You are in: eMedicine Specialties > Physical Medicine and Rehabilitation > OCCUPATIONAL MEDICINE Evaluation of the Injured WorkerArticle Last Updated: May 9, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 10
 
Author: Divakara Kedlaya, MBBS, Clinical Associate Professor, Department of Physical Medicine and Rehabilitation, Loma Linda University School of Medicine Divakara Kedlaya is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Paraplegia Society, Association of Academic Physiatrists, and Colorado Medical Society Coauthor(s): JienSup Kim, MD, Medical Director, Occupational Health Center, Assistant Professor, Department of Physical Medicine and Rehabilitation, Loma Linda University Medical Center Editors: Patrick J Potter, MD, Director of Spinal Cord Injury Program, Associate Professor, Department of Physical Medicine and Rehabilitation, Parkwood Hospital, Lawson Health Research Institute; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Richard Salcido, MD, Chairman, Erdman Professor of Rehabilitation, Department of Physical Medicine and Rehabilitation, University of Pennsylvania School of Medicine; Kelly L Allen, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Lourdes Regional Rehabilitation Center, Our Lady of Lourdes Medical Center; Consuelo T Lorenzo, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Alegent Health Care, Immanuel Rehabilitation Center Author and Editor Disclosure Synonyms and related keywords: occupational rehabilitation, ergonomics, work-related musculoskeletal disorders, repetitive motion disorders, low back pain, carpal tunnel syndrome INTRODUCTIONSection 2 of 10
 
In 1996, more than 647,000 American workers experienced serious injuries due to overexertion or repetitive motion on the job. These work-related musculoskeletal disorders account for 34% of lost workdays. In 1995, these injuries cost employers an estimated $15-20 billion in workers' compensation costs and $45-60 billion in indirect costs. When treating an injured worker, the clinician must be aware of factors that can affect the duration and outcome of an injury. Addressing these factors results in more effective treatment and a more favorable outcome. Work-related musculoskeletal disorders occur when there is a mismatch between the physical requirements of the job and the physical capacity of the human body. More than 100 different injuries can result from repetitive motions that produce wear and tear on the body. Specific risk factors associated with work-related musculoskeletal disorders include repetitive motion, heavy lifting, forceful exertion, contact stress, vibration, awkward posture, and rapid hand and wrist movement. Specific aspects of the injury must be addressed when obtaining the history, as this information helps a practitioner be knowledgeable about concerns that have medical and medicolegal implications. The answers to these questions provide information regarding an industrial injury case, including causation and work restrictions. In addition, this information can help determine the individual's prognosis and, if needed, apportionment and disability. Complicating factors, while potentially numerous, are present only in a small number of cases. Helping workers with injuries is rewarding, as most workers only wish to receive help in recovering from their injuries or illnesses so they can return to work. For excellent patient education resources, visit eMedicine's Back, Ribs, Neck, and Head Center. Also, see eMedicine's patient education article Muscle Strain and Chronic Pain. This article provides information about the specific questions to ask when first meeting an injured worker and during the continued follow-up. In addition, several musculoskeletal diagnostic categories that require special attention in an industrial setting are addressed. SPECIFIC ISSUESSection 3 of 10
Many practitioners avoid evaluating and treating injured workers for 2 main reasons.
