"It's still my back, Doc," said the talented 40-year-old auto
mechanic as he put his hand on his lower back. "It's been over six
weeks and it still bothers me."
When he had complained about his back the day after moving a transmission,
the service manager at the auto dealership sent him to the local hospital
emergency room. When the X-rays didn’t reveal a medical problem, the attending
physician gave the mechanic Tylenol and a prescription and directed him
to take a few days off and to "go back to work on Monday if you feel
OK." The mechanic reported what had happened at the emergency room
to the service manager.
When Monday came, the worker was still bothered by lower back pain and
called the physician who wrote a new prescription and indicated that the
employee should take the week off. "Let's see how you're doing by
the end of the week," said the doctor.
On Friday, the mechanic reported, "My back doesn't seem to be any
better...." At that point, the physician prescribed a specific number
of physical therapy sessions. Even so, the pain persisted, keeping the
employee from returning to work.
The auto mechanic's experience with pain is repeated thousands of times
While managing pain is a critical medical intervention when it comes
to musculoskeletal injuries such as the auto mechanic's lower back problem,
finding ways to deal with it successfully is often illusive. This is a
particularly important issue since such conditions account for a high
percentage of job-related injuries and a high proportion of Worker's Compensation
Such cases can result in legal action, substantial settlements, loss
of a job and employers having to replace valuable workers.
It's important to point out that pain is both real and imagined, even
though there are times when employers may feel that some employees are
"faking it" or using pain to "milk the system."
The role of pain in work-related disabilities is attracting more attention.
The reason is that pain control – "the biomedical promise of
a cure for persistent pain and the elimination of pain-related disability"
– has never been realized. This is the conclusion of a group of
university, government and private industry researchers. Their findings
are summarized in an article, "Integrating Psychosocial and Behavioral
Interventions to Achieve Optimal Rehabilitation Outcomes" in the
Journal of Occupational Rehabilitation (December 2005).
They do not question the reality of pain, only how it is treated. Some
of the findings can be particularly helpful in understanding the injured
employee who is experiencing pain from a musculoskeletal injury. While
the research deals only with injuries to the lower back, the psychosocial
implications may have a broader application.
They point out that there are both internal and external psychosocial
factors influencing how the injured worker reacts to pain. Some experts
suggest that musculoskeletal disabilities are often 10 percent pain driven
and 90 percent influenced by psychosocial issues. If this is accurate,
injury management programs should acknowledge the role of these factors
and take them into account.
• Pain preoccupation. Anyone who has "back trouble"
knows how pain can be become overwhelming and all encompassing. The individual
becomes preoccupied with it; it's the only thing they can think about.
• Fear of re-injury. The child who touches a hot stove stays
away from it for a long time. The same is true with the possibility of
re-injury. No one wants to go through a painful experience a second time.
As a result, the disability becomes worse than the pain itself.
• Perceived disability. When an injured worker has been away
from the job for an extended period, it's not uncommon to think that others,
including family and co- workers, assume they are "faking it"
or shirking their responsibility. Feeling uncomfortable and embarrassed,
the worker finds it difficult to go back to work.
• The ways we think about pain influences our behavior.
In summary, it has been found that "an individual's beliefs about
the severity of the health condition are significant predictors of RTW
[Return to Work] outcomes."
It may be that, as the researchers suggest, "poor problem solving
abilities, low expectancies about the probability of returning to work,
and lack of confidence in the ability to perform work-related activities
have been associated with prolonged work disability."
It appears that the fear of pain can become more disabling than the injury
Along with internal factors, there are external psychosocial issues that
can impact the injured individual. However, identifying the problem is
only the first step toward finding a solution. Here are some examples
of how research in psychosocial factors point in some helpful directions.
• The psychosocial implications of the work environment.
One researcher discovered that the amount of job stress and co-worker
support impacts the length of a person's disability. "The lack of
social support at work and work dissatisfaction were predictors of prolonged
disability." It has also been found that the employer's attitude
toward work-related disability can influence an employee coming back to
the job. A survey of occupational health physicians and HR managers revealed,
"a lack of coworker support for modified work re-entry programs was
perceived as a major obstacle to successful RTW."
• Preventing acute injuries from becoming chronic disabilities.
The objective here is to help avoid an injury from becoming one of the
20% of musculoskeletal injury cases that turn into extended disabilities.
These are the cases that cause serious problems for the employee and result
in high Workers' Comp costs for the employer.
• Public education should not be ignored. Too often the role
of education is ignored when it comes to dealing with psychosocial issues.
Yet, it has been shown to help change attitudes toward job-related disability.
In Australia, there was a "decline in the number of compensation
claims" following a two and one-half year long advertising campaign
that focused on "attitudes and beliefs associated with work disability."
• Primary physicians can play a valuable role in terms of what
the researchers call "medical reassurance." Physicians emphasize
the role of activity in a patient's recovery including dealing with the
fear of re-injury and "encouraging return to an active lifestyle
in spite of the persistence of pain symptoms. In other words, to help
the injured worker avoid developing what might be called a "disability
One study found that "advice to stay active and information aimed
at reducing fear can lead to significant reductions in sick days and higher
rates of RTW."
• Combining cognitive-behavioral and psychosocial approaches.
A group of back pain patients off the job for less than six months were
taught problem solving skills. Compared to a group that did not have the
training, those receiving problem solving skills training showed better
In another study, employees off the job for an average of three months
were given RTW skills training. One year later they had "significant
less absenteeism" than those who did not receive the training.
• Customized approaches to specific psychosocial factors.
One study suggests "disability results from the development of high
levels of pain-related fears."To test the hypothesis, researchers
gradually exposed “individuals with high levels of pain-related fears...to
activities that have been avoided" with a methodology similar to
that for treating phobias. The results indicated that such an approach
"can be effective in reducing levels of fear, pain and pain-related
Understanding the significance of psychosocial factors in musculoskeletal
injuries is an important first step. The researchers indicate that the
preliminary results of a training program for 300 physiotherapists and
occupational therapists suggest, "front-line professionals can be
taught to detect and intervene on psychosocial risk factors." This
more effective approach can benefit the injured employee and provide cost
savings for the employer.
Summarizing their work, the researchers conclude, "... superior
RTW outcomes were achieved without demonstrating a greater magnitude of
pain reduction." The message is clear: dealing with the psychosocial
factors associated with musculoskeletal injury pain can have a positive
influence on helping injured employees avoid disability and get back to
an active lifestyle faster including returning to work.