Guest Blogger: Dr. Michael B. Vessely
Injuries have predictable recovery trajectories. Sprains, strains and most fractures heal within consistent timeframes.
However, there are individuals with these types of injuries who continue to have more than minor symptoms without objective findings, long after their injury has healed. Some have greater symptom intensity or functional incapability than would be expected. What accounts for this variation in recovery time, symptom intensity and capability?
Our workers compensation system is built around legal policy that reinforces the biomedical paradigm of human illness. This model asserts that all human illness is directly associated with underlying pathology. If pathology is not identified, it may be considered that someone is pretending to be ill.
This paradigm reinforces a mind-body dichotomy in which unexpected symptom intensity must be accounted, therefore leading to tests looking for elusive pathology, non-specific treatments (because the pathology is unknown) and unnecessary work restrictions. However, human illness is not this simple.
An alternative approach is the biopsychosocial paradigm. This model considers human illness to be the result of pathology, mindset and circumstance. A disease is a medical condition. Illness is an individual’s reaction to that condition and includes behavior. A disease condition includes objective findings, pathophysiology, and impairment. Illness includes subjective findings, activity intolerance, and disability. The biopsychosocial model asserts that human illness exists along a continuum involving the mind, body and environment, not a mind-body dichotomy.
The human mind functions to prioritize information quickly. This has led us to develop cognitive biases. Cognitive biases are inherent in all of us. They include discarding specifics to form generalizations. Many of these cognitive biases serve us well. They allow us to make determinations and to react and respond quickly. However, they can sometimes lead to erroneous perceptions with respect to some aspects of objective reality.
One negative cognitive bias is that pain always indicates the presence of pathology. Pain is a protective sensation in general, but is subject to modulation by cognitive and physiologic factors. Pain does not always indicate the presence of pathology.
An individual’s cognitive bias toward pain can lead to unhelpful thoughts such as feelings of helplessness and pessimism about one’s pain or the perception that one’s pain is uncontrollable and unbearable, thus magnifying the effects of pain so that challenges seem insurmountable. These unhelpful thoughts are common in individuals who are pre-disposed to pain catastrophization (worst case thinking).
Pain catastrophizing, and the bias that pain must represent new pathology, can lead to and reinforce the beliefs that pain indicates more damage is being done, or that one must be pain-free to return to activity.
In additional to these psychologic factors, the injured worker may also have concerns regarding their societal roles as a spouse, earner, co-worker and employee. They may be worried about how they will provide for their family, be perceived at work, or be able to return to recreational activities.
The totality of these factors can cause feelings of distress, despair, and insecurity that impact an individual’s illness. There is solid and consistent evidence that variation in symptom intensity and duration, and magnitude of incapability relates more to the presence of unhelpful thoughts around role and livelihood, than pathophysiology.
If no objective pathology is found and these psychologic and social factors are not taken into account (biomedical paradigm), these individuals may feel that they are labelled as “other” or “lesser than” the rest of us. They may feel misunderstood, or a sense of injustice.
Ultimately, if we are to improve the health of these injured workers, in addition to indicated medical treatment, we must help them redirect unhelpful thoughts. There are ways to address this and help develop self-efficacy (feeling that one has some control over their situation), resiliency, and coping skills. These are concepts that can be taught.
Teaching these strategies will be better for these worker’s overall health, return to work, and enjoyment of life–much better than chasing pathology that likely does not exist, or considering the individual as pretending to be injured.
Dr. Michael B. Vessely is an Orthopedic Surgeon and past President of the Oregon Association of Orthopedists. He has completed Research Fellowships in Hip & Knee Arthroplasty and in Adult Reconstructive Surgery. He is currently a panel physician with Integrity Medical Evaluations.