The second reason noted above presents a dilemma for the physician, as patients often do not get better with the interventions commonly prescribed for a specific injury. When this occurs, enormous effort can be required to tease out specific reasons why patients are not getting better. Often, the patient's failure to improve is attributable to reasons that a practitioner cannot affect or influence, causing frustration on the part of the physician. This is especially true when an additional report or a disability rating is required on an individual who, according to the practitioner, would improve under other circumstances (eg, who may have improved if circumstances were different with regard to external influences in recovery and return to work). The initial scope of involvement in an industrial injury case includes the employee, employer, insurance adjusters, and the physician. This list of involved parties eventually can grow to include nurse case managers, medical consultants, ergonomic consultants, physical therapists, occupational therapists, applicant attorneys (representing the employee), defense attorneys (representing the insurer or employer), vocational rehabilitation specialists, disability raters, and workers' compensation judges or referees. This involvement of many professionals can complicate matters quickly, as involved parties may have differences of opinion and different agendas. Each party can also have a positive or negative effect on the outcome of the case. Being aware of how each party can affect outcome can greatly enhance a physician's management of an industrial injury case. INITIAL MANAGEMENT OF WORK-RELATED INJURYSection 4 of 10
When first assessing an injured worker the physician must address several aspects of the injury when obtaining the history. Determination of the cause of the injury can be influenced by many factors in the medical history, including the following:
Causation pertains to whether or not the injury actually was associated with work. "Arising out of employment" (AOE) or in the "course of employment" (COE) examinations can be directed specifically at answering the causation question. The answer to the question of causation determines responsibility for treatment of the injury. If the injury is associated with work, then treatment is provided for and paid for by the employer's workers' compensation insurance carrier. In addition, if the injury is due to work, lost time from work is compensated for, and the employer often accommodates for work restrictions. If the employer is not willing to make special accommodations, the individual has to take sick time. Prolonged recovery time often can exceed available sick time and can lead to termination of the employee. Despite the hassle, individuals accrue certain advantages in reporting that an injury occurred at work or was due to work. Because of this possibility, causation must be determined accurately to avoid requiring the employer to assume the responsibility for an injury or illness that actually is not work related. Although physicians are not trained as detectives, no other professional can compile information obtained in the history with the findings on physical examination to determine the probability that the injury is work related. One distinction that must be remembered is that, under workers' compensation, it is not possibility but probability that is accepted in determination of which injuries are considered subject to compensation. Is it probable or greater than 50% likely that symptoms originated with an incident or activities performed at work? If doubt exists and future investigation is instigated, document specific dates, specific times, specific location, mechanism of injury, and the presence or absence of witnesses to corroborate accounts of the injury. Companies that have pending layoffs or seasonal workers at the end of the work season show a higher number of reported work-related injuries. Individuals who recently have had poor evaluations of their work performance have a higher incidence of work-related injuries. Be cautious when determining causation in cases with unwitnessed injuries that are reported early Monday morning or upon an individual's return from vacation. The injury should correspond to the given history. Prolonged typing does not correlate with a wrist fracture in a healthy individual. A wrist contusion should not cause ankle pain. Performing sedentary work without history of specific injury should not cause lumbar disc herniations. Injuries reported as having occurred hours earlier should not be associated with greenish-yellow bruising at the site of injury, indicating a longer time since onset of injury. If there is any uncertainty, ask the insurance company to obtain additional information, such as statements from supervisors, statements from coworkers, and prior medical records. Causation can be quite confusing. When an employee has a motor vehicle accident while going to an office supply store to pick up office stock for his/her supervisor, are the injuries sustained work related? What if the employee had taken a small detour to pick up personal dry cleaning on the way back from the office supply store? What if an employee comes in on his/her day off to catch up on paperwork at the office and trips and falls? What if, while on the clock, a mechanic at work decides to change the oil in his own car and has chemicals splash into his eyes? As the physician is asked to comment on causation, the medical opinion must be based on specific aspects of history and examination. The physician's opinion is the basis for adjudication when a disputed case goes to court. Past medical history can be very important when determining causation and apportionment. Apportionment of disability