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Follow-up of persons with litigation related injuries.

Follow-up of Persons with Litigation Related Injuries

One of the more perplexing problems in vocational rehabilitation is the prediction of client success. When first confronted with a client who is disabled, the rehabilitation professional has little research data to assist in determining the person's chances of success and the specific barriers to success. Reviews and predictive studies (Bolton, 1972; Carlsson & Corbett 1987; Moriarty, Walls & McLaughlin, 1987; Poole, 1987; Rubin, Bolton & Sally, 1973; Vander Kolk & Springfiled, 1985) have shown that characteristics such as younger age, higher intelligence, and higher education are related to positive vocational rehabilitation outcome.

Previous research has demonstrated that many factors contribute to client difficulty in returning to employment. These factors may include lack of transferable skills to reduced exertional limits, inability to emotionally cope with the disability, chronic pain, sexual dysfunction, financial disincentives etc. (Beaudet & Rasch, 1988; Borgen, Amundson & Biela, 1987; Eaton, 1979; Garron & Leavitt, 1983; Huenke, 1982; Nagi, 1969; Rasch, 1985; Schlenoff, 1979). Stewart, Chubon, and Ososkie (1988) have discussed the degree of limitation imposed by an injury and the implications for future vocational potential, employability status and earnings capacity. They recommend that vocational experts address numerous variables related to an injured person's degree of vocational disability. Vocational factors and earnings capacity assessment were viewed as most important by the various groups surveyed.

This study focused on injured persons' vocational and psychological status months and years after injury. Although a majority of injured people return to work (Sawyer, 1976), 400,000 per year must seek a new job (Rasch, 1985). In some cases the new job must accommodate residual functional capacities and limitations. Nagi (1969) was an early presenter of information on people injured sufficiently to impair their ability to work, at least on temporary basis. Others such as Newman, Perry and Pan (1985), Nussbaum, Puig, Schneidmuhl and Schaffer (1981), and Vander Kolk and Stewart (1988) have added knowledge concerning the characteristics of injured persons. The commonly found composite description of an injured worker is someone who is blue collar, carried out medium to heavy exertion work, have limited reading and arithmetic skills, most often have musculoskeletal injuries, fall in the age group from early thirties to early fifties, and are most frequently married men. From a general vocational rehabilitation caseload in the state/federal system Harrison and Crystal (1982) found the successful rehabilitation clients averaged 20.3 months in the system, and clients closed non-rehabilitation averaged 24.9 months in the system.

One might presume that persons injured on the job would experience a degree of success in returning to the work world. Not only do they have public and private rehabilitation sectors available to them, the injured worker who has the history of work experience has an advantage over many rehabilitation clients who have never been meaningfully employed. Yet, unemployment rates are quite high for industrially injured workers (Conley & Noble, 1978).

The purpose of this research was to investigate the physical, emotional, vocational, and financial status of injured workers several years post-injury. The research questions to be answered were:

* Would a large proportion of injured persons continue to have physical restrictions, psychological adjustment problems, or employment difficulties?

* Were injured persons receiving assistance (medical, psychological, vocational, financial) years after injury?

* Do injured persons seek employment? What are the major barriers to employment? How many return to work?

* In which ways are the injured people who return to work different from those who remain unemployed?

Method

The analysis began with a collection of data on 40 injured clients seen for psychovocational evaluation after they were referred by plaintiff attorneys in a southeastern state.

After collecting demographic and psychometric information at the time of evaluation it was decided to follow up with the clients at a later date. Sample selection was done by first making a list of referring attorneys who provided client home phone numbers. Next, clients referred by these attorneys were placed on a list. On a random basis, clients from the list were phoned and surveyed until a sample size of 40 was obtained. Phone calls were made during the day and in the evening. All clients were willing to participate. A structured interview form was utilized up to 31 months following the evaluation, and 16 to 58 months following the client's injury. The average time since injury was three years. One interviewer spoke with clients by phone and recorded their responses to each question. Respondents did not answer every question, therefore, the number responding is indicated with each result.

