Catastrophic Thinking Derails Injured Worker Recovery; Here’s How to Manage It

By: | April 9, 2019

Mariellen Blue, RN, CCM, is national director of case management at Genex Services where she is responsible for overall product management and development, as well as regulatory compliance, accreditation, and quality assurance initiatives related to utilization management, telephonic and field case management, IME, and MCO services. A graduate of the Helene Fuld School of Nursing, Ms. Blue has an extensive background in nursing, case management and utilization review.

Delayed recovery is a challenge coming to the forefront of workers’ comp. It’s defined as a lack of anticipated functional recovery in a medically reasonable period of time. Recently, many organizations have been seeking new ways — whether through telephonic or field case management services — to identify injured employees who are at risk for delayed recovery.

For years, we’ve used predictive modeling to identify cases that score high for delayed recovery, using factors like age, gender and comorbidities, such as diabetes, obesity, smoking or substance abuse. These are proven biological factors that can lead to delayed recovery, and we’ve implemented clinical interventions to address them.

However, there are still many delayed cases that aren’t attributable to these traditional biological factors. Today, the industry must delve deeper into cases and identify potential psychosocial issues that could be at the root of the reason why certain cases don’t progress as expected.

Delayed Recovery: A Tale of Two Cases

Let’s consider two individuals. Both are men of the same age with approximately the same health status. They hold the same position and sustain the same low-back injury. Neither individual has a comorbidity. On paper, the cases seem identical. However, each case results in significantly different outcomes.

The first patient attends all of his medical appointments. His pain level gradually decreases, while his functionality improves. This individual returns to work within a reasonable period of time, slightly ahead of evidence-based guidelines.

There have been studies that show 64 percent of people who have low back pain are actually afraid to move.

Meanwhile, the second patient struggles. He has difficulty keeping his appointments. He seems to experience a higher level of pain. He’s not compliant with his prescribed at-home exercise program.

The case soon exceeds typical treatment guidelines for this type of injury. The patient ends up staying on pain medication for a much longer period of time and is not experiencing the expected level of recovery. What factors make this second case different from the first?

Identifying Psychosocial Issues

Research over the past few decades has shown that psychosocial issues can have a significant impact on recovery rates. Having psychosocial issues doesn’t mean individuals have a psychiatric disorder; instead, they may exhibit minor cognitive distortions, which relate to how they think and feel about a situation. These individuals are fine during the course of normal life, but when presented with an added stressor, like a painful work-related injury, they may experience a tense and fearful response.

Nurse case managers are uniquely positioned to recognize when cognitive, emotional or social barriers may be at play. For example, injured employees may not tell supervisors or doctors about their fears or family problems, but they may have built up enough rapport with case managers to share such information with them.

In addition, nurse case managers are trained to listen for queues that may indicate cognitive distortions. For example, in talking with an injured employee, a nurse case manager may sense an exaggerated fearful response to pain.

There have been studies that show 64 percent of people who have low back pain are actually afraid to move. Since they’re experiencing pain, they think that if they move — such as doing their prescribed home exercises — the condition will become worse, so they don’t comply.

However, by remaining immobile, they become stiffer. Their muscles tighten up, and the pain might increase due to a lack of movement. This is condition is called “disuse syndrome” and as the name implies the individual may experience muscle atrophy from a lack of activity. Their initial fear — that pain will cause their condition to become worse — has become a self-fulfilling prophesy.

Recognizing Maladaptive Coping Strategies

Injured employees may exhibit other irrational fears.

A 2015 WCRI study showed that people who had a fear of being fired due to their workplace injuries could experience a four-week increase in their average duration of disability.

A big issue may be “catastrophic thinking,” where injured employees may feel as if their injury is the end of the world. Their thoughts may go something like this: I have a low back injury. It’s really painful. I’m never going to recover. I’m going to be disabled for the rest of my life, and I’ll never be able to provide for my family again.

The fears create a snowball effect, becoming bigger and bigger in their minds. Nurse case managers will identify individuals with this type mindset. For example, closely related to catastrophic thinking is a feeling of fateful injustice: If only I hadn’t come to work that day, this never would have happened to me.

These expressed feelings often indicate maladaptive coping mechanisms. Perhaps these individuals have not had to develop positive adaptive behaviors to get them through a time of crisis or stress. Because of this, when something stressful happens, they become practically incapacitated by their own negative thoughts and fears.

Related: Less CBD, More CBT: Exploring the Mind/Body Connection in Workers’ Compensation

Social factors can also contribute to an inability to cope. For example, an injured employee may have a difficult home life. This situation may not impact everyday life, but a weak social support system could fall apart in the face of an added stressor, like an injury.

Utilizing Questionnaires to Identify Psychosocial Risks

To pinpoint psychosocial issues, nurse case managers may use a patient questionnaire. An example of one that’s used to identify delayed recover is the Örebro Musculoskeletal Screening Questionnaire (OMSQ) Short Form (Gabel, C. P 2012). This short version uses 12 questions.

The questionnaire is filled out by the patient, and it collects information about how the person is feeling, if he or she is able to manage a daily routine, and it detects unhealthy perceptions or low social support.

The OMSQ Short Form produces a score, which can then be used as a predictor for risk of delayed recovery or the potential for chronic symptoms, including delayed return to normal daily activities or work. A higher score indicates a higher risk. The resulting score would be categorized as follows:

  • Low risk — below 57 points
  • Medium risk — between 57 and 72 points
  • High risk — greater than 72 points

Ideally, the questionnaire would be administered within the first 30 days of an injury or within the first two visits to a treating physician. If the injured employee has already exceeded treatment guidelines, the questionnaire can still be administered and can still be useful. But optimally, the earlier the risks are identified, the earlier that strategies can be applied to prevent a case from going off track.

The risk factors could also be discussed with treating physicians, so they’re aware of the non-medical issues affecting the patient. Physicians may decide to handle treatment differently. For example, they might prescribe cognitive behavioral therapy to help alleviate fears or other distorted thoughts.

The Role of Case Management

Nurses are trained to listen to what injured employees say, why they’re saying it, and if they represent issues hindering their recovery. That’s why they’re often the ones to suggest a questionnaire be administered, although treating physicians may also request them.

Throughout a claim’s duration, nurse case managers will encourage injured employees to take responsibility and play an active role in their own care and recovery. With added information from the questionnaire, they can better understand the underlying thoughts and feelings delaying progress.

Once high-risk cases are identified, nurses work with employers to aggressively utilize transitional or modified duty. It’s important to get these individuals re-engaged in the work setting and have a return-to-work mindset as soon as possible.

Nurse case managers also work to reframe an injured employee’s unhealthy thought process by establishing proper expectations: Yes, you’re injured but you’re going to gradually recover, and the pain will eventually go away. You’ll actually make faster progress if you consistently perform your home exercises.

They also get injured employees to focus on function rather than pain. For example, they may set functional goals: Within two weeks, if you consistently attend your physical therapy appointments, you should be able to walk your dog again and take the stairs.

And of course, case managers are also there to provide positive reinforcement: Fantastic! Look at the progress you’ve made!

In the end, the longer injured employees are out from work, the less likely they’ll be able to return. That’s why it’s vital to catch psychosocial issues early, so injured employees can be provided with the cognitive behavioral tools they need to successfully cope with a stressful, painful injury, to comply with care, and not reach a state of delayed recovery.

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