is determining the percentage of disability that can be placed on prior injuries or on to underlying, preexisting disease. Often, apportionment can occur only if there was preexisting disability. If an individual sustained a previous back injury but made a full recovery without symptoms and was able to return to work without any limitation or disability, no apportionment can be made to that prior injury; however, if disability is associated with a previous back injury with reduced capacity or reduced tolerance, then apportionment should be determined. Apportionment should also be considered when there is a preexisting disease; however, this determination can be performed only if the natural course of the disease would have caused disability on its own progression, without work-related activities. The examiner cannot apportion disability in cases such as when an individual with osteoarthritis falls and sustains a wrist fracture and heals with reduced range of motion (ROM) at the injured wrist. Work restrictions, if needed, must be determined at the conclusion of the evaluation of an injured worker. To establish appropriate work restrictions, the clinician must consider the injured body part and activities that exacerbate the injury, as well as the job requirements. Restrictions should be clear and tailored to the individual for the type of work that he or she does. Restrictions are primarily established to prevent the employee from engaging in activities that would exacerbate the injury or illness; however, activity restriction is also recommended to guide the employer in finding alternative work that is suitable for the injured worker. Therefore, it is important to communicate with the employer about the activities that the injured worker can do. For example, if a counselor at a behavioral medicine unit is seen for a shoulder strain, implement restrictions regarding the use of the injured shoulder, eg, set limits on lifting, reaching activities, and pulling and pushing activities. The clinician should also make it clear that because this patient's line of work might require him or her to take part in takedowns of violent individuals, he or she should be restricted from engaging in such potential activities. Knowing what an individual does and how and where he/she works allows for proper determination of causation and suggests appropriate work restrictions. Understanding the work situation of the patient also provides insight into what might be the source of injury, especially in repetitive or cumulative trauma injuries. Prognosis in work-related injuries is a question that concerns everyone. The injured worker wants to know how soon he/she can recover and, in some cases, how much recovery time is expected. The employer, along with the workers' compensation insurance carrier, wants to know this information as well. If there is significant injury and it is obvious that the individual is not able to return to his/her usual and customary work activities, this information should be communicated to all involved parties as soon as possible. Proper communication expedites the initiation of reasonable accommodations or of vocational rehabilitation if necessary. Most medical prognoses for recovery from injuries and illnesses are predicated on the basis of proper treatment and rest. Individuals should rest the injured body part until there is sufficient recovery to reengage in activities with minimal risk of reinjury. What if an individual who works as a loader at a warehouse presents with an ankle sprain? If this individual continues working in circumstances that exacerbate his/her injury, what is the prognosis? If the individual wishes to continue at his/her regular work and does not wish to take time to allow the ankle injury to heal, the patient may have a delayed and limited recovery. This reality should be considered and reflected in the prognosis. Initial evaluation of injured workers with psychiatric disorders varies significantly from the above. Refer to the National Guideline Clearinghouse for more details. The Practice Guidelines Committee of the American College of Occupational and Environmental Medicine (ACOEM) has developed the ACOEM Occupational Medicine Practice Guidelines. This book is considered the criterion standard for effective occupational medical practice. Presenting essential consensus- and evidence-based information, it provides step-by-step guidelines and practical aids to help busy practitioners manage growing caseloads. The State of California in 2004 required that its utilization review in workers' compensation cases be "consistent with" the second edition of the ACOEM Occupational Medicine Practice Guidelines. PREVENTION OF WORK-RELATED MUSCULOSKELETAL INJURIESSection 5 of 10
In almost every job, there are different ways of performing the work duties that can reduce the risk of injury. Simple, inexpensive solutions often can prevent painful musculoskeletal disorders. The science of fitting the job to the worker is called ergonomics. Properly designing the work and the work environment can prevent injuries. Employers who have implemented ergonomics programs have had great success in avoiding work-related musculoskeletal injuries, keeping workers on the job, and boosting productivity and workplace morale. Employers and employees should work together effectively to reduce work-related injuries. Strategies for the employer to reduce work-related injuries may include the following:
Simple solutions often work best. Workplace changes to reduce pain and cut the risk of disability do not need to cost a fortune. Examples of these simple ideas include the following:
COMPLICATING FACTORS THAT DELAY RECOVERYSection 6 of 10
