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Factors prolonging disability in work-related cumulative trauma disorders
Factors Prolonging Disability in Work-Related Cumulative Trauma Disorders Paul J. Bonzani, OTR, CHT, Durham, NC, Lewis Millender, MD, Beth Keelan, OTR, CHT, Boston, MA, Marjorie G. Mangieri, MS, OTR, Waltham, MA Workers' compensation costs for management of soft tissue disorders continue to increase. The complexity of medical management of these cases has increased due to social factors. The purpose of this study is to improve the physician's ability to recognize nonmedical issues that prevent a rapid return to employment. A classification system is presented that will allow the clinician to identify administrative and pyschosocial issues that prolong disability. Additionally, the patients' job demands were classified by known ergonomic risk factors. The system was applied retrospectively to 50 random cases referred to two occupational hand clinics over a l-year period. The results indicated that the psychosocial classification of the patient and the current employment status are the most impotrtant factors in prolonging disability workers. (J Hand Surg 1997;22A:30-34.)
Soft tissue disorders of the upper extremity remain a difficult and costly problem for surgeons and industry.l-3 These disorders frequently result in prolonged disability and delayed return to work. 4,5 The costs of these conditions to employers and insurers continue to mount. We have found that management of these disorders improves greatly when a multidisciplinary approach is used. 6-8 The difficulty has been identification of the factors responsible for prolonging disability.9 A previous attempt to categorize these disorders did not fully consider ergonomic factors as a source of prolonged disability, to The purposes of this
From the Occupational Medicine Department, New England Baptist Hospital, Boston, MA and Occupational Health & Rehabilitation, Waltham, MA. Received for publication April 20, 1995; accepted in revised form April l, 1996. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Paul J. Bonzani, OTR, CHT, 909 Grove Street, Chapel Hill, NC 27514.
30
The Journal of Hand Surgery
article are to propose a classification system that will assist the surgeon with identification of these factors and to present a multidisciplinary treatment model with an emphasis on expanding case management roles by all team members.
Methods A retrospective review of 50 patient charts was completed. The patients involved were seen from August 1993 to February 1994 in an upper-extremity work disorder clinic. All patients had a diagnosis of a soft tissue disorder that was related to a repetitive motion or awkward posture. The patient's employer or insurance provider established causal relationship prior to referral (Table 1). Three major variables were involved: type of musculoskeletal disorder, ergonomic issues, and psychosocial issues.
Musculoskeletal Disorders The specific musculoskeletal disorder was determined by standard methods of clinical and radiographic examination. After examination we classified patients as follows:
The Journal of Hand Surgery/Vol. 22A No. 1 January 1997
Table 1. Patient Classification by Diagnosis Diagnosis Carpal tunnel syndrome de Quervain's disorder Epicondylitis Tendinitis Tenosynovitis Thoracic outlet syndrome Unreasonable, subjective, symptoms (no specific diagnosis)
No. of Patients 8 6 4 3 2 2 25
Group 1. The objective findings for group 1 were swelling, limited joint passive range of motion, abnormal radiographic findings, or positive electrodiagnostic results. Group 2. Those in group 2 had reasonable, subjective symptoms: pain, tenderness, weakness, and/or sensory loss that was consistent with an injury. Group 3. Those in group 3 had unreasonable, subjective symptoms: diffuse, vague, nonreproducible pain not corresponding to anatomic distribution, or out of proportion to the injury. Ergonomic Issues We classified these factors as follows: Group 1. Those in group 1 had minor ergonomic issues. This group had an easily correctable workstation or tool design problem. Stretch breaks and rest periods could be implemented based on physician recommendation. Furthermore, these patients worked for supportive companies that could arrange for job rotation and/or job sharing to control the nature of the patient's symptoms. Group 2. Those in group 2 had moderate ergonomic issues. This group had minimal opportunity for job restructuring. The patients had limited opportunity for stretch breaks and rest periods. Modifications of the workstation were possible, but the nature of the patient's job could not be changed. The most common example was a legal secretary. Workstation redesign was possible, but the patient continued to perform full typing duties. Group 3. Those in group 3 had major ergonomic issues. This group had a combination of workstation design and job demands that could not be modified in any substantial way. For example, for electronic assemblers, redesign of the assembly line was not possible. Additionally, production timetables and worker productivity had to be maintained.
