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Preventing Needless Disability

Why do some workers find themselves permanently disabled when medical evidence suggests they should be able to recover from their injuries? Understanding neuroscience may offer a solution.

Tuesday, May 15, 2012
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"Twenty percent of claims cause 80 percent of pain," says Robert Aurbach, former general counsel of the New Mexico Workers' Compensation Administration.

"These are people who, for no physical reason, have fallen into this morass of disability behavior and become a disabled person to themselves and deal with the world that way. It becomes a habit of mind and behavior that is incredibly hard to fix once it is established," says Aurbach, who is CEO of workers' comp consultancy Uncommon Approach in Albuquerque, N.M., as well as journal editor for the International Association of Industrial Accident Boards and Commissions.

An attorney and researcher, he believes there are clear, scientific explanations for why some injured workers become permanently disabled -- despite medical evidence suggesting their injuries are recoverable. By changing the messages and empowering the injured worker, stakeholders can prevent needless disability.

Roots of Disability Mentality

Disability behavior is learned much like a habit, Aurbach says. The injury itself is not the actual cause of the disability for many injured workers. It has more to do with the myriad factors associated with the injury.

"If economic stress and physical pain from an injury are presented at the same time, the brain has to deal with them at the same time," Aurbach says. "The way the brain deals is by creating a network of neurons that actually wire together."

When the brain experiences thoughts, emotions or physical sensations presented in temporal proximity to each other, it processes them at the same time -- creating this network of connections between the neurons in the brain that are involved.

With time and repetition, this network of neurons strengthens, as physical changes in the connecting structure facilitate quicker and more automatic responses.

"What that does is the genesis of all long-term learning and habit," he says. "It's how you learned to speak without thinking. ... Every complex behavior we learn is learned this way."

Simplified, the injured worker experiencing economic stress may actually feel pain when the economic stress presents because of the temporal association. Pain, he says, has more to do with the brain than the injury.

"The physical stimulus of pain is mechanical but the experience of pain itself is a mix of physical and neurological," Aurbach says. "You feel pain if and when the brain pays attention to it."

In the case of the injured worker who experiences economic stress, that particular trigger "gives you the message to pay attention to your pain," he says.

Eventually, a complex set of triggers creates the network that causes the disability mentality, which becomes the injured worker's new identity.

"Identity is a basic human need and when the identity that has previously been established as a worker is removed, the mind will replace it with something else," he says. "If you try to tell a person who is firmly into their disability, 'Just go back to work,' you are taking away their newly acquired disability identity and not replacing it with anything."

Control, Fear and Anxiety

One of the most universal triggers for disability is the perceived loss of control over one's environment. Aurbach says virtually everyone who is injured experiences this.

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"All your normal routine is put on hold and ... it's all taken away from you in a moment. The sense of loss is profound," he says. "Change of locus of control is a strong predictor of outcome. It changes medical outcomes."

Part of the feeling stems from having other people controlling your daily activities.

In addition to the loss of control, individuals experience fear and anxiety. "You wonder if you are going to get your life back," he says. "You wonder how you will take care of yourself, how you will take care of your bills."

When the injury extends for a while, it creates dependency, feelings of helplessness and disempowerment, anger and relationship difficulties.

Disability Prevention

"There is no magic bullet" to preventing claims from turning into permanent disabilities. "It's a multiphase attack. But you have to start somewhere," Aurbach says.

The most important thing is to realize that time and repetition are the enemy, and the central concept is loss of control. Preventing injured workers from feeling out of control can be done through a combination of actions.

"Return-to-work is really important," he says, noting that an individual's "identity is hooked in very strong ways with their work."

Additionally, educating the injured worker about the entire claims process can help. Early intervention is also key.

"Early intervention [should] send the message, 'You are still in control of this. This isn't who you are becoming. You are going to get back your life.' Reinforce the thought of control," he says.

Coping skills can help injured workers learn to relax and sleep -- avoiding the sleeplessness that often accompanies injuries.

"The thing to do here in every way, shape or form is reduce the time and repetition, particularly around loss of control," he says.

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