The survey instrument (19 questions) included only current information since past work history, nature of injury and related before-injury data had been collected at the time of evaluation. Clients were asked about their employment status and pay, attempts to find work, medical status and treatment, barriers to employment, current financial sources, mental health services utilized, and vocational services used.

Results

Demographics

Clients ranged in age from 23 to 65, with a mean of 43 years at time of injury. Education ranged from 4 to 17 grades completed, with a mean of 10.73 grades. Two thirds N.(27) were male. Thirty-six cases (90%) were musculoskeletal disabilities while one person each was diagnosed with each of the following disabilities: cardiovascular, post-traumatic stress disorder, depression, and head trauma.

Forty three percent (N=17) of the group performed "heavy" exertion work before their injury, 33% (N=13) performed "medium" exertion work, 10% (N=4) "light," five percent (N=2) "sedentary," and 10% (N=4) "very heavy" work. Only 10% (N=4) of the sample had performed unskilled work.

Case record material obtained before the survey yielded the following information. Most clients (N=33) were administered the Wide Range Achievement Test - Revised (Reading mean grade level = 6.44; Arithmetic mean grade level = 5.4). Average scores on the Purdue Pegboard Test for the group (N=27) were: Right hand 16%, Left hand 17%, Assembly 13%). Scores on the Minnesota Multiphasic Personality Inventory (MMPI) validity scales for 34 of the possible 40 cases fell in the average range on their mean scores. Significant elevations (T score of 70 or above) were found on the following clinical scales, beginning with the most highly elevated; depression, hypochondriasis, hysteria, schizophrenia, and pscychasthenia. Thus, this group of injured persons showed evidence of psychological distress.

It should be noted that cases were selected randomly. No attempt was made to identify the more difficult or the less disabled clients from those referred. These clients had been referred for evaluation over a one year period of time. They were then called at least one year (average time = 12 months) after the evaluation.

Medical

Medical factors were addressed to determine whether people continued to have physical problems which would impair their ability to function. Sixty percent (N=24) of the total group responded that they had reached "maximum medical improvement" (their treating physician had told them no more could be done medically to help them). Yet, all individuals surveyed complained of physical limitations. In spite of more than half reaching maximum medical improvement, 54% received medication as the only form of treatment, while 73% remained on some form of medication alone or along with other treatment such as exercise or physical therapy. Twenty percent (N=8) of the sample were receiving no medical care.

The injured people were asked what was their major problem (38 responded). Seventy-one percent stated limitations in physical exertion as their major problem. The importance of physical capacity is further illustrated in the fact that another 16% (N=6) identified a combination of physical exertion and depression as the primary problem, and an additional 5% (N=2) named a combination of physical exertion and sleep. Only three people failed to name physical limitations as a major problem; they cited depression (N=2) and headaches (N=1) as their chief concern.

The above findings were checked for consistency by asking people. "what is your major barrier to employment?" Seventy-three percent included physical restrictions as the primary or as one of the two primary elements handicapping their return to employment. One person stated employer attitudes, one reported lack of skills, and two indicated disincentives (e.g. social security or disability retirement) as a major reason for not being employed.

Form and Frequency of Assistance

It was hypothesized that subjects would be engaged in therapeutic counseling if they continued to have substantial vocational and medical problems. Thirty-seven people responded to this question, and six (16%) stated they had been or currently were involved in counseling sessions. At least two of the six people stated they were actually seeing a psychiatrist for medical checks only and received little or no counseling. Most (N=37) of the cases had been initially evaluated relative to workers compensation. Since the injury (mean = 3 years) it was found that nine of the 37 (almost 1/4 or 24%) workers compensation cases continued to receive workers compensation payments. Forms of assistance break down as follows:

Employment Factors

Of 40 respondents, 35 had not had any training or education since the time of their injury. Two were in vocational training and one was attending adult education classes at the time of the survey. Two had taken college classes.