31
Psychosocial Issues We classified psychosocial factors as follows: Group 1. Those in group 1 had minor psychosocial issues. These were administrative issues, such as arranging modified duty, modified work schedules, breaks, and/or job rotation. Group 2. Those in group 2 had moderate psychosocial issues. Job frustrations or stresses causing employee anger were manageable by physician or therapist intervention with the employer. Group 3. Those in group 3 had major psychosocial issues. These patients had long-standing frustration or anger stemming from job and/or family stresses that could not be resolved. These stresses often included chronic pain behaviors that required referral to formal chronic pain programs. Our clinic did not have standard criteria or a protocol for chronic pain referral. We reviewed each record to determine what factors were present and how they combined to prolong or reduce disability.
Results
Objective/Reasonable, Subjective Group Six patients had objective findings and 19 had reasonable, subjective symptoms. Analysis of the data caused us to combine these groups. This was done because patients in these groups followed similar patterns of return to work. In this group, 5 patients had group 1 ergonomic or administrative issues, 14 patients had group 2 ergonomic issues, and 6 patients had group 3 ergonomic issues. Twenty-one patients had minor psychosocial issues, 2 patients presented with moderate issues, and two presented with major psychosocial issues. Twenty-three of the 25 patients returned to employment or continued in their jobs until symptom resolution. The remaining 2 patients had a combination of major ergonomic and major psychosocial issues and did not return to work.
Unreasonable, Subjective Group Twenty-five patients had unreasonable, subjective symptoms. Five patients had a minor ergonomic problem, 13 had a moderate one, and 7 patients had a major one. Eight patients had minor psychosocial issues; all returned to modified-duty programs. Of the 15 patients with moderate psychosocial issues, 8 returned to adjusted work after the physician or ther-
32
Bonzani et al. / Factors Prolonging Work-Related Disability
apist employed case-management techniques. Two patients had major psychosocial issues; attempts to return these patients to work were unsuccessful. The data also revealed a subset of patients. Twenty-three patients in this group had a moderate or major psychosocial issue; 6 of these were in musculoskeletal group 1 or 2 (objective or reasonable, subjective symptoms) and 17 were in musculoskeletal group 3 (unreasonable, subjective symptoms). The six group 1 and 2 patients were working at the time of referral, and all continued to work during treatment. Five group 3 patients were working at the time of their initial visit. They were referred for a short course of hand therapy. We then contacted the patient's employers and obtained their assistance by arranging adjusted work programs. These patients continued working (Table 2). Twelve patients were not working at the time of their first clinic appointment. These patients all received the same treatment. Six of these patients returned to modified duty; the remaining six patients could not be returned to employment. Case Study
A 36-year-old computer operator referred to our occupational medicine program with a diagnosis of cervical strain and carpal tunnel syndrome. Previous treatment included steroid injection and traditional physical therapy for 2 years without resolution of her symptoms. After initial evaluation, we classified her as a musculoskeletal group 2 (reasonable, subjective findings). On physical examination, results of both Roos test and Wright maneuver were positive. Furthermore, there was tenderness upon palpation of the axilla and the supraclavicular fossa. She was diagnosed as having thoracic outlet syndrome and a possible double crush affecting the median nerve. Analysis of her ergonomic status led to a group 2 classification (moderate). The patient had an inappropriate workstation that required adaptation. She also required relief from her company's quota-based productivity system. Finally, she was rated as being
in psychosocial group 2 (moderate issues), as she was clearly angry at and frustrated with her direct supervisor. Following our initial assessment, her company's h u m a n resource department was contacted by the hand therapist at the direction of the physician. The occupational safety officer discussed the possibility of work-duty and workstation modifications and consented to job-site analysis by the hand therapist. Adaptions of the patient's workstation included installation of mobile forearm supports, lowering the computer monitor, and centering the computer terminal to reduce awkward head positions. This followed standard office ergonomic recommendations.U Typing was limited to 2 hours per day, with no more than 15 minutes in succession. Finally, the patient began a program of upper-extremity strengthening, postural exercise, and aerobic conditioning. This program lasted 8 weeks and required 12 sessions. During this time, the team slowly reduced her work restriction. Our hand surgeon followed her for 6 months and she resumed work with a permanent modification of no more than 4 hours per day of typing. She resumed all her other office duties. This case demonstrates the necessity for all members of the team to expand their roles and assume case-management responsibilities when confronted with these difficult cases. Discussion
