment; and that usually, but not always, greater reduction in work impairment among treated patients. 

            Stein2 et al evaluated whether financial incentive/disincentive predicted participation in health promotion activities, and whether participation improved future health risk and productivity.  Overall health was measured by levels of body fat, cholesterol, and blood pressure.  Health promotion participants improved their subsequent-year health risk more than did non-participants.  Participation was associated with reduced illness-related absenteeism and (although inconsistently) with medical claims paid and short-term disability.

            Brines3 et al examined return to work from the perspective of the injured worker.  Among the factors determined to affect the return to work experience were psychosocial variables including job satisfaction and relationship with employer and coworkers, financial pressures; system issues such as securing benefits; and process factors such as interaction with service providers and with the workers’ compensation system.

            Young4 et al studied 348 active duty military members who underwent sequential lumbar microdiscectomies over a 31-month period, and how the amount of compensation for disability influenced surgical outcome.  Overall, 75.3% of the patients were able to return to full military duty after surgery, and 24.7% received disability compensation.  Analysis showed higher compensation incentive was a significant determinant of poor surgical outcome. The influence of compensation incentive was proportional to the amount of anticipated pay-out, and relative to a military service member’s usual income.

            Valat 5 et al state that the high social and economic cost of low back pain is related to the minority of individuals who lose more than six months from work.  Occupational factors have a very substantial impact on: workers in blue-collar jobs, those involved in heavy labor or in jobs that require efforts beyond their physical capabilities and those who have a low level of job satisfaction or poor working conditions, who are new at their job, or who are not well rated by their superiors, are more likely to develop chronic pain.  A history of compensation for a spinal condition, receipt of work-related sickness payments, or litigation about compensation are also associated with an increased risk of chronic pain.  Social and economic factors predictive of a chronic course are a low level of schooling, language problems, a low income and an unfavorable family status.  Depression, difficulty coping and a sensation of being “sick all the time” may be associated with an increase in the risk of chronicity.  Overall, progression to a chronic pattern of pain is more closely dependent on demographic, psychosocial and occupational factors than on the medical characteristics of the spinal condition itself.

            Rosomoff6 et al set about to demonstrate a relationship between intent to return to the pre-injury job and pre-injury job perceptions about that job; and to demonstrate that worker compensation chronic pain patients would be more likely than non-worker compensation chronic pain patients not to intend to return to a pre-injury type of job because of pre-injury job perceptions.  An association between intent not to return to work and the perceptions of pre-injury job dissatisfaction and job dislike was found in chronic pain patients regardless of work-related injury status.

            Himmelstein7 et al state that although most upper-extremity disorders are acute and self-limited, a small percentage of workers with symptoms go on to permanent disability and account for the majority of costs associated with these conditions.  They evaluated the demographic, vocational, medical, and psychosocial characteristics of patients with work-related upper-extremity disorders and examined several hypotheses regarding the differences between working and work-disabled patients.  One hundred twenty-four consecutive patients were evaluated in a clinic specializing in occupational upper-extremity disorders.  Patients currently working (55) and work-disabled patients (59) were similar with regard to age, gender, and reported job demands.  The work-disabled group reported less time on the job, more surgeries, a higher frequency of acute antecedent trauma, and more commonly had “indeterminate” musculoskeletal diagnoses.  They also reported higher pain levels, more anger with their employer, and a greater psychological response or reactivity to pain.

            Ready8 et al related performance on fitness and back related isometric strength tests, as well as the response to a lifestyle questionnaire, to the subsequent occurrence of back injuries in 119 nurses.  In all, 22% of subjects sustained injuries during the 18-month study.  Prior compensation pay, smoking status, and job satisfaction were the most useful discriminators.

            Brewin9 et al investigated the social and psychological determinants of the time taken to return to work in a sample of male manual workers referred to an accident clinic with mostly minor industrial injuries.  Patients who showed a rapid recovery relative to the severity of their injuries were more often married, had greater job satisfaction, were less likely to be receiving an income supplement from their employers, and blamed themselves more for their accidents.

            In summary, when managing injured workers, you may want to consider the following variables that can affect a patient’s motivation to achieve recovery: job satisfaction, income relative to disability pay, the employer / employee relationship, coping skills, personal / family issues, poor health habits such as smoking, conflicts regarding the case.

References

1. Simon GE, Barber C, Birnbaum HG, Frank RG, Greenberg PE, Rose RM, Wang PS, Kessler RC. Depression and work productivity: the comparative costs of treatment versus nontreatment. J Occup Environ Med 2001 Jan;43(1):2-9

2. Stein AD, Shakour SK, Zuidema RA. Financial incentives, participation in employer-sponsored health promotion, and changes in employee health and productivity: HealthPlus Health Quotient Program. J Occup Environ Med 2000 Dec;42(12):1148-1155.

3. Brines J, Salazar MK, Graham KY, Pergola T. Return to work experience of injured workers in a case management program. AAOHN J 1999 Aug;47(8):365-372.

4. Young JN, Shaffrey CI, Laws ER Jr, Lovell LR. Lumbar disc surgery in a fixed compensation population: a model for influence of secondary gain on surgical outcome. Surg Neurol 1997 Dec;48(6):552-558.

5. Valat JP, Goupille P, Vedere V. Low back pain: risk factors for chronicity. Rev Rhum Engl Ed 1997 Mar;64(3):189-194.

6. Rosomoff HL, Fishbain DA, Cutler RB, Steele-Rosomoff R. Do chronic pain patients’ perceptions about their preinjury jobs differ as a function of worker compensation and non-worker compensation status? Clin J Pain 1995 Dec;11(4):279-286.

7. Himmelstein JS, Feuerstein M, Stanek EJ 3rd, Koyamatsu K, Pransky GS, Morgan W, Anderson KO. Work-related upper-extremity disorders and work disability: clinical and psychosocial presentation. J Occup Environ Med 1995 Nov;37(11):1278-1286.

8. Ready AE, Boreskie SL, Law SA, Russell R. Fitness and lifestyle parameters fail to predict back injuries in nurses. Can J Appl Physiol 1993 Mar;18(1):80-90.

9. Brewin CR, Robson MJ, Shapiro DA. Social and psychological determinants of recovery from industrial inj