Measurement of effort to find employment after the injury was done through self-report of application or request for a job from an employer. It was found that 17 (45%) of the respondents (N=38) to the query on job seeking had looked for employment. Thirty percent of the sample had made contacts with employers. Four of these had made over 20 employer contacts, while two had made 11-20 contacts, three had made 6-10 contacts, and one made one to five contacts. Persistence in job seeking was measured by the length of time (months) injured persons continued to apply for jobs. The range for number of months each person sought employment was three to 48 months. The mean number of months was 18. Seventy-one percent of the respondents (27 of 38) expressed "transportation problems" as an impediment to get to work, or it could actually prevent them from obtaining employment.

A most salient question in this survey was, "Are you working now?" Twenty percent (N=8) of the sample were employed at the time of the survey. Six were working full-time while two worked part-time. Three were doing the work performed at the time of injury, and two were with the same employer in other positions.

Financial

To determine if loss of earning capacity had occurred, eight persons who were employed at the time of the survey were asked to give their before-injury income and their current income. The monthly gross income of the seven respondents averaged $880.57 per month. The before-injury average income of this small group was $917.71 per month. Thus, the employed people as a group were making less money ($37.14 per month at least two years post-injury) than they were before the injury. This figure does not account for pay raises and increased benefits they may have accrued during this time had they not been injured.

Two personal injury cases were willing to state their award amount, and they were settled for $4,500 and $21,000 respectively. There were nine persons with workers compensation cases willing to state the awarded amount. These ranged from $10,000 to $89,000.

Return to Work

On most client characteristics the returned workers in this sample (N=8) are very similar to the total sample. Examination of variables demonstrate few meaningful differences. Seventy-five percent of returnees listed physical exertion limitations as a barrier to employment, while 87% of the total sample responded in the same way. Eighty-eight percent of job returnees performed skilled or semi-skilled work pervious to injury, and 89% of the total sample had before-injury work skills. Eighty-eight percent of clients who returned to work had performed "medium" or "heavy" exertion work versus 75% of the total group.

Returnee average grade completed in school was the tenth (versus 10.73 for total group), Wide Range Achievement Test average reading score at the seventh grade (versus 6.44 for total group), and tested arithmetic at the fifth grade (versus 5.4 for total group). A final example of similarity between groups is average MMPI profile for each group. The returnee's average score on each of the ten clinical scales differed no more than 4.1 T-score points from the average score of the total sample.

Three characteristics were found which distinguished the returned workers from the non-workers. As a group, the people who returned to work were younger (35.4 years) than those remaining unemployed (44.8 years). The second difference was the scores on the dexterity test (Purdue Pegboard). The employed people scored much higher on all three scores obtained. For example, the "assembly" score for the employed group was 24.3% and 11.6% for the total sample.

The final difference was in diagnoses. Three (38%) of the employed people as a group were making less money ($37.14 per month at least two years post-injury) than they were before the injury. This figure does not account for pay raises and increased benefits they may have accrued during this time had they not been injured.

Two personal injury cases were willing to state their award amount, and they were settled for $4,500 and $21,000 respectively. There were nine persons with workers compensation cases willing to state the awarded amount. These ranged from $10,000 to $89,000.

Discussion

Results from this study are limited in their generalizibility because conclusions are based on a small sample of people who are primarily workers compensation cases (N=37) consisting primarily of musculoskeletal impairments, which had been referred mostly by plaintiff attorneys in one state without mandatory rehabilitation. In the state surveyed, insurance carriers were not required to provide non-medical rehabilitation services to workers compensation clients, and the clients are not required to accept non-medical rehabilitation services. These constraints could well affect the availability and client usage of services, which in turn may impact vocational success. This is unfortunate in view of Broe's (1983) finding that successfully rehabilitated clients received more restoration and maintenance services, and more vocational training and on-the-job training than clients who did not obtain gainful employment. Disincentives were also likely factors, in the form of continued workers compensation payments for some people (Schlenoff, 1975; Walls, 1982). Results would apply to similar settings and where the client population shared characteristics of this group.