The musculoskeletal classification is important in the diagnosis of these patients and in predicting their return to work. In work-related soft tissue disorders, objective findings are uncommon. This creates difficulties in evaluating the significance of subjective symptoms. Our study shows that return-to-work rates are identical for the objective and the reasonable, subjective group. We believe this demonstrates that when subjective symptoms of pain, tenderness, weakness, and sensory loss are consistent with the history of the injury and present in well-recognized constellations of symptoms, patients respond to
Table 2. Employment Status by Musculoskeletal Classification Group
Musculoskeletal 1 and 2 Musculoskeletal 3 Musculoskeletal 3
Working at Presentation
6 5 0
Not Working at Presentation
0 0 12
Returned to Work After Treatment
6 5 6
The Journal of Hand Surgery/Vol. 22A No. 1 January 1997
treatment predictably. A second finding is that the ergonomic classification does not independently predict return-to-work potential. All cases with group 3 ergonomic problems returned to employment in the absence of group 2 or group 3 psychosocial issues. This study identified two important factors that contribute to prolonged disability in workers diagnosed with soft tissue disorders. Psychosocial classification is the primary factor in prolonged disability. Workers who presented with objective or reasonable, subjective symptoms and lacked moderate or major psychosocial issues returned to work. Review of the results in the unreasonable, subjective group is also consistent with this finding. In this group, eight patients had minor or no psychosocial issues. All returned to some form of employment. This matches the return-to-work rate seen in the objective and reasonable, subjective groups. The 17 patients who presented with unreasonable, subjective symptoms and moderate or major psychosocial issues did not respond to conventional treatment. Disability was prolonged in seven of these patients. The other important factor in prolonged disability is employment status at diagnosis. For the subset of 23 patients with moderate or major psychosocial issues who were working when seen, we used a multidisciplinary approach to address their pain complaints. Our hand surgeon assessed each case. Patients were referred to hand therapy for ergonomic consultation, strengthening, and flexibility programs. Our program expands the hand therapist's role from that in the traditional model. Treatment programs have clear functional goals with established time frames. When psychosocial issues are limiting the patient's work function, the therapist listens to the patient's concerns, validates the pain, and acts as a support system as the patient returns to the job market or continues in the current job. The therapy program continues as work restrictions are lifted. T h i s support is necessary to monitor the patient's improvement and ensure continued progress. Any failure to progress leads to a discussion of treatment goals with all team members, including the patient. The plan is adjusted and implemented. This process empowers the patient by making him or her a participant in the process and helps to diffuse adversarial situations. Patient-education techniques are an effective tool in reducing worker anxiety and frustration. An example is the "safe pain" concept. This reassures the
33
patient that although pain continues to be experienced, it is not causing more physiologic damage. Frequently, this knowledge allows the patient to improve functional abilities in the presence of continued pain. This support is critical for the patient to redevelop the confidence needed to resume or continue employment.12 The therapist also assumes a more active casemanagement role. Case-management techniques employed by the therapist include contacting the employee health nurse or physician to integrate care, coordinating care with insurance companies, and obtaining rehabilitation nurses to help coordinate care in difficult cases. We have found that these efforts effectively reduce patient anxiety and facilitate clear communication among all involved parties. This approach was successful in maintaining all working patients in their jobs. In nonworking patients, the same techniques succeeded in 50%. This is consistent with other published data.13 Two of the nonworking patients were referred for psychological testing and treatment through a behavioral medicine program. Both patients did not fully comply with their treatment programs and did not return to work. A final consideration is the cost of this approach. All services for our program are approved and reimbursed under the Massachusetts workers' compensation system at standard I.A.B. rates.
