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The body is willing, but is the mind able?

The Body is Willing, But is the Mind Able?

Thousands of industrial injury claims are filed each year with insurance carriers across the United States. If these injuries occur in connection with an individual's employment, workers' compensation benefits are paid. These benefits include medical care for the injury, lost wages and rehabilitation.

Despite the tremendously large number of claims, 1987 statistics from the National Council on Compensation Insurance indicate that approximately 90 percent of individuals suffering an injury recover and return to work within 18 months. These persons respond to medical care and return to either their occupation, modified employment or a new job.

The remaining 10 percent, however, typically do not recover. Despite attempts to modify and minimize the physical demands of their jobs, these individuals do not respond to medical care and do not return to any form of sustained gainful employment. They tend to elicit maximum attention and assistance from the insurance company handling the claim and represent more than 75 percent of the dollars paid out in medical care, lost wages and rehabilitation. In the end, these individuals are often classified as permanent total disability claims.

At first glance, it seems logical to assume that the 10 percent group has severely disabling injuries or illnesses. However, yearly statistics kept by the federal Occupational Safety and Health Agency indicate that catastrophic injury (i.e., spinal coard, brain injury, amputations of major limbs, blindness, etc.) represents less than 2 percent of all bodily injury claims. The California Workers' Compensation Institute found a 1 percent incidence of catastrophic injury in claims filed in that state. The institute also found, however, that 8 percent of claims involving minor disability (i.e., strains, sprains, muscle or ligament tears, etc.) resulted in no return to gainful employment and were classified as permanent total disability claims.

Personality/emotional factors can interfere with recovery and delay a return to work. Accurate assessment of these relevant psychological factors should provide useful data for determining who is at risk for recovery complications and a delayed return to work.

Human Factors Claim Survey

There are many factors other than severity of injury which influence and may predict the response to an injury. While many assessment tools are available to measure some of these factors, no single tool has been designed for the industrially injured population, nor do most available inventories incorporate the multiple factors found in the literature. The Human Factors Claim Survey (HFC) is an 89-item instrument developed by St. Paul Fire and Marine Insurance Company. Subscales were developed based on psychological factors that should logically predict poor rehabilitation potential. This information is critically important in the proper management of an injured employee's care and may prevent permanent total disability. HFC items were devised to be easily comprehensible and nonthreatening to respondents. The total number of items was purposely limited so the survey would take less than 15 minutes to complete. The majority of items are written at a third-grade reading level to accommodate individuals with minimal education. The HFC contains five scales, including chronic pain behavior, emotional distress, locus of control, stressful life change and job dissatisfaction. In addition, a distortion scale and total rehabilitation potential scale are included in the inventory. Percentile scores ranging from 0 to 100 are presented for each scale. Higher scores mean greater need for intervention but a poorer prognosis as well.

Chronic Pain Behavior

This scale assesses an injured individual's ability to cope with pain. The individual suffering from chronic pain tends to complain of multiple pains rather than pain localized to the specific injury locations, and as a result, the pain becomes the major focus of the individual's attention. Usual activities, both recreational as well as work, are avoided and a disturbance of the individual's usual sleep pattern is reported. Relief is temporary, regardless of the nature and potency of treatment and heavy use of pain medication is common.

To discover chronic pain potential, the HFC survey asks respondents to react to the following statements and scale their responses from "strongly agree" to "strongly disagree." Key sample statements are:

* "This is the worst pain I have ever felt;"

* "The pain is so bad I cannot sleep at


* "It would help if I had a stronger


* "I hurt most of the day;"

* "I feel like surgery is the only solution to

my pain."

Emotional Stress

This scale essentially measures depression in cases in which the individual lacks the energy to perform usual activities, much less follow an aggressive medical recovery regimen. The feeling of helplessness is prevalent. The individual often feels like crying, experiences feelings of helplessness and can withdraw from social interaction. Some key sample items are:

* "I often feel tired and fatigued;"

* "Everything I do takes great effort;"

* "I feel hopeless about the future;"

* "I often feel worthless;"

* "I cry easily these days."

Locus of Control

This scale combines items that assess control orientation beliefs related to health and safety. Internally controlled individuals feel responsible and take an active role in their health and safety. These individuals are likely to follow a prescribed recovery plan and home exercise regimen, self-monitor medication use, obey safety rules and use caution upon a return to employment. As a contrast, externally controlled individuals feel their health and safety is the responsibility of others or in the hands of fate. Key sample statements are:

* "I am directly responsible for my own


* "I can only do what my doctor tells me;"

* "If I take care of myself, I can avoid


* "I can avoid on the job back injuries if I

use proper lifting techniques;"

* "I can do very little to avoid slips and falls

while working."

Stressful Life Changes

This scale measures the amount of stressful life changes an individual has experienced in the past 12 months. Examples of stressful life changes include, death of spouse, divorce or separation, legal problems and changes in financial status.

