Journal of Occupational Rehabilitation, Vol. 6, No. 1, 1996

Editorial Comment

Does the Workers' Compensation System Think Multidimensionally? 1 Michael Feuerstein 2,3

This issue marks the sixth year of the Journal of Occupational Rehabilitation. Journal of Occupational Rehabilitation continues to grow as does research and practice on the multidimensional aspects of occupational musculoskeletal disorders (OMDs) and work disability. Over the years, several readers have indicated their support for a journal that addresses the multidimensional aspects of prevention, evaluation, and rehabilitation. Clearly, the problem of work disability is a complex one and the input from a number of disciplines continues to make sense as the factors contributing to the etiology, exacerbation, and maintenance of both occupational musculoskeletal disorders and work disability appear to be varied. However, a major challenge that continues to be ever present in this area relates to the apparent inability or resistance of the workers' compensation system (broadly defined) in the U.S. to move from acknowledgment that OMDs and work disability are multiply determined to the application of multidisciplinary approaches to address these problems in the workplace and the clinic. Clearly, there is a continued need for empirical data to support the potential of these multidisciplinary approaches along with a need to determine the critical components of such approaches for primary, secondary, and tertiary prevention of work disability so as to maximize limited resources. Data will not be enough. Efforts at integrating the concepts and methods of a multidisciplinary approach within the workers' compensation system through education and legislation will also be required. Methods for implementation within the broad range of practice formats that currently exist will also rieed to be developed and communicated to all interested parties. Just what does a "multidisciplinary approach" mean and how does it differ from consid6ration of the multidimensional aspects of OMDs and disability by a single speciality? Oftentimes, the answer to these questions is a function of the discipline or the speciality provider who is asked. At present, it is clear that with IDepartments of Medical/Clinical Psychology and Preventive Medicine/Biometrics, Uniformed Services University of Health Sciences, Bethesda, Maryland. 2Correspondence should be directed to Michael Feuerstein, Departments of Medical/Clinical Psychology and Preventive Medicine/Biometrics, Uniformed Services University of the Health Sciences, 4301 Jones Bridg~ Rd., Bethesda, Maryland 20814-4799. 3The opinions contained herein are the private ones of the author and are not to be construed as official or reflecting the views of the Department of Defense or the Uniformed Services University of the Health Sciences.

1053-0487/96/0300-0001509.50/09 1996PlenumPublishingCorporation

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Feuerstein

the ever-increasing concern for the provision of cost-effective intervention, it is becoming less likely that providers of care from multi-specialties can allocate the time to evaluate an injured worker from their vantage point as an integrated team under one roof. However, through the appropriate allocation of responsibilities and resources along with more effective and efficient communication and a greater understanding of the role of various providers in addressing factors contributing to disability, it is possible that a variant of multidisciplinary care can be provided and improved upon to enhance outcomes in appropriately selected cases. Should all injured workers see a physical therapist? Should all patients with a delayed functional recovery of greater than 1 month be referred to a physiatrist or orthopedist? Do all patients who experience distress related to their presenting problem need to be evaluated by a psychologist or psychiatrist? What is the role of the occupational physician and nurse in the prevention, evaluation, and rehabilitation of workers with OMDs and episodic or prolonged work disability? When is the conservative care provided by chiropractors appropriate? These questions remain unanswered for the most part. Despite this, the U.S. has witnessed several recent changes in workers' compensation health care delivery (e.g., 24-hour coverage, workers comp HMOs, increases in case management) much of it is predicated on the implicit assumption that there is a universally agreed-upon approach to occupational musculoskeletal disorders and disability which can serve as the foundation for appropriately managing care. These new strategies have been proposed to solve the problem of rising health care costs. However, it can be argued that if these approaches do not address the several factors that research continues to indicate can play a role in work disability, they may actually create more problems regarding cost than they solve. While short-term reductions in medical costs may be noted, friction costs related to litigation over restriction of treatment may reduce any savings. Also, by limiting treatment options targeted at a number of barriers to work reentry, indemnity-related costs may increase as injured workers experience greater difficulties returning to work because such factors as ergonomic risks were not reduced or physical and psychosocial accommodations were not adequately addressed. Of course, the necessary outcome studies have yet to be done--those comparing innovative workers' compensation health care delivery vs. variations of comprehensive multidisciplinary care on outcomes that not only measure cost but quality of care and other health and functional outcomes as well. The continued concern over evaluating and assisting injured workers with the psychological consequences or precursors of prolonged pain and disability represent another sleeping giant in this area. Outcome research indicates that the psychological well being of patients is a predictor of health care utilization and other outcomes. Also, data exist that indicate that individuals receiving workers' compensation experience significantly higher levels of distress, and have a range of poorer outcomes than those not on workers' compensation. While the exact set of factors that may account for poorer outcomes have not been delineated, data exist to suggest that high levels of distress can exacerbate pain and prolong disability. It is rare for those involved in the evaluation and treatment of injured workers within the workers' compensation system not to treat patients with heightened levels of distress

The Workers' Compensation System

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fueled by the workers' compensation system. This distress needs to be evaluated and addressed, not ignored, avoided, or presumed to subside over time. The problems with the implementation of multidisciplinary prevention and rehabilitation services continue at full force. Clearly, there is a need for more definitive research to guide application. However, there also appears to be a need to move from a verbal recognition that these problems are determined by some combination of medical, physical, ergonomic, psychosocial, and economic factors to the development and implementation of systems of care that truly allow for the consideration of these factors within appropriate limits. This is not simply an issue of academic concern. There is a need for a major rethinking and operationalization of new models of care that are sensitive to cost but also allow the injured worker access to the type of care he or she needs to truly enhance a range of outcomes and r~turn to a safer workplace with reduced exposure to ergonomic and psychosocial hazards. Such an approach should facilitate a long term and productive return in contrast to simply a return to work. Does the system think multidimensionally? Certainly not yet. Whether it ever will and to what long-term benefit remains to be determined. What is evident is that history has indicated that no one specialty has the answer or the ability to effectively prevent or manage these problems. Clearly, the challenge continues.

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