New Insights: How A Worker’s Mental State Influences Injury Recovery

Episode Notes

Transcript

Speaker 1:

Workers Comp Matters, the podcast dedicated to the laws, the landmark cases, and the people that make up the diverse world of workers compensation. Here are your hosts, Judd and Alan Pierce.

Alan Pierce:

Welcome to Workers Comp Matters here on the Legal Talk Network. I’m attorney Alan Pierce. Today without my co-host, attorney Judson Pierce. We are lawyers at Pierce, Pierce and Napolitano in Salem, Massachusetts where we have been representing injured workers and their families in cases involving injuries. We have been hosting this podcast for several years now and over the years we have had a variety of guests from the Workers’ Comp Research Institute and we have a returning guest today, Vennela Thumula. She is with WCRI. They are a workers’ comp research institute, an independent non-for-profit research organization striving to help those interested in making improvements to the workers’ compensation system by providing highly regarded objective data and analysis. They perform studies of individual state systems. They make presentations on their research findings to legislators, workers’ compensation administrators, industry groups, and other stakeholders. Dr. Thumula has a PhD in pharmacy administration from the University of Mississippi, and she’s the lead researcher in a study published in March of 2024 by WCRI entitled, the Importance of Psychosocial Factors for Physical Therapy Outcomes. Having said that, mouthful, I want to welcome you Ella Tula to our program.

Dr. Vennela Thumula:

Thank you very much, Alan for having me here today.

Alan Pierce:

Let’s start by defining some terms, psychosocial factors for physical therapy outcomes. What do you mean as to psychosocial factors and what are they?

Dr. Vennela Thumula:

So psychosocial factors could include a variety of psychological or social factors that have been identified in previous research as factors that can impede a person’s recovery after they have had an injury or an illness. Some examples of these factors could include things such as poor recovery expectations after a person has an injury or fear of pain due to activity, which might stop them from getting effective physical therapy. They could have negative coping mechanisms or it could be workplace factors that can also influence recovery such as being dissatisfied with their job. Maybe they perceive injustice at the workplace in terms of how the supervisor may have reacted after their injury and they could have general low support. So it could be a multitude of factors. The reason we looked into this is because we did a white paper on behavioral health in workers’ compensation in 2022 and unanimously workers’ compensation stakeholders have identified that psychosocial risk factors are the most important thing to consider when we talk about behavioral health and workers’ compensation.

Alan Pierce:

And when you get into psychosocial risk factors, from my reading of your report, and I’d like to perhaps dig into this a little deeper, is that focus on perhaps the psychological aspects that the injured worker brings to the job and the injury. And are some of these psychosocial risk factors best addressed by some mental health screening or an awareness or acknowledgement of non-physical risks that might make recovery more difficult?

Dr. Vennela Thumula:

That is correct, Alan. So we of this plethora of factors, the ones that we looked at in this study are the psychological aspects. However, I won’t be able to say that the worker brought this into the injury because the timing of the screening, if you take screenings, that can be done right. I mean within the workers’ compensation system they would be done after the person gets injured. So it’s going to be cumulative of their perceptions before the injury plus how the injury was. So it’s the screenings that can be done within the workers’ compensation system always are going to have some of the injury itself influencing their psychological beliefs and perceptions.

Alan Pierce:

And you identified what some of these psychosocial risk factors are, including job dissatisfaction, poor coping mechanisms of how people respond to pain, whether they have family support, whether they have other coping issues as well as a fear of pain or fear of being touched or examined. Did your study, did you also include other maybe social less psychological factors, but social factors such as culture, ethnicity, race, age, body type, comorbidities, things like that that might influence a person’s recovery response to a physical injury?

