Psychology, personal injury and rehabilitation

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A recent British report has found that in about 20-30% of personal injury cases, the victim suffers disability and distress significantly greater than might be expected from the injury alone. In about 5% of cases, the physical and social outcomes are seriously adversely affected to an extent that cannot be explained by the initial or remaining injury. The report refers to these outcomes as ‘Apparently Disproportionate Outcome’ (ADO), and notes that it can have a significant effect on the cost of treatment, complexity of case handling, rehabilitation and compensation outcomes.

The report describes the mechanisms for developing ADO in some detail—noting that the main factors are psychosocial, based on individual beliefs and perceptions, together with practices in medicine, employment and compensation systems. It notes that in the worst cases, the operation of these factors can lead to permanent incapacity for work and profound withdrawal, even in cases where the initial injury was apparently minor.

However, the report suggests that all cases of ADO can be prevented. Monitoring and responding to psychological and social factors can produce faster, better recovery. Cases at high risk of developing ADO can be identified early on using the ‘flags model’ so that appropriate interventions are programmed in to the treatment and rehabilitation process. In most cases, signs of difficulty can be detected within three months of an injury or disease.

The flags model

Table 1 summarises the flags model which can be used to predict and avoid disproportionate outcomes.

Clearly, poor outcomes or delayed recovery can be anticipated where a serious injury/disease is diagnosed, other injuries/diseases co-exist or there have been treatment failures—these clinical factors are known as ‘red flags’.

Psychosocial risk factors (or ‘yellow flags’) have a strong effect on expectations and behaviours, and have been found to be predictive of poor outcomes. These factors can be addressed by appropriate guidance, information and discussion.

‘Blue flags’ are perceived features of the work or social environment that are generally associated with higher rates of symptoms, ill-health and time off work, which in the context of injury may delay recovery or present an obstacle to it.

‘Black flags’ include policy concerning conditions of employment, sickness and working conditions, and certain other factors related to financial security, litigation/disputation and work contact. These factors are not a matter of perception and affect all workers in a workplace or occupation equally.

Avoiding disproportionate outcomes

The report finds that, in general, the risk of chronic problems developing can be reduced by:

• good communication between all those involved;
• clear identification of who is responsible for leading and co-ordinating care;
• a maximum emphasis on encouraging self management by patients, together with their families;
• paying attention to psychological and social issues;
• identifying meaningful, realistic objectives and adopting a problem solving, consensual approach; and
• avoiding factors such as inconsistent care, inappropriate investigation, lack of explanation or excessively cautious advice about returning to work.

The report provides a summary of guidelines (see box below) for psychosocially appropriate care. While noting that serious injury cases are more complex to handle, the report suggests that the general behavioural management principles outlined are similar for both simple and more serious injury cases.

Behavioural management guidelines

• Provide a positive expectation that the individual will return to work.
• Be directive in scheduling regular reviews of progress.
• Keep the individual active and at work.
• Acknowledge difficulties of daily living.
• Help maintain positive co-operation.
• Communicate that having more time off work reduces the likelihood of a successful return.
• Beware of expectations of ‘total cure’ or expectations of simple ‘techno-fixes.’
• Promote self-management and self-responsibility.
• Be prepared to say: ‘I don't know.’
• Avoid confusing the report of symptoms with the presence of emotional distress.
• Discourage working at home.
• Encourage people to recognise that pain can be controlled.
• If barriers are too complex, arrange multidisciplinary referral.

Source: Kendall, Linton and Main (1997) quoted in Psychology, Personal Injury and Rehabilitation.

In relation to the first point under the guidelines, the report suggests that an employer who expects and wants an employee to return to work full-time should confirm this expectation by:

• ensuring regular contact while the employee is absent;
• explaining and agreeing the process of rehabilitation into the workplace;
• providing resources; and
• asking the employee for their opinion.

The report emphasises the need to ensure that rehabilitation objectives have real meaning and benefit to the injured person, and are agreed. Rehabilitation interventions should also meet actual needs as opposed to:

• clinical or organisational convenience;
• counter-productive claims handling objectives;
• insensitive policy constraints; or
• inappropriate tests.

To optimise rehabilitation outcomes the report recommends a move away from a narrow biomedical model of injury management towards an approach that address a range of non-medical factors—psychological, social and work-related. It also emphasises that identifying the potential for, and avoiding disproportionate outcomes requires pro-active claims management processes and effective communication and co-ordination between line managers, case managers, claims managers, doctors, rehabilitation providers and claimants.

The report found that in Britain there are too few doctors and therapists who are adequately trained in the recognition and management of psychological and social factors. However, it noted that education in these aspects was improving. Co-ordination and funding for specialist rehabilitation and psychosocial interventions was also found to be lacking. The merging of a clinical and occupational approach designed to overcome obstacles to recovery and an approach to case management that facilitates effective post-injury rehabilitation was seen as offering ‘exciting new possibilities’.

Implications of the report

The report suggests that Australia and some other countries are ahead of Britain in recognising the relevance of non-medical factors to effective rehabilitation. Within Comcare’s approach to the integration of case and claims management, the roles of rehabilitation providers, case managers and claims managers provide the potential to facilitate and co-ordinate post-injury rehabilitation.

Nevertheless, scope clearly exists to develop systems and approaches that ensure the identification of indicators of poor outcomes, and that those indicators are addressed effectively. There are many examples of occupational overuse injuries, back conditions, psychological injuries and other more minor injuries that fail to respond to appropriate medical care and result in disproportionate periods of incapacity. Related to this, we know that around 20% of claims generally account for around 80% of liability.

The British report strongly supports the need for early intervention and an integrated approach. Improving knowledge and understanding of the ‘flags model’ (which has been confirmed by extensive research) by a broader range of stakeholders could also assist in improving rehabilitation outcomes. The report’s findings in relation to the importance of effective communication between the key stakeholders are also relevant. In some cases, any of a number of individuals (professional service providers, line managers, case managers, claims managers and others) may identify some elements of the risk of chronicity, but failure to share this knowledge appropriately may result in treatment and rehabilitation failures. The potential for this to occur points to the need to develop new and extended approaches to case conferencing—to allow all relevant stakeholders to exchange views in a constructive manner.