"It's still my back, Doc," said the talented 40-year-old auto mechanic as he put his hand on his lower back. "It's been over six weeks and it still bothers me."

When he had complained about his back the day after moving a transmission, the service manager at the auto dealership sent him to the local hospital emergency room. When the X-rays didn’t reveal a medical problem, the attending physician gave the mechanic Tylenol and a prescription and directed him to take a few days off and to "go back to work on Monday if you feel OK." The mechanic reported what had happened at the emergency room to the service manager.

When Monday came, the worker was still bothered by lower back pain and called the physician who wrote a new prescription and indicated that the employee should take the week off. "Let's see how you're doing by the end of the week," said the doctor.

On Friday, the mechanic reported, "My back doesn't seem to be any better...." At that point, the physician prescribed a specific number of physical therapy sessions. Even so, the pain persisted, keeping the employee from returning to work.

The auto mechanic's experience with pain is repeated thousands of times each day.

While managing pain is a critical medical intervention when it comes to musculoskeletal injuries such as the auto mechanic's lower back problem, finding ways to deal with it successfully is often illusive. This is a particularly important issue since such conditions account for a high percentage of job-related injuries and a high proportion of Worker's Compensation costs.

Such cases can result in legal action, substantial settlements, loss of a job and employers having to replace valuable workers.

It's important to point out that pain is both real and imagined, even though there are times when employers may feel that some employees are "faking it" or using pain to "milk the system."

The role of pain in work-related disabilities is attracting more attention. The reason is that pain control – "the biomedical promise of a cure for persistent pain and the elimination of pain-related disability" – has never been realized. This is the conclusion of a group of university, government and private industry researchers. Their findings are summarized in an article, "Integrating Psychosocial and Behavioral Interventions to Achieve Optimal Rehabilitation Outcomes" in the Journal of Occupational Rehabilitation (December 2005).

They do not question the reality of pain, only how it is treated. Some of the findings can be particularly helpful in understanding the injured employee who is experiencing pain from a musculoskeletal injury. While the research deals only with injuries to the lower back, the psychosocial implications may have a broader application.

They point out that there are both internal and external psychosocial factors influencing how the injured worker reacts to pain. Some experts suggest that musculoskeletal disabilities are often 10 percent pain driven and 90 percent influenced by psychosocial issues. If this is accurate, injury management programs should acknowledge the role of these factors and take them into account.

Internal influencers

• Pain preoccupation. Anyone who has "back trouble" knows how pain can be become overwhelming and all encompassing. The individual becomes preoccupied with it; it's the only thing they can think about.

• Fear of re-injury. The child who touches a hot stove stays away from it for a long time. The same is true with the possibility of re-injury. No one wants to go through a painful experience a second time. As a result, the disability becomes worse than the pain itself.

• Perceived disability. When an injured worker has been away from the job for an extended period, it's not uncommon to think that others, including family and co- workers, assume they are "faking it" or shirking their responsibility. Feeling uncomfortable and embarrassed, the worker finds it difficult to go back to work.

• The ways we think about pain influences our behavior. In summary, it has been found that "an individual's beliefs about the severity of the health condition are significant predictors of RTW [Return to Work] outcomes."

It may be that, as the researchers suggest, "poor problem solving abilities, low expectancies about the probability of returning to work, and lack of confidence in the ability to perform work-related activities have been associated with prolonged work disability."

It appears that the fear of pain can become more disabling than the injury itself.

External influencers

Along with internal factors, there are external psychosocial issues that can impact the injured individual. However, identifying the problem is only the first step toward finding a solution. Here are some examples of how research in psychosocial factors point in some helpful directions.

• The psychosocial implications of the work environment. One researcher discovered that the amount of job stress and co-worker support impacts the length of a person's disability. "The lack of social support at work and work dissatisfaction were predictors of prolonged disability." It has also been found that the employer's attitude toward work-related disability can influence an employee coming back to the job. A survey of occupational health physicians and HR managers revealed, "a lack of coworker support for modified work re-entry programs was perceived as a major obstacle to successful RTW."

• Preventing acute injuries from becoming chronic disabilities. The objective here is to help avoid an injury from becoming one of the 20% of musculoskeletal injury cases that turn into extended disabilities. These are the cases that cause serious problems for the employee and result in high Workers' Comp costs for the employer.

• Public education should not be ignored. Too often the role of education is ignored when it comes to dealing with psychosocial issues. Yet, it has been shown to help change attitudes toward job-related disability. In Australia, there was a "decline in the number of compensation claims" following a two and one-half year long advertising campaign that focused on "attitudes and beliefs associated with work disability."

• Primary physicians can play a valuable role in terms of what the researchers call "medical reassurance." Physicians emphasize the role of activity in a patient's recovery including dealing with the fear of re-injury and "encouraging return to an active lifestyle in spite of the persistence of pain symptoms. In other words, to help the injured worker avoid developing what might be called a "disability mindset."

One study found that "advice to stay active and information aimed at reducing fear can lead to significant reductions in sick days and higher rates of RTW."

• Combining cognitive-behavioral and psychosocial approaches. A group of back pain patients off the job for less than six months were taught problem solving skills. Compared to a group that did not have the training, those receiving problem solving skills training showed better RTW results.

In another study, employees off the job for an average of three months were given RTW skills training. One year later they had "significant less absenteeism" than those who did not receive the training.

• Customized approaches to specific psychosocial factors. One study suggests "disability results from the development of high levels of pain-related fears."To test the hypothesis, researchers gradually exposed “individuals with high levels of pain-related fears...to activities that have been avoided" with a methodology similar to that for treating phobias. The results indicated that such an approach "can be effective in reducing levels of fear, pain and pain-related disability."

Understanding the significance of psychosocial factors in musculoskeletal injuries is an important first step. The researchers indicate that the preliminary results of a training program for 300 physiotherapists and occupational therapists suggest, "front-line professionals can be taught to detect and intervene on psychosocial risk factors." This more effective approach can benefit the injured employee and provide cost savings for the employer.

Summarizing their work, the researchers conclude, "... superior RTW outcomes were achieved without demonstrating a greater magnitude of pain reduction." The message is clear: dealing with the psychosocial factors associated with musculoskeletal injury pain can have a positive influence on helping injured employees avoid disability and get back to an active lifestyle faster including returning to work.