Dr. Vennela Thumula:

That’s a great question and before I jump into that, I just want to clarify one thing. I did mention a lot of psychosocial factors earlier, but we don’t have data on all of them. The clinics that participated in focus on outcome in a company called Photo from which we got the data, they have used specific screening tools that screen for poor recovery after an injury, fear of pain due to activity and other psychological factors, but not so much the workplace related factors. We don’t have data on that in this study with regards to the social aspects and the cultural aspects, the data source, they do have these questions included in the patient history forms and stuff like that, but they are not complete. So we won’t be able to answer how they may influence. But we did include some other factors such as comorbidities because when we go into a doctor’s office, we do check in all the preexisting conditions that we have and the same thing with the PT clinics as well. They collected that information and we have that information and that’s fairly complete so we know whether the person has preexisting diabetes, if they have been diagnosed with other mental health conditions in the past such as anxiety, depression, and about 30 other physical comorbidities as well. And we also know whether the patient has engages in exercise typically, but we don’t have other important factors such as income or education or the specific occupation of the patient. We don’t have those in the data.

Alan Pierce:

Now your study, which was quite extensive, first of all, how many individuals or groups of people were studied? How extensive was this across all states? Many states? So

Dr. Vennela Thumula:

The data source that we used for the purpose of this study, they collect data from physical therapy clinics across the United States, all states, and they collect the data from about 13,000 physical therapy clinics. So overall we had a really large sample size of patients that completed psychological screening tools and overall we had about half a million patients that are receiving physical therapy for low back pain, of which about 28,000 are workers’ compensation patients. But this data source was good in that we also had similar measures collected for group health patients, for Medicaid patients, auto insurance patients, as well as some of the Medicare patients who are younger as older, so some disability patients as well.

Alan Pierce:

Okay. So you are basically looking at an entire patient population from all of these physical therapy clinics that include workers’ comp and I guess we’d say not workers’ comp patients.

Dr. Vennela Thumula:

That’s correct.

Alan Pierce:

Now I noticed your study is based upon data from physical therapists and physical therapy facilities. Would you say that the overall conclusions that you reached in terms of the differences in workers’ comp patients and non-work comp patients is also translatable to orthopedics or other types of medical disciplines aside from physical therapy? I think you’re focusing primarily on musculoskeletal back injuries and back pain. Am I correct?

Dr. Vennela Thumula:

Yes. So far the study that we published, it looked at physical therapy outcomes and it looked at low back pain specifically. And it is important that we look at other conditions as well to see to what extent are these results extrapolatable to other situations, to other treatments, whether post-surgical outcomes are similar or not. We looked at within this, within low back pain, we looked at whether the relationship between psychosocial risk factors and outcomes for non-surgical patients and surgical patients and patients that have acute pain versus chronic pain. So across within low back pain and physical therapy, we do see that the results are really robust across different patient groups and there is also external data in the primary care setting, similar results we’re seen, but again, it cannot be extrapolatable just based on our data to all treatments.

Alan Pierce:

Okay. At this point we’re going to take a brief break and we’ll be right back to talk a little bit further about the results of this study and its importance in understanding the workers’ compensation experience. So we’ll be right back. Welcome back to our discussion about psychosocial factors and physical therapy outcomes or for that matter, musculoskeletal, low back pain outcomes in workers’ compensation cases as opposed to other patient populations. So Dr. Tula, what were the essential main points that your study brought to light having looked at all of this data?

Dr. Vennela Thumula:

So there are two main findings that I’m going to talk about today. One is that psychosocial risk factors, specifically the psychological risk factors such as fear avoidance, negative coping, they are very prevalent in workers’ compensation. For example, if we take the K startback screening tool, which is commonly used in workers’ compensation as well as outside, we found that about one in three low back, low back pain patients receiving physical therapy, they had high levels of psychosocial risk factors. If we look at other patient groups, we see that Medicaid disability patients as well as auto insurance patients also had high levels of psychosocial factors. Whereas if we take the other patients such as group health and Medicare, they had roughly half of that. So about 15% of group health patients had high levels of psychosocial risk factors versus 33% of workers’ compensation patients. So that’s one factor.