References 1. Silverstein B, Fine LJ, Armstrong TJ. Hand and wrist cumulative trauma disorders in industry. Br J Industrial Medicine 1986;43:779-784. 2. Conti DJ, Burton WW. The economic impact of depression in the workplace. J Occup Med 1994;36: 983-988. 3. Williams R, Westmorland M. Occupational cumulative trauma disorders of the upper extremity. Am J OccHpTher 1994;48:411-420. 4. Ireland DCR. Psychological and physical affects of occupational arm pain. J Hand Surg 1988;13B:5-10. 5. Brown R The role of motivation in the recovery of the hand. In: Kasdan M, ed. Occupational hand and upper extremity diseases. Philadelphia, Hanley & Belfus, 1991: 7-11. 6. Fuerstein M, Callan S, Hickey P e t al. Multidisciplinary rehabilitation of chronic work-related upper extremity disorders. J Occup Med 1993;35:396-403. 7. DelTatto CD, Swanson EC. Rehabilitation management for work related injuries. In: Levy B, Wegman D, eds. Occupational health: recognizing and preventing work related disease. Boston: Little, Brown, 1988:175-176. 8. Pheasant S. Ergonomics, work, and health. Gaithersburg: Aspen, 1991:77-80. 9. Millender L. Occupational disorders of the upper extremity: orthopedic, psychosocial, and legal implications. In:
34
Bonzani et al. / Factors Prolonging Work-Related Disability
Millender L, Louis D, Simmons B, eds. Occupational disorders of the upper extremity. Churchill Livingstone, 1992:1-3. 10. Millender L. Occupational disorders of the upper extremity: orthopedic, psychosocial, and legal implications. In: Millender L, Simmons, eds. Occupational disorders of the upper extremity. New York, Churchill Livingstone, 1992:3-9.
11. Pheasant S. Ergonomics, work, and health. Maryland: Aspen, 1991:277-282. 12. Johnson RK. Psychological assessment of patients with industrial hand injures. Hand Clin 1993;9:221-223. 13. Derebery VJ. Delayed recovery in the patient with a work compensable injury. J Occup Med 1983;25:829-830.
Soft tissue disorders of the upper extremity remain a difficult and costly problem for surgeons and industry.l-3 These disorders frequently result in prolonged disability and delayed return to work. 4,5 The costs of these conditions to employers and insurers continue to mount. We have found that management of these disorders improves greatly when a multidisciplinary approach is used. 6-8 The difficulty has been identification of the factors responsible for prolonging disability.9 A previous attempt to categorize these disorders did not fully consider ergonomic factors as a source of prolonged disability, to The purposes of this
From the Occupational Medicine Department, New England Baptist Hospital, Boston, MA and Occupational Health & Rehabilitation, Waltham, MA. Received for publication April 20, 1995; accepted in revised form April l, 1996. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Paul J. Bonzani, OTR, CHT, 909 Grove Street, Chapel Hill, NC 27514.
30
The Journal of Hand Surgery
article are to propose a classification system that will assist the surgeon with identification of these factors and to present a multidisciplinary treatment model with an emphasis on expanding case management roles by all team members.
Methods A retrospective review of 50 patient charts was completed. The patients involved were seen from August 1993 to February 1994 in an upper-extremity work disorder clinic. All patients had a diagnosis of a soft tissue disorder that was related to a repetitive motion or awkward posture. The patient's employer or insurance provider established causal relationship prior to referral (Table 1). Three major variables were involved: type of musculoskeletal disorder, ergonomic issues, and psychosocial issues.