Many factors, some surprising, can delay recovery for patients with work-related injuries. Whatever the source of delay in recovery, signs that a patient is not committed fully to recovery and returning to work can easily be missed. This lack of commitment to recovery can be seen when a patient does not pick up prescriptions or lets them run out between appointments. When a patient begins by missing therapy appointments or demonstrates poor compliance with home exercise programs (eg, inability to demonstrate home exercises that were taught at prior visits or by therapists), the physician should be aware that the patient might lack the desire to recover fully. Frequently missing follow-up appointments or showing up very early or very late for appointments is an indicator of this type of attitude. The patient may come to the clinic and state that he or she is very busy and may leave if not seen right away. Others may state that they cannot return to work even when extensive restrictions are implemented for relatively minor injuries. The one sign that is most uncomfortable for practitioners is when injured workers blame their situations on others. This laying of blame even can be directed to the physician. When the individual is able to return to work, he or she often tells the employer that the physician was responsible for the late return to work. The practitioner can be deemed less than caring if he or she does not acknowledge the patient's pain and discomfort, despite normal examination findings and negative diagnostic studies. When a worker returns to work, the worker often states that he or she will go back to the job as recommended but, if further injury ensues, that it will be the doctor's fault and responsibility. Other patients can return time after time, stating that there has been no change. These patients report that none of the interventions have helped and that they continue to be in considerable pain and discomfort. Yet, when asked to localize the pain or identify activities or times of day when the symptoms are most bothersome, they remain vague and responses are generalized (eg, hurts all the time or hurts all over.). Statements such as these could be indicative of other potential reasons for continued symptoms. This overgeneralization can be due to the worker's unrealistic expectations or unresolved conflicts with coworkers, supervisors, or bosses. A large shift in thought as to what sick time or sick leave is for has taken place. In the past, days were set aside to be used when an individual was ill and could not work. If the employee did not get sick, sick leave was not used. This old concept has changed to include many workers thinking that calling in sick is a way to have a day off work to do other things. The slang term mental health day is used to rationalize this type of action, and, unfortunately, this social trend has become very prevalent. Each company decides whether this is an acceptable practice; however, some individuals have come to use work injury claims as a means of obtaining extra days off from work without using their vacation or sick leave days. Physicians often find themselves drawn into this fraudulent action. Processing each individual claim takes numerous hours of work on the part of the employer, physician, clinic staff, and insurance carrier. When a patient requests a couple of days off to recover, the question of whether this is a reasonable request corresponding to the severity of the injury must be considered. Unhappy workers seldom are eager to return to the work environment. If the patient hates his or her job, recovery can be delayed, as the individual does not become a willing participant in the recovery process. Supervisors or coworkers who are understanding and supportive, especially when a worker has work restrictions in place, can be very helpful in helping an individual recover from an injury or illness. On the other hand, supervisors or coworkers who are unsympathetic and tend to belittle the patient can make an individual not want to get better. A supervisor who ignores work restrictions and assigns workers to tasks that continue to exacerbate their symptoms can be a barrier to recovery. In some cases, conflict at the work place must be recognized and addressed before recovery can occur. Some workers have a sense of entitlement that leads them to feel that, because they have dedicated a career of work to a company, the company should take care of all their health care needs. Although most companies have programs set up to provide their workers with health insurance, some individuals feel that all health issues should be covered under workers' compensation. This misconception is very difficult to change and often leads the individual to feel that the company does not appreciate their years of dedication to the company. Evaluation of industrial cases requires determining if symptoms are real or not. This process is very difficult and extremely tricky. Some workers with injuries underreport. Underreporting may occur when individuals want to return to regular work and therefore falsely state that they are better. Underreporting places these individuals at risk for further injury. Some patients overreport, making symptoms seem greater than they are. The physician must exercise care, as some individuals sent to see a doctor wish to appear as if they are coming with a significant problem. They believe they must validate the reason they have come to see the physician. However, some patients make poor efforts, wincing and grimacing with benign physical examination maneuvers. The physician evaluating the case has to assess the true level of weakness, loss of function, and the amount of subjective pain. This type of examination is vastly different from examinations for patients who are not seeking evaluation of work-related