Psychological risk factors are really important there to consider in the workers’ compensation. And then the second thing is we see a very strong association between the presence of these factors and their functional recovery at the end of their physical therapy. So the information about psychosocial factors was collected on the first visit of physical therapy and then when recovery or function was measured between the first and last visits over the course of the physical therapy episode of care, then we see that patients that are in the high risk group with high levels of psychosocial risk factors, they had functional recoveries that were 40% smaller than patients that had low levels of psychosocial risk factors. So this is the finding for the workers’ compensation patients. We see similar patterns for non-work compensation patients as well, but the magnitude was 30% as opposed to 40%.

Alan Pierce:

And you mentioned either a resource or a study, you said it was keel. Is that KEEL? Could you give us a little more information as to that?

Dr. Vennela Thumula:

It’s K-E-E-L-E STARTBACK screening tool

Alan Pierce:

And it’s a screening tool.

Dr. Vennela Thumula:

Yes.

Alan Pierce:

You also used other screening tools as well. I think in your paper you identified them by acronym SPST and spare S-P-A-R-E. What exactly are those screening tools and how do they work

Dr. Vennela Thumula:

These tools? Spare is the screening for pain vulnerability and resilience tool. And then the other one that we mentioned in the paper is the fear avoidance beliefs questionnaire. So each of these tools were developed to identify specific psychological risk factors. For example, the spare tools identify three factors, fear avoidance and negative coping and negative mood. I’ll provide example of how coping is assessed using four questions on a scale of one to seven, from not at all confident to completely confident I can enjoy things despite the pain. I can cope with my pain in most situations. So those are examples of questions that the patient is asked and they rate it and a score is created. And if they have about the one standard deviation about the mean population mean, then they’re categorized as having high risk. And these tools have been validated to be used for musculoskeletal injuries in primary care settings, the SPSD and the spare and FABQ tools.

Alan Pierce:

Okay, I think I get it. Basically this data that comes from a patient is done by questionnaire with a variety of obviously carefully drawn questions. The closest analogy that I want to draw is something that we’re all familiar with. I do it all the time, and I know doctors do it with their patients all the time. When they’re complaining of pain, they say on a scale of one to 10 is where is your pain? And I can’t tell you how many times clients tell me it’s an 11 or a 10, not scientifically very reliable, but an indicator of perception of pain and perhaps not a conscious exaggeration of pain, but a self-reporting. So am I correct that it is sort of a more advanced system of pain questionnaire then just rate your pain from one to 10?

Dr. Vennela Thumula:

So I would say that our outcome is something related to the pain questionnaire, right? But although lumbar computer adaptive test is used, so it’s based on how you respond to one question, a different question is asked and multiple questions are asked so that you get a more valid response than asking that singular question. So yes, I mean I would say they are more advanced methods to capture the pain experience of a patient and it is self-reported. Now these other screening tools are designed to capture more specific perceptions and behaviors too. Like for example, the fear avoidance. The questions are such as I go immediately to bed when I feel severe pain, or before I can make any serious plans, I have to get some control over my pain. So it’s about the perceptions that the patient has and their behavior. So that information such as that is collected using multiple questions to come up with a score. And yeah, all of them are self-reported.

Alan Pierce:

I’m going to take another quick break and we will finish our conversation by getting into a little more detail about how this affects the injured worker, how this affects their claim, and what conclusions can we draw from this study. So after a short break, we will be back to finish our conversation on psychosocial factors in workers’ comp outcomes. Welcome back to our discussion on psychosocial risk factors. When we left off, we’re talking about the differential between workers’ comp patients that are part of your study and not. I know that a lot of my audience, and certainly a lot of my clients where they’d be listening to this would be wondering if there are some perhaps unfair or unjust conclusions that might relate these differentials to secondary gain or conscious manipulation of the system or outright malingering. May I assume that that is not one of the conclusions here, that there is a conscious attempt by these patients to overexaggerate their pain levels or their functional abilities, but rather something deeper going on.