Furthermore, time from injury to time of evaluation (21 months) and to time of outcome survey (36 months) can be a major barrier to re-employment. Early intervention for vocational and psychological services to the injured person appears appropriate as a usual course of intervention; yet it was found that the majority of this sample had received neither services. The people in this sample would be considered relatively chronic and difficult to rehabilitte at the time of the study. Had they received early vocational and psychosocial rehabilitation services, success in the form of reduced symptoms and increased job placement may have taken place. Another research study comparing a group receiving a full range of psychovocational and medical services with a group similar to the one in this study would help clarify the issue.

Most of these injured people have used their before injury physical capabilities to earn an income, and their skills are directly tied to the ability to carry out physically demanding work tasks. The person who must frequently sit, or alternately sit and stand, and who further fits the profile of a middle-aged injured person, has few vocational alternatives. Some, however, could function in light industrial work such as assembly type jobs.

In view of the set of limitations found in this sample of injured persons, it seems to make sense that a major effort to get people involved in vocational, educational and psychosocial services is justified. Soon after injury adult education would be useful in many cases to upgrade reading, arithmetic and other deficient areas. Furthermore, this activity would often be of therapeutic value as the person has a goal, meets with some success, and finds himself or herself as a more capable and confident person. While recovering from an injury, just having a specific place to go and lessons or goals to accomplish can minimize emotional problems such as withdrawal from others, depression and anxiety.

It would appear that a portion of this sample would benefit from psychosocial services. For those clients not ready for vocational or educational services due to severe chronic pain, depression, etc., programs including pain therapy, personal counseling, group counseling, family guidance and counseling, and medication in selective cases could prepare an individual to benefit from vocational services.

With regard to comparisons between the employed and unemployed group, there were three meaningful differences. The fact that the employed group was nearly 10 years younger than the unemployed group suggests that younger injured workers have a better chance of returning to the work place. Middle-aged and older injured people are less likely to return to work, and will likely require more sophisticated rehabilitation efforts in order to assist them in reentering the work would. It is suggested that multiple factors impact upon the relationship between older age and lower frequency in return to work. First, the older person may be less willing to return to work, fear additional injury, or be apprehensive about liability to adequately carry out job duties. Employers may be less willing to take back or to hire an older person with a history of physical injury. Older age in combination with a more frequent diagnosis of bulging or herniated disc should alert professional people to greater difficulty in getting the person prepared for a return to work. Further research is needed to clarify the relationship between age of an injured person and their return to work. The relative higher aptitude in fine manula dexterity with the employed group can be viewed as a variable affected by several client characteristics which may contribute to performance of dexterity tasks. Factors such as pain and emotional distress can interfere with concentration and with work capability.

In summary, with a sample of injured people averaging three years post-injury we find a 20% employment rate, reduced earning capacity, receipt of little in the way of vocational and mental health services, and test scores suggesting significant distress.

Early, intensive rehabilitation services in the form of personal counseling, vocational counseling, pain therapy management, appropriate medication when necessary, use of physical therapy, adult education, vocational re-training, skilled case management, and aggressive job placement are recommended for injured persons similar to those found in the sample used in his study.

References

Beaudet, J. & Rasch, J. (1988). The relationship of depression to work status during the acute period of low back pain. Rehabilitation Counseling Bulletin, 31(3), 198-203.

Bolton, B. (1972). The prediction of rehabilitation outcomes. Journal of Applied Rehabilitation Counseling, 3, 16-24.

Borgen, W.A., Amundson, N.E., & Biela, P.M. (1987). The experience of unemployment for persons who are physically disabled. Journal of Applied Rehabilitation Counseling, 18(3), 25-32.

Broe, T. (1983, March). Rehabilitation services and their relationship to rehabilitation outcomes with clients who have sustained a work-related mental disability. Unpublished paper presented at the American Association for Counseling and Development Conference, Houston, TX.