injuries. Although all physicians do this type of assessment at an intuitive level, the examiner seldom is asked to comment on whether the subjective complaints are realistic or not. Assessment of the genuineness of injury complaints can be made only by close observation. Observe the patient as he or she enters or leaves the examination room and, at times, within the clinic itself. Observe how the patient moves about the room, changing from the chair to the examination table. Take note of how the examinee removes his or her jacket or removes shoes and socks. Compare the behavior, attitude, and movements when the patient is speaking with office staff in contrast to when the physician is examining him or her. Note the time it takes to change into an examination gown. Note also how the examinee reaches for a purse or grips a pen. All these observations can provide clues as to the validity of the patient's complaints. Observational signs can be a great help, especially in dealing with patients who have low back pain (LBP). Waddell signs of nonorganic back pain also should be documented. An effort should be made to observe the patient further if there is some suggestion that complaints do not correlate to the amount of injury. The physician may identify various things during the evaluation that do not correlate, such as the following:
All observations cannot be made on a single visit, as they take special effort, special consideration, and clear documentation from visit to visit. Getting to know the worker who is injured is imperative. In addition, knowledge of the kind of work and awareness of the workstation, current work situation, relationships at work, and degree of job satisfaction must be considered when making an assessment of the patient's validity in reporting a job-related injury. WORK-RELATED MYOFASCIAL PAIN SYNDROMESection 7 of 10
Both employers and employees often fail to recognize that, with time and the aging process, physiological changes occur. Jobs usually are given to people who demonstrate a capacity to perform the tasks associated with that job; however, as people age and decondition, their physical tolerances gradually decline. On the other hand, as their familiarity with the company grows, they often are assigned additional tasks. This observation is true especially for companies that are forced to downsize because of a change in the economic environment. The increase in workload at some point intersects with the decline in physical tolerances and leads to work-related injuries or illness. Overuse injuries, such as myofascial pain in the forearms, arms, or shoulders of workers performing repetitive activities, occur when individuals exceed their physical tolerance and have declining physical capacity. Such individuals present to the physician having performed the same type of work for years, but they develop pain in their arms without any new activity, change in their work area, or specific injury. Although workup should include looking for all potential causes, in many cases it comes down to muscles that have become irritable and tight. Pain is perceived not only when tissue damage occurs but also when the potential for tissue damage is present. One form of punishment for children when they misbehave is to have them hold a heavy book out at arm's length. Initially, this position does not cause any discomfort, but, within minutes, the outstretched arms can become extremely uncomfortable. When muscle tissue capacity is exceeded, especially as a result of performing repetitive activity for hours at work, 5 days a week, individuals often have discomfort and pain. Treatment for these problems is similar to treatment of any muscle strain (ie, relative rest, stretching, improving muscle endurance and strength); however, these problems often times persist despite conservative care. The expectation that these types of problems quickly improve and resolve, as one might expect in acute injuries, often is mistaken, as rapid improvement frequently is not the case. Most individuals with myofascial pain syndrome have experienced gradual onset of pain over the course of several months. This type of indolent development of pain commonly is associated with a prolonged recovery. Once muscles have become irritable, they behave as if they are contracted, shortened, or in spasm, responding with pain when stretched, palpated, or activated. When treating these types of injuries, the clinician must realize that the irritable musculature is displaying a learned response. Just as the condition took months to develop, it can take months to improve. Eliminating potential causative factors, such as an improper work area with poor ergonomics and underlying physiological factors (eg, poor sleep, inadequate rest), is critical. Adequate rest and sleep is an absolute requirement for muscle recovery. A vicious cycle can develop when myofascial pain symptoms prevent an individual from sleeping at night. The lack of sleep prevents the muscles from gaining sufficient recovery and rest from the previous day's activities. When treating individuals with myofascial pain, explain the nature of the problem to the patient. When running a marathon, the athlete does not sprint the entire race at top speed. Few individuals besides athletes realize the importance of stretching to maintain muscle strength and flexibility. Prevention of the prolongation or recurrence of myofascial pain can be achieved when individuals understand and realize the importance of daily stretching and pacing of activities at work. WORK-RELATED LOW BACK PAINSection 8 of 10