Musculoskeletal Disorders The specific musculoskeletal disorder was determined by standard methods of clinical and radiographic examination. After examination we classified patients as follows:
The Journal of Hand Surgery/Vol. 22A No. 1 January 1997
Table 1. Patient Classification by Diagnosis Diagnosis Carpal tunnel syndrome de Quervain's disorder Epicondylitis Tendinitis Tenosynovitis Thoracic outlet syndrome Unreasonable, subjective, symptoms (no specific diagnosis)
No. of Patients 8 6 4 3 2 2 25
Group 1. The objective findings for group 1 were swelling, limited joint passive range of motion, abnormal radiographic findings, or positive electrodiagnostic results. Group 2. Those in group 2 had reasonable, subjective symptoms: pain, tenderness, weakness, and/or sensory loss that was consistent with an injury. Group 3. Those in group 3 had unreasonable, subjective symptoms: diffuse, vague, nonreproducible pain not corresponding to anatomic distribution, or out of proportion to the injury. Ergonomic Issues We classified these factors as follows: Group 1. Those in group 1 had minor ergonomic issues. This group had an easily correctable workstation or tool design problem. Stretch breaks and rest periods could be implemented based on physician recommendation. Furthermore, these patients worked for supportive companies that could arrange for job rotation and/or job sharing to control the nature of the patient's symptoms. Group 2. Those in group 2 had moderate ergonomic issues. This group had minimal opportunity for job restructuring. The patients had limited opportunity for stretch breaks and rest periods. Modifications of the workstation were possible, but the nature of the patient's job could not be changed. The most common example was a legal secretary. Workstation redesign was possible, but the patient continued to perform full typing duties. Group 3. Those in group 3 had major ergonomic issues. This group had a combination of workstation design and job demands that could not be modified in any substantial way. For example, for electronic assemblers, redesign of the assembly line was not possible. Additionally, production timetables and worker productivity had to be maintained.
31
Psychosocial Issues We classified psychosocial factors as follows: Group 1. Those in group 1 had minor psychosocial issues. These were administrative issues, such as arranging modified duty, modified work schedules, breaks, and/or job rotation. Group 2. Those in group 2 had moderate psychosocial issues. Job frustrations or stresses causing employee anger were manageable by physician or therapist intervention with the employer. Group 3. Those in group 3 had major psychosocial issues. These patients had long-standing frustration or anger stemming from job and/or family stresses that could not be resolved. These stresses often included chronic pain behaviors that required referral to formal chronic pain programs. Our clinic did not have standard criteria or a protocol for chronic pain referral. We reviewed each record to determine what factors were present and how they combined to prolong or reduce disability.
Results
Objective/Reasonable, Subjective Group Six patients had objective findings and 19 had reasonable, subjective symptoms. Analysis of the data caused us to combine these groups. This was done because patients in these groups followed similar patterns of return to work. In this group, 5 patients had group 1 ergonomic or administrative issues, 14 patients had group 2 ergonomic issues, and 6 patients had group 3 ergonomic issues. Twenty-one patients had minor psychosocial issues, 2 patients presented with moderate issues, and two presented with major psychosocial issues. Twenty-three of the 25 patients returned to employment or continued in their jobs until symptom resolution. The remaining 2 patients had a combination of major ergonomic and major psychosocial issues and did not return to work.
