© Springer International Publishing Switzerland 2016
Brian P. Jacob, David C. Chen, Bruce Ramshaw and Shirin Towfigh (eds.)The SAGES Manual of Groin Pain10.1007/978-3-319-21587-7_4747. Workers’ Compensation: An Occupational Perspective on Groin Pain, Including Psychosocial Variables, Causality, and Return to Work
(1)
University of Connecticut, 358 Mansfield Road, Storrs, CT 06269, USA
(2)
Icahn School of Medicine at Mount Sinai, New York, NY, USA
(3)
Laparoscopic Surgical Center of New York, New York, NY, USA
(4)
AngelMD, New York, NY, USA
(5)
International Hernia Collaboration, Inc., New York, NY, USA
Keywords
DisabilityReturn to workWorkers’ compensationPermanencyCausalityPsychosocialHerniaGroin painCatastrophizingIntroduction
Groin pain and inguinal hernias are a frequent cause of lost work time [1]. Despite the fact that elective inguinal hernia repair is a commonly occurring surgery, there is surprisingly little evidence-based guidance available regarding return to work, causality determination, and psychosocial variables that impact post-herniorrhaphy functional recovery [2]. These issues are of particular relevance to disability insurance payers, such as workers’ compensation carriers, which are contractually responsible for medical treatment, as well as indemnity payments for lost wages that are the result of a workplace injury. Especially since this financial responsibility may extend for years, there is an interest in addressing any potentially contributory comorbid conditions that might result in a more expeditious return to work. In addition to the fiduciary responsibility to accurately assess causation, there is an incentive to identify all of the factors that may have contributed to an injury, so that appropriate prevention practices can be applied as related to future claims.
Evidence and Recommendations
There is significant variability in recommendations regarding return to work post-herniorrhaphy [2]. Survey data suggest that when the occupational job demands involve heavy lifting, return to work recommendations vary from a few days to as long as 3 months post-op [3]. There is evidence that post-herniorrhaphy recommendations for early return to work and unrestricted activity are more likely to result in functional recovery [4]. There is good evidence that return to full duty work, even with high physical demands, should generally not exceed 30 days and this time should generally be even less with laparoscopic surgery [2]. Even in the case of more conservative recommendations for return to work with physical demands that include frequent lifting of greater than 25 lbs., disability of more than 6–8 weeks is not supported by available evidence [5].
Return to Work
In most cases, return to work recommendations can include time-limited initial work restrictions (e.g., sedentary work). These recommendations should never be based on the patient report of job availability, but instead upon sound medical judgment regarding work capacity. Even if accommodated work is not available, this determination is occupational, not medical. Furthermore, there is a good deal of evidence that early return to work, even with appropriate time-limited restrictions, reduces long-term disability [6].
In general, workers’ compensation carriers are motivated by expeditious return to work, quality outcomes, appropriately limited use of pre- and postoperative opiate analgesics, and the absence of recurrence. Regarding the latter, the available evidence suggests that there is no difference related to recurrence in the case of early return to work following elective inguinal repair [6]. Not surprisingly, self-employed post-herniorrhaphy patients have been found to return to work sooner than those patients who are receiving disability benefits [7]. There is also evidence that workers’ compensation patients report a greater duration of pain and disability post-herniorrhaphy as compared to patients who are receiving group health benefits [8].
Psychosocial Variables
Much of the variation in disability following hernia repair appears to be a function of psychosocial variables. Jones et al. [2] found that apart from age, educational level, income level, occupation, symptoms of depression, and the expectation for return to work accounted for nearly two thirds of the variance in return to work. These authors found that depression significantly delayed return to work in this setting. Parés [9] emphasized the importance of preoperative expectations, as well as cultural and motivational issues related to return to work post-herniorrhaphy. The inflection point as related to likely prolonged disability in workers’ compensation appears to be 3 months absence from work [10].
Pain as Basis for Disability Decision
If pain alone is considered to be an ambiguous indication for surgery, this subjective report is even more unclear when used as a basis for disability decisions. There is some evidence that at least 3–6 % of post-herniorrhaphy patients will report some degree of chronic pain and that this is more likely if there was a history of prior chronic pain [11]. It is reasonable to hypothesize that a history of prior workers’ compensation claims would similarly be a predictor of chronic post-herniorrhaphy pain, and this may be worth considering in preoperative evaluation. It is also worth noting that opiate analgesics can be a particular concern when there is a claim of work-related pain, with regard to the potential for diversion, medication misuse, and prolonged disability [12].
Catastrophizing
Tripp and Nickel [13] have emphasized the role of “catastrophizing” as related to chronic groin pain and increased disability. Shaw et al. [14] have demonstrated that this psychosocial variable can significantly impact the duration of disability. In this case, catastrophizing refers to misattribution and exaggeration of physiological experiences of groin pain. There is emerging evidence that pain catastrophizing can be effectively mitigated [15]. For example, although a complete discussion of these issues is beyond the scope of this chapter, informing the patient that some time-limited postoperative pain is often evidence of tissue healing and repair incorporation, can reduce negative affect and improve outcome perception [16].
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