Return-to-work barriers may be a matter of ‘time’

Depression, sleep apnea may delay recovery

When it comes to boosting return-to-work success after occupational injuries, sometimes more is more.

Taking extra time to determine underlying causes of continued discomfort or pain from an occupational injury results in better outcomes, says Jonathan Torres, MD, MPH, medical director of the WorkMed Occupational Health Services at St. Mary’s Health System in Auburn, ME.

“If we can prevent even a small number of people who go on long-term disability, it’s a huge benefit,” says Torres, who is scheduled to speak at the upcoming conference of the American College of Occupational and Environmental Medicine ( “There’s a window of opportunity for us to intervene at the proper time.”

Too often, in the initial treatment of occupational injuries such as back pain, providers take a narrow view of the problem and focus on purely the medical condition, he says. Then more money and resources may be spent later in care, when the chances of full recovery are low, he says.

“We [occupational medicine providers] see people and if they’re not getting better, we tend to over-medicalize and refer out to other providers. We may not realize what’s causing their lack of improvement,” he says. “There may have been an important issue that wasn’t addressed early on.”

Torres conducts an in-depth evaluation of patients who haven’t improved significantly a month after their injury.

He demonstrated success with comprehensive evaluations — lasting about an hour and a half — of low injury back patients who hadn’t returned to work within one to three months after injury. He compared 100 low back injury patients before implementing the new protocol and 100 patients who received the tailored intervention.

Torres relies on a model known as SPICE (Simplicity, Proximity, Immediacy, Centrality, and Expectancy). Based on a program developed by the military, SPICE is a comprehensive approach to reducing the incidence and costs of occupational injuries. It involves building morale and support for employees, handling claims swiftly and keeping a central focus and expectation on return to work. If employees don’t recover as expected, Torres uses tailored disability prevention evaluations.

“We found the number of days they were treated in our office was less after implementing this program,” says Torres, who noted that injured employees also had fewer days away from work. The data have not yet been published.

Consider psychosocial factors

Psychosocial issues play a key role in recovery, says Torres. He keeps that in mind from the very first visit with an employee.

For example, a nursing assistant with first-time back pain may feel anxious. If the diagnosis is mild muscle strain, Torres emphasizes the positive prognosis: “We think you have a mild muscle strain. It’s hurting a lot now, but within a few days you’re going to feel a lot better.”

If symptoms have not improved significantly within four weeks, Torres uses common screening tools for depression and sleep apnea, conditions that can worsen pain or delay recovery. More importantly, Torres takes a more complete history, with questions about factors at work and at home that may be taking an emotional or physical toll.

“They’re not getting better and there’s a reason for that,” he says. “I can’t tell you how many times I’ll get to the source of the delayed recovery that would not have been identified. It’s been an eye-opener for me.”

Severe back injuries may require surgery and prolonged pain and discomfort is not uncommon, Torres notes. But delayed return-to-work often occurs with more moderate injuries, as well.

“Depression is one of the most underdiagnosed conditions in an outpatient practice,” says Torres. “If someone has a musculoskeletal condition but they have depression that’s untreated or undertreated, this may be an important reason why they are not getting better. They can have higher pain levels because of the depression and be less motivated to carry through with treatment recommendations.”

Torres also helps patients with anxiety about returning to work by arranging for a simulation of their work tasks. The employee can then see that they can safely perform their job duties.

Process benefits employees

Other medical and even personal factors can influence return to work. Are there stressors at home that impact recovery? Are other factors leading to a loss of restorative sleep or are other, undiagnosed medical conditions interfering with recovery?

In one case, Torres recalls an employee who was worried about child care and getting his children to school if he returned to work in the first shift. “In the team meeting, the employer was willing to accommodate restructuring return to work,” he says.

The workers’ compensation costs can be huge in cases of long-term disability. But the implications for individual workers are also grave. Employees who never return to work have a permanent reduction in their income and may struggle to maintain their homes and pay bills.

Delayed return to work also takes a physical toll, says Torres. “Disconnection with the workplace is not healthy,” he says. “It’s a huge risk factor for people in terms of health if they’re not able to work any longer. If we can make a small difference to prevent long-term disability, we’re making a huge impact in their lives.”