Unreasonable, Subjective Group Twenty-five patients had unreasonable, subjective symptoms. Five patients had a minor ergonomic problem, 13 had a moderate one, and 7 patients had a major one. Eight patients had minor psychosocial issues; all returned to modified-duty programs. Of the 15 patients with moderate psychosocial issues, 8 returned to adjusted work after the physician or ther-
32
Bonzani et al. / Factors Prolonging Work-Related Disability
apist employed case-management techniques. Two patients had major psychosocial issues; attempts to return these patients to work were unsuccessful. The data also revealed a subset of patients. Twenty-three patients in this group had a moderate or major psychosocial issue; 6 of these were in musculoskeletal group 1 or 2 (objective or reasonable, subjective symptoms) and 17 were in musculoskeletal group 3 (unreasonable, subjective symptoms). The six group 1 and 2 patients were working at the time of referral, and all continued to work during treatment. Five group 3 patients were working at the time of their initial visit. They were referred for a short course of hand therapy. We then contacted the patient's employers and obtained their assistance by arranging adjusted work programs. These patients continued working (Table 2). Twelve patients were not working at the time of their first clinic appointment. These patients all received the same treatment. Six of these patients returned to modified duty; the remaining six patients could not be returned to employment. Case Study
A 36-year-old computer operator referred to our occupational medicine program with a diagnosis of cervical strain and carpal tunnel syndrome. Previous treatment included steroid injection and traditional physical therapy for 2 years without resolution of her symptoms. After initial evaluation, we classified her as a musculoskeletal group 2 (reasonable, subjective findings). On physical examination, results of both Roos test and Wright maneuver were positive. Furthermore, there was tenderness upon palpation of the axilla and the supraclavicular fossa. She was diagnosed as having thoracic outlet syndrome and a possible double crush affecting the median nerve. Analysis of her ergonomic status led to a group 2 classification (moderate). The patient had an inappropriate workstation that required adaptation. She also required relief from her company's quota-based productivity system. Finally, she was rated as being
in psychosocial group 2 (moderate issues), as she was clearly angry at and frustrated with her direct supervisor. Following our initial assessment, her company's h u m a n resource department was contacted by the hand therapist at the direction of the physician. The occupational safety officer discussed the possibility of work-duty and workstation modifications and consented to job-site analysis by the hand therapist. Adaptions of the patient's workstation included installation of mobile forearm supports, lowering the computer monitor, and centering the computer terminal to reduce awkward head positions. This followed standard office ergonomic recommendations.U Typing was limited to 2 hours per day, with no more than 15 minutes in succession. Finally, the patient began a program of upper-extremity strengthening, postural exercise, and aerobic conditioning. This program lasted 8 weeks and required 12 sessions. During this time, the team slowly reduced her work restriction. Our hand surgeon followed her for 6 months and she resumed work with a permanent modification of no more than 4 hours per day of typing. She resumed all her other office duties. This case demonstrates the necessity for all members of the team to expand their roles and assume case-management responsibilities when confronted with these difficult cases. Discussion
The musculoskeletal classification is important in the diagnosis of these patients and in predicting their return to work. In work-related soft tissue disorders, objective findings are uncommon. This creates difficulties in evaluating the significance of subjective symptoms. Our study shows that return-to-work rates are identical for the objective and the reasonable, subjective group. We believe this demonstrates that when subjective symptoms of pain, tenderness, weakness, and sensory loss are consistent with the history of the injury and present in well-recognized constellations of symptoms, patients respond to
Table 2. Employment Status by Musculoskeletal Classification Group
Musculoskeletal 1 and 2 Musculoskeletal 3 Musculoskeletal 3
Working at Presentation
6 5 0
Not Working at Presentation
0 0 12
Returned to Work After Treatment
6 5 6
The Journal of Hand Surgery/Vol. 22A No. 1 January 1997