Dr. Vennela Thumula:

So one thing that I will say is that we have some information about the nature of the low back pain, the intensity of the low back pain and factors such as that. When we control for some of those differences between the payer groups, we see that the differences get diminished. So definitely these differences are not all coming from what you said. There is no indication from our study about that. And another important thing is are we able to distinguish to what extent there could be potential, these system contextual level factors or the scope of secondary gains contributing to the differences are studies in design to answer that question. Because the challenges in measuring something like that, we do not have the standardized measures that are typically used to measure that from our findings. If we could infer something that we do see that Medicaid patients also had high levels of psychosocial risk factors, same as workers’ compensation in workers’ compensation.

One could say that there is potential for secondary gains, but you won’t be able to say the same thing with Medicaid population wherein you see similarly high levels of psychosocial risk factors. So it seems that there are many other social economic factors that one needs to, or family support factors that one needs to consider when thinking about the differences between the different patient groups. It’s a very complex problem and we would need a large amount of data on individual factors, on system factors to be able to tease out why these differences exist. And it’s definitely not one factor.

Alan Pierce:

And I’m glad to hear that because I think a lot of people will look at a higher or a less favorable recovery rate among workers’, comp patients or claimants and immediately make the jump that this is being accounted for by secondary gain and work avoidance. And from my experience of almost 50 years representing injured workers, I’m not saying that doesn’t occur on a sporadic basis, but I don’t think it happens anywhere near with as much frequency as many employers or some casual observers would seem to think that if you’re on workers’ comp naturally you’re not going to get better as quickly as somebody who is. And I think it’s much more complex than that. And I think your study outlines that. But getting to your study, you make a point that early identification of these risk factors is recommended by occupational medical treatment and disability guidelines and that you would recommend or certain other entities recommend a biopsychosocial approach, routine psychosocial screening and other types of identification and preventative measures that then becomes a cost issue. Do you find that employers or insurers will be receptive to employing these screening tools to help identify these potential cases where the outcomes could be less, but for this early screening? And what do you recommend that the stakeholders that are impacted by their workers’ comp cost and claims experience do to use your findings in a way to change the outcomes for some of these folks?

Dr. Vennela Thumula:

I want to first summarize what we learned from our study. It is that psychosocial factors are frequently occurring and they are important predictors of recovery. So if a person has high levels of psychosocial risk factors, then they are likely to have delayed recovery. And delayed recovery is associated with medical costs, higher medical costs, higher indemnity costs, which in this study we haven’t quantified to what extent that happens, but not addressing them could also have implications for costs. So overall, our findings suggests one thing is that there needs to be heightened awareness of the extent of this problem, which is very frequent from all stakeholders and from our white paper for which we had conversations with a diverse group of workers’, compensation stakeholders from the industry, we did see a recognition of the importance of identifying psychosocial risk factors. Now that was a convenient sample. I’m not saying that everybody in the industry agrees, but there is more acceptance of the importance of addressing psychosocial risk factors. And the guidelines are also going that way in that they are recommending the early screening of psychosocial factors. And there are guidelines that came out like in 2019 from the Washington states that specifically addresses the importance of this issue. So I hope that answers the question.

Alan Pierce:

It does, and I’m not sure there is an easy answer to the question other than the fact that you have done a wonderful job of identifying something and actually putting some meat on the bones of something that people have known or studied for many years. That is why is there a difference? Well, first of all, is there a difference? And if so, why is there a difference from accident victims and their recovery as to non accident victims? And to that extent, how much of it that is predictable, preventable, or how can it be changed? So I want to thank you and thank WCRI for this study. If any of our audience members wants to learn more about this particular study, how could they contact you or WCRI to get some more information?

Dr. Vennela Thumula:

They would be able to download our study from our website wcr.org. And thank you very much for the opportunity to share our findings and spotlight our study.

Alan Pierce:

Well thank you. And again, it’s www.wcrnet.org. Once again, thank you for joining us and thank you all for listening to us and hope you join us again on Legal Talk Network, on Workers Comp Matters, and go out and make it a day that matters. Thank you for listening. Bye-Bye.

Continue Reading