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Tackling lower back pain with words

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What is said to a worker grappling with lower back pain has the potential to lead to a better outcome, according to experts who say the workers compensation industry is moving away from immediate medical imaging and surgery toward conservative care that starts with words.

Don’t call it “your injury,” said Dr. Jennifer Christian, president and chief medical officer at Wayland, Massachusetts-based Webility Corp. at the California Workers Compensation and Risk Conference in Dana Point, California, in September.

Instead, she said, call it “your recovery process.” Don’t say “getting you back to work.” Say, “getting your life back to normal.” Don’t ask about pain; ask about progress. The list goes on.

“(There are) people who have relatively moderate conditions who end up creeping toward catastrophe,” Dr. Christian said. “A lot of it has to do with words.”

Lower back injuries comprise roughly one-third of all workers comp claims, according to Mary O’Donoghue, Boston-based chief clinical and product officer, MedRisk Inc., who called both chronic, cumulative back injuries and more acute incidents the “leading cause of workplace disability.”

An overlooked element of the injury is what is going on in a suffering worker’s head, she said in an interview. “The medical is easier; it’s more black and white. But getting inside the psychosocial is very gray, yet that’s not a reason to shy away from it.”

“Any perceived injustice can impact recovery,” Ms. O’Donoghue added. “We typically focus so much on the medical and that leads to our over-aggressiveness in treatments and got us to where we are with opioids.”

While an MRI scan is often the first line of treatment, experts are leaning toward interventions such as cognitive behavioral therapy as a go-to for treating a back injury.

“MRIs trigger illness and increase likelihood of catastrophization,” Michael Rosenthal, an assistant professor in the Doctor of Physical Therapy Program with San Diego State University, told conference attendees. “They go from having a mild problem … then they get the results and they rate their pain at a higher level even though there has been little change.

“(Their) perception of pain is not accurate … when patients start having pain outside of the proportion than what we expect,” he added. “Some patients may need a little more than reassurance and simple education … others may need more advanced psychological informed rehabilitation. You may send them to the best physical therapy clinic in California. … That patient may not respond very well without that multidisciplinary approach.”

Dr. Christian said claims handlers and employers can be on the front lines by helping to answer questions a worker suffering a back injury may have, instead of leaving it up to the doctor.

“They are wondering, how long am I going to be laid up? How long do I have to take it easy? When am I going to be back to normal, if ever?” she said. “As I realized, in medical school we are not trained to answer any of those questions. … The patient is left alone to figure this out.

“What we say (and) how we say it … words can reassure or frighten,” continued Dr. Christian. “(Words) can build trust or confidence. … They can empower or undermine. Your words are either going to establish yourself as someone helpful or create distance.”

Ms. O’Donoghue said the focus should be on developing what she called a “therapeutic” relationship between the claimant and the claims handler — she doesn’t even like the phrase “injured worker.” “In terms of words, you have to start at the very beginning of the claim,” she said. “These sound like simple things but in the work comp world, it’s an ‘injured worker’ instead of someone who needs assistance. I think we could do a better job.”