treatment predictably. A second finding is that the ergonomic classification does not independently predict return-to-work potential. All cases with group 3 ergonomic problems returned to employment in the absence of group 2 or group 3 psychosocial issues. This study identified two important factors that contribute to prolonged disability in workers diagnosed with soft tissue disorders. Psychosocial classification is the primary factor in prolonged disability. Workers who presented with objective or reasonable, subjective symptoms and lacked moderate or major psychosocial issues returned to work. Review of the results in the unreasonable, subjective group is also consistent with this finding. In this group, eight patients had minor or no psychosocial issues. All returned to some form of employment. This matches the return-to-work rate seen in the objective and reasonable, subjective groups. The 17 patients who presented with unreasonable, subjective symptoms and moderate or major psychosocial issues did not respond to conventional treatment. Disability was prolonged in seven of these patients. The other important factor in prolonged disability is employment status at diagnosis. For the subset of 23 patients with moderate or major psychosocial issues who were working when seen, we used a multidisciplinary approach to address their pain complaints. Our hand surgeon assessed each case. Patients were referred to hand therapy for ergonomic consultation, strengthening, and flexibility programs. Our program expands the hand therapist's role from that in the traditional model. Treatment programs have clear functional goals with established time frames. When psychosocial issues are limiting the patient's work function, the therapist listens to the patient's concerns, validates the pain, and acts as a support system as the patient returns to the job market or continues in the current job. The therapy program continues as work restrictions are lifted. T h i s support is necessary to monitor the patient's improvement and ensure continued progress. Any failure to progress leads to a discussion of treatment goals with all team members, including the patient. The plan is adjusted and implemented. This process empowers the patient by making him or her a participant in the process and helps to diffuse adversarial situations. Patient-education techniques are an effective tool in reducing worker anxiety and frustration. An example is the "safe pain" concept. This reassures the
33
patient that although pain continues to be experienced, it is not causing more physiologic damage. Frequently, this knowledge allows the patient to improve functional abilities in the presence of continued pain. This support is critical for the patient to redevelop the confidence needed to resume or continue employment.12 The therapist also assumes a more active casemanagement role. Case-management techniques employed by the therapist include contacting the employee health nurse or physician to integrate care, coordinating care with insurance companies, and obtaining rehabilitation nurses to help coordinate care in difficult cases. We have found that these efforts effectively reduce patient anxiety and facilitate clear communication among all involved parties. This approach was successful in maintaining all working patients in their jobs. In nonworking patients, the same techniques succeeded in 50%. This is consistent with other published data.13 Two of the nonworking patients were referred for psychological testing and treatment through a behavioral medicine program. Both patients did not fully comply with their treatment programs and did not return to work. A final consideration is the cost of this approach. All services for our program are approved and reimbursed under the Massachusetts workers' compensation system at standard I.A.B. rates.
References 1. Silverstein B, Fine LJ, Armstrong TJ. Hand and wrist cumulative trauma disorders in industry. Br J Industrial Medicine 1986;43:779-784. 2. Conti DJ, Burton WW. The economic impact of depression in the workplace. J Occup Med 1994;36: 983-988. 3. Williams R, Westmorland M. Occupational cumulative trauma disorders of the upper extremity. Am J OccHpTher 1994;48:411-420. 4. Ireland DCR. Psychological and physical affects of occupational arm pain. J Hand Surg 1988;13B:5-10. 5. Brown R The role of motivation in the recovery of the hand. In: Kasdan M, ed. Occupational hand and upper extremity diseases. Philadelphia, Hanley & Belfus, 1991: 7-11. 6. Fuerstein M, Callan S, Hickey P e t al. Multidisciplinary rehabilitation of chronic work-related upper extremity disorders. J Occup Med 1993;35:396-403. 7. DelTatto CD, Swanson EC. Rehabilitation management for work related injuries. In: Levy B, Wegman D, eds. Occupational health: recognizing and preventing work related disease. Boston: Little, Brown, 1988:175-176. 8. Pheasant S. Ergonomics, work, and health. Gaithersburg: Aspen, 1991:77-80. 9. Millender L. Occupational disorders of the upper extremity: orthopedic, psychosocial, and legal implications. In:
34
Bonzani et al. / Factors Prolonging Work-Related Disability
Millender L, Louis D, Simmons B, eds. Occupational disorders of the upper extremity. Churchill Livingstone, 1992:1-3. 10. Millender L. Occupational disorders of the upper extremity: orthopedic, psychosocial, and legal implications. In: Millender L, Simmons, eds. Occupational disorders of the upper extremity. New York, Churchill Livingstone, 1992:3-9.
11. Pheasant S. Ergonomics, work, and health. Maryland: Aspen, 1991:277-282. 12. Johnson RK. Psychological assessment of patients with industrial hand injures. Hand Clin 1993;9:221-223. 13. Derebery VJ. Delayed recovery in the patient with a work compensable injury. J Occup Med 1983;25:829-830.