LBP is common in the general population. Lifetime prevalence of LBP has been estimated at nearly 70% for industrialized countries; sciatic conditions may occur in 25% of individuals experiencing back problems, according to Andersson.3 Studies of workers' compensation data have suggested that LBP represents a significant portion of morbidity in working populations. Data from a national insurer indicate that back claims account for 16% of all workers' compensation claims and 33% of total claims costs. Studies have demonstrated that back disorder rates vary substantially by industry, by occupation, and by job within given industries or facilities. Back disorders are multifactorial in origin and may be associated with both occupational and nonwork-related factors and characteristics. Nonwork-related factors may include age, gender, cigarette-smoking status, physical fitness level, anthropometric measures, lumbar mobility, strength, medical history, and structural abnormalities. Both work-related and nonwork-related psychosocial factors have been associated with back disorders. The relationship of the disorder with employment can be complex. Some individuals may experience impairment or disability at work because of back disorders even though they were or were not caused directly by job-related factors. The degree to which ability to work is impaired often depends on the physical demands of the job. Furthermore, a back disorder experienced at work may be a new occurrence or an exacerbation of an existing condition. Again, originally it may have been caused directly by work-related or nonwork-related factors. Patients complaining of back pain may modify their work activities in an effort to prevent or lessen pain. Thus, the relationship between work exposure and disorder may be direct in some cases but not in others. When discussing causal factors for low back disorders, it is important to distinguish among the various outcome measures, such as LBP, impairment, and disability. LBP can be defined as chronic or acute pain of the lumbosacral, buttock, or upper leg region. Sciatic pain refers to pain symptoms that radiate from the back region down one or both legs. Lumbago refers to an acute episode of LBP. In many cases of LBP, specific clinical signs are absent. Low back impairment generally is regarded as a loss of ability to perform physical activities. Low back disability is defined as LBP necessitating restricted duty or time away from the job. Although it is not clear which outcome measure is best suited for determining the causal relationship between low-back disorder and work-related risk factors, keep in mind that it is important to consider severity when evaluating the literature. In addition to level of severity, outcomes may be defined in a number of other ways, either subjectively or objectively. Information on symptoms can be collected by an interview or a questionnaire self-report. Back incidents or reports include documentation of conditions reported to medical authorities or on injury/illness logs. These conditions may be signs or symptoms that provoke an individual to seek medical or other attention, perhaps due to acute symptoms, chronic pain, or injury related to a particular incident. The need for medical attention may be determined subjectively or objectively. Whether an incident is reported depends on the individual's situation and inclinations. Other back disorders can be diagnosed using objective criteria (eg, various types of lumbar disc pathology). Many conditions in the low back may cause back pain, including muscular or ligamentous strain, facet joint arthritis, or disc pressure on the annulus fibrosis, vertebral endplate, or nerve roots. In most patients, the anatomical cause of LBP, regardless of its relationship to work, cannot be determined with any degree of clinical certainty. Muscle strain is probably the most common type of work-related or nonwork-related back pain. While sometimes a relationship exists between pain and findings of disc abnormalities on MRI (eg, herniated disc, clinical findings of nerve compression), the most common form of back disorder unfortunately is nonspecific symptoms that often cannot be diagnosed. Include subjectively defined health outcomes in any consideration of work-related back disorders because they comprise a large subset of the total. Defining back disorder with objective medical criteria may be too restrictive. Risk factors for work-related low back pain
REPETITIVE MOTION (CUMULATIVE TRAUMA) DISORDERSSection 9 of 10
Carpal tunnel syndrome In 1988, carpal tunnel syndrome (CTS) had an estimated population prevalence of 53 cases per 10,000 current workers. Twenty percent of these individuals reported absence from work because of CTS. In 1994, the Bureau of Labor Statistics (BLS) reported that the rate of CTS cases that result in days away from work was 4.8 per 10,000 workers. In 1995, the BLS also reported that the median number of days away from work for CTS was 30, which is even greater than the median reported for cases of back pain. In 1993, the incidence rate (IR) of CTS cases qualified for workers' compensation was 31.7 per 10,000 workers; only a minority of these cases involved time off from work. These data suggest that approximately 5-10 workers per 10,000 miss work each year because of work-related CTS. In recent years, the literature relating occupational factors to the development of CTS has been reviewed extensively by numerous authors. Most of these reviews reach a similar conclusion that work factors are one of the important causes of CTS. In 1992, Moore performed a study and found the evidence more equivocal, but he stated that the epidemiologic studies revealed a fairly consistent pattern of observations regarding the spectrum and relative frequency of CTS among jobs believed to be associated with risk of CTS. REFERENCESSection 10 of 10
Evaluation of the Injured Worker excerpt Article Last Updated: May 9, 2007 |
