Dr. David B. Adams – Psychological Blog

Psychology of Illness, Pain, Anxiety and Depression

Fit for Duty, but…still in Pain

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The final months of treatment in workers’ compensation sees the surgeon complete his/her role in the patient care. The management of residual symptoms has been referred to pain management. In the latter case, injections and physical therapies have been discontinued, and, ideally, a medication regimen has been determined that will assist the patient in managing pain.

Functional capacity exam (FCE) has been performed, a disability rating has been assigned (PPD) and the patient is released with restrictions as maximally medically improved (MMI).

The patient, for a variety of reasons, makes no attempt to return to any form of employment. In many cases, the employer has no available work for the patient/employee within this framework. In other cases, the employee may have been terminated by the employer. And in still other cases, in this economy, the employer may no longer be in operation.

While this is psychologically interesting…if not fascinating…, resources are not brought to bear to determine why the patient is making this decision. Factors that direct injured-worker decision making behavior are arguably seen as of little interest or even relevance to securing case closure.

In my own practice, I most often see patients during the transition between the surgeon putting closure on his/her role and pain management beginning to schedule patient returns every 3 months.

And these are the top ten factors that slow or halt the patient’s complying with work-release:

1. The patient has been led to believe that the employer will discharge him/her after s/he returns to work

2. The patient is concerned that the medication prescribed by pain management will not be available after release from care

3. The patient believes that the employer has enacted no safety measures that would prevent his/her injury from occurring to self or others

4. The patient does not meet the criteria for PTSD but has residual aversion to the setting in which the injury occurred.

5. The patient has seen the injury as a battle between worker and employer and is unwilling to relinquish this competition

6. The household has adjusted its financial needs downwards, and the need to return to employment is no longer pressing

7. The patient has a preferred area of employment and is unwilling to consider other work options

8. The patient believes that some, unspecified, disorder and form of treatment remains which has not been pursued

9. The patient is certain that specified limitations far exceed his/her capacity

10. The patient feels that closure is due to reasons other than his/her condition

While the patient, with assistance, will address these sources of resistance with his/her psychologist, the patient is less likely to mention these concerns to either the surgeon who is seen briefly or the pain management team which is now seen infrequently.

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