Job Dissatisfaction

This scale assesses how dissatisfied individuals are with various aspects of their jobs, such as pay, promotional opportunities, co-worker relationships and overall management effectiveness. Key sample items are:

* "I am very satisfied with my job;"

* "My supervisor is supportive of my


* "The company I work for really cares

about me;"

* "I felt burned-out on my job;"

* "I am paid fairly for what I do."


This scale identifies individuals who are truthful with their responses and those who are faking replies. Some key sample statements are: "I have never felt the urge to tell someone off;" "I always tell the truth to others;" and "I never listen to gossip."

Rehabilitation Potential

This is a very important HFC scale. It is derived by weighing key items from the chronic pain, emotional distress, job dissatisfaction and locus of control scales. Rehabilitation potential is influenced by the multiplicity of elevated scores on each scale, as well as an extreme elevation of any one scale. The individual's rehabilitation potential is an important factor in considering treatment options and intensity, especially from a cost effectiveness standpoint. It is a prognostic indicator, with high scores suggesting a serious potential for permanent total disability due to recovery complications.

The HFC scores significantly predict the number of days an injured employee stays away from work and the total cost for the absences and medical treatment. The next section illustrates the usefulness of the HFC by examining two actual cases and the suggested treatment plans based on HFC scores.

Case Studies

The first subject is a college-educated female professional in her early thirties, slightly overweight, with a history of three to five illnesses or injuries in the past three years. Her HFC profile indicates she is somewhat depressed (based on her emotional stress score) and feels she has little control over her health and well-being (from the locus of control scale). She has experienced at least two stressful life changes in the past year which may have contributed to her illnesses and injuries and may be draining her energy to cope with her physical injury. However, she has a fair prognosis (from the rehabilitation potential scale) and apparently is able to cope with chronic pain (from the chronic pain scale). Furthermore, she appears satisfied with her job (job dissatisfaction scale is fairly low) and was candid in her responses (from her distortion score).

This individual may return to employment without intervention, but her history of three to five prior serious injuries/illnesses suggests that a permanent return to employment is unlikely without custom-designed treatment using the HFC results. In this case, treatment planning can be expanded beyond appropriate medical care. The options include:

* Inform the treating physician that this

patient exhibits an "external locus of

control" and should be counseled to take

greater responsibility for her physical

recovery. She could be advised to begin a

home exercise program with target dates

for progress.

* To help the patient deal with her stressful

life changes, referral (through an

employee assistance program, if available) to

an outpatient mental health facility or

some other community counseling

resource is appropriate.

* Immediate referral to a rehabilitation

professional is another treatment option,

particularly because of the subject's

"external locus control" score. The

rehabilitation professional also could work

closely with the employer to design a

return-to-work strategy, minimizing the

potential for reinjury.

The second subject is a high school-educated male in his late thirties who reports no prior illnesses or injuries but is significantly depressed. He obtained a high chronic pain score, suggesting the risk for chronic pain syndrome. The job dissatisfaction scale indicates that the subject is very unhappy with his job and his overall prognosis for rehabilitation is poor. Although he has a tendency to exaggerate symptoms, this is a valid high risk case.

This case has strong potential for permanent, total disability regardless of the nature of this subject's injury or illness. Therefore, an immediate and aggressive treatment plan is warranted and an immediate referral to a rehabilitation professional is necessary. These high risk findings should be communicated to the treating physician who should take them into consideration when developing any treatment plan. Immediate referral also is needed to an inpatient chronic pain program due to the severity of the expressed symptoms.

The source of job dissatisfaction should also be examined. A return to employment is unlikely when the individual is highly dissatisfied with his employment and the employer likely will be dissatisfied as well. This issue should be resolved quickly so that either alternative employment opportunities can be developed with the current employer or so the subject can begin vocational rehabilitation planning.

The treatment recommendations based on the administration and interpretation of the HFC are nontraditional within the insurance industry. It is evident, however, that the traditional methods of handling industrial injury (i.e., financial compensation and medical management) are inadequate in certain cases resulting in permanent total disability insurance claims. Consequently, nontraditional, innovative approaches like Human Factors Claim Survey assessment and custom-designed treatment planning are necessary to better predict and potentially avoid permanent total disability. This assessment assists the treating physician in that custom-designed treatment plan as well.

Using HFC and its treatment plans might require a higher initial investment to achieve a benefit, but this is offset by the great potential for long-term savings by reducing the number of permanent total disability cases and their resulting drain on society's financial and human resources.

Jonathan Gice is a senior workers' compensation manager in the home office of St. Paul Fire and Marine Insurance Company in St. Paul, MN.
COPYRIGHT 1989 Risk Management Society Publishing, Inc.
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1989 Gale, Cengage Learning. All rights reserved.

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Title Annotation:industrial injuries
Author:Gice, Jonathon
Publication:Risk Management
Date:May 1, 1989
Previous Article:The benefits of prevention programs.
Next Article:Making second-injury funds your number two priority.

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