Burg, M.A., Crandall, L.A. & Muthard, J.E. (1988). The impact of benefit entitlements, health perceptions and work attitudes on the labor force commitment of disabled persons. Journal of Rehabilitation Administration, 12(1), 5-9.

Carlsson, R. & Corbett, A. (1987). Vocational rehabilitation and earning enhancement. Journal of Rehabilitation, 53(1), 26-32.

Conley, R. & Noble, J. (1978). Workers compensation reforms: Challenge for the 1980s. American Rehabilitation, 3(3), 19-26.

Eaton, M. (1979). Obstacles to the vocational rehabilitation of individuals receiving worker's compensation. Journal of Rehabilitation, 45(2), 59-63.

Garron, D.C. & Leavitt, F. (1983). Chronic low back pain and depression. Journal of Clinical Psychology, 39, 486-493.

Harrison, D.K., & Crystal, R.M. (1981). Vocational rehabilitation standards analysis of the fiscal year 1979 data. Ann Arbor: The University of Michigan, School of Education, Rehabilitation Research Institute.

Hueneke, B. (1982). Working with chronic low back clients in rehabilitation: The need for early intervention. Journal of Applied Rehabilitation Counseling, 13, 15-17.

Moriarity, J., Walls, R. & McLaughlin, D. (1987). The preliminary diagnostic questionnaire (PDQ): functional assessment of employability. Rehabilitation Psychology, 32(1), 5-15.

Nagi, S. (1969). Disability and rehabilitation. Columbus: Ohio State University Press.

Newman, S., Perry, D. & Pan, E. (1985). Characteristics of the private rehabilitation client: Implications for the rehabilitation specialist. In L. Taylor, M. Golter, and T. Backer. Handbook of private sector rehabilitation. New York: Springer.

Nussbaum, K., Puig J.G., Schneidumuhl, A.M. & Shaffer, (1981). Assessment of psychiatric impairment under Social Security. American Journal of Psychiatry, 2, 39-45.

Poole, D. (1987). Competitive employment of persons with severe physical disabilites: A multivariate analysis. Journal of Rehabilitation, 53, (1), 20-25.

Rasch, J.D. (1985). Rehabilitation of worker's compensation and other insurance claimants: Case management, forensic, and business aspects. Springfield, IL: Charles C. Thomas.

Rubin, S., Bolton, B. & Sally, K. (1973). A review of the literature on the prediction of client outcome and the development of a research model. Monograph No. 5. Fayetteville: Arkansas Rehabilitation Research and Training Center.

Sawyer, G. (1976). The industrially injured: Proceedings of the National Training Institute. Chicago: Medical Rehabilitation Research and Training Center.

Schlenoff, D. (1979). Obstacles to the rehabilitation of disability benefits recipients. Journal of Rehabilitation, 45, (2), 56-58.

Stewart, W.W., Chubon, R.A. & Ososkie, J.N. (1988). Understanding vocational disability: A critical issue in the adjudication of disability related problems. Journal of Rehabilitation, 54(1), 29-32.

Vander Kolk, C.J. & Springfield, W. (1985). Program planning and prediction of visually impaired client success. Yearbook for the Association for Education and Rehabilitation of the Blind and Visually Impaired, 2, 38-44.

Vander Kolk, C.J. & Stewart, W.W. (1988). Characteristics of injured persons involved in litigation. Vocational Evaluation and Work Adjustment Bulletin, 21(3), 103-106.

Walls, R.T. (1982). Disincentives in vocational rehabilitation: Cash and inkind benefits from other programs. Rehabilitation Counseling Bulletin, 26, 37-45.

CHARLES J. VANDER KOLK, Rehabilitation Counseling Program, Department of Education Psychology, University of South Carolina, Columbia, South Carolina 29208.
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Author:Vander Kolk, Jo Anna K.
Publication:The Journal of Rehabilitation
Date:Oct 1, 1990
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