Evaluation and Treatment

of the Acutely Injured Worker

GREG VANICHKACHORN, MD, MPH; BRAD A. ROY, PhD; RITA LOPEZ, MSN; and REBECCA STURDEVANT, MSN
Occupational Health Services Clinic, Kalispell Regional Healthcare, Kalispell, Montana

Approximately 3 million work-related injuries were reported by private industries in 2011,

and primary care physicians provided care for approximately one out of four injured work-
ers. To appropriately individualize the treatment of an injured worker and expedite the return
to work process, primary care physicians need to be familiar with the workers’ compensation
system and treatment guidelines. Caring for an injured worker begins with a medical history
documenting preexisting medical conditions, use of potentially impairing medications and
substances, baseline functional status, and psychosocial factors. An understanding of past and
current work tasks is critical and can be obtained through patient-completed forms, job analy-
ses, and the patient’s employer. Return to work in some capacity is an important part of the
recovery process. It should not be unnecessarily delayed and should be an expected outcome
communicated to the patient during the initial visit. Certain medications, such as opioids, may
delay the return to work process, and their use should be carefully considered. Accurate and
legible documentation is critical and should always include the location, date, time, and mecha-
nism of injury. (Am Fam Physician. 2014;89(1):17-24. Copyright © 2014 American Academy of
Family Physicians.)

T
CME This clinical content he evaluation and treatment of the tasked with evaluating injured workers.
conforms to AAFP criteria injured worker has become a com- Overall, 25% of patients with work-related
for continuing medical
education (CME). See CME
mon challenge in the practice of conditions are cared for by primary care
Quiz Questions on page 6. medicine. In 2011, about 3 million physicians, providing nearly three times as
workplace injuries were reported in pri- many visits for injured workers compared
Author disclosure: No rel-
evant financial affiliations. vate industries.1 More than one-half of these with occupational medicine specialists.5
involved an injury severe enough that work
restrictions, job transfer, or time off from Evaluation
work was required.1 The occupations with the The evaluation of the injured worker extends
most injuries requiring time off were laborers beyond determining an appropriate diagno-
(construction trades), nursing aides/atten- sis and treatment plan. The evaluation also
dants, and janitors/cleaners.2 Persons 45 to assesses how related the condition is to work,
54 years of age had the highest incidence of the hazards within the work and nonwork
injuries, with sprains, strains, and tears the environments, and the patient’s functional
most common diagnoses, accounting for 38% abilities, pertinent psychosocial factors, and
of all injuries requiring time off work.2 The occupational history.
back (36%), shoulder (12%), and knee (12%) It is important to note that, in some circum-
were most often injured.2 In 2007, the costs stances, employers and workers’ compensation
for workers’ compensation care in the United insurance providers have arranged for injured
States was approximately $50 billion, about employees to be evaluated by specific clini-
four times the cost of breast cancer treatment.3 cians. The injured worker may not be aware
Occupational medicine is one of the small- of such an arrangement. Ideally, employers
est medical specialties, producing about 130 should be contacted before or at the time of
board-eligible physicians annually.4 With worker presentation to ensure eligibility for
the shortage of occupational medicine spe- care and to discuss the need for additional
cialists, primary care physicians are often services, such as postaccident drug testing.

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Injured Worker

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Evidence
Clinical recommendation rating References

Psychosocial factors should be assessed in the injured worker C 6, 13, 14, 21-23
because they may significantly affect recovery.
A detailed occupational history should be obtained when evaluating C 6, 13, 25
the injured worker.
Patients with work-related injuries should be educated on their C 6, 23, 29-31
diagnosis, treatment, and prognosis.
Prompt and appropriate return to work improves outcomes in work- C 6, 27
related injuries.
Opioids and other impairing medications should be used cautiously C 6, 35, 36
in injured workers because they may prolong recovery and prohibit
return to work.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evi-

dence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information
about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Table 1. Factors Associated with Common Work Injuries

Injury Occupational factors Nonoccupational factors

Carpal tunnel Potentially excessive hand vibration, large Obesity, previous wrist fracture,
syndrome8-11 grip force, repetitive wrist motion rheumatoid arthritis, diabetes
mellitus, genetics

Injury from slips Poor lighting, weather, slippery surfaces, Inappropriate footwear, fatigue,
and falls12 clutter advanced age

Low back pain13-16 Repetitive motion, heavy lifting, bending Obesity, psychiatric disorders,
and twisting of the trunk, whole body family history, advanced age
vibration

Rotator cuff Prolonged shoulder flexion, repetitive Advanced age, overhead sports
injuries/shoulder and forceful one-handed lifting, activities, previous shoulder
pain17-20 awkward work positions, repetitive injuries
motion, work above shoulder height

Information from references 8 through 20.

MEDICAL HISTORY A detailed medical history is necessary

The assessment of an injured worker begins for two reasons. First, preexisting medical
with a medical history.6 Workers can be conditions can make workers more prone
exposed to many hazards, and a high suspi- to certain injuries and can impact recovery.
cion for serious medical conditions is prudent, Transparency of such a history is necessary
especially following acute injuries. Common for proper treatment (Table 1).8-20 Second,
sources of fatal injuries in the workplace one of the primary goals of treating the
from a 2012 census included motor vehicle injured worker is the return to preinjury
crashes, falls and trips, strikes by equipment medical status. A description of preexisting
or objects, acts of violence, and exposure to function, specifically in regards to activi-
harmful substances or environments.7 ties of daily living, and comparison with

18 American Family Physician www.aafp.org/afp Volume 89, Number 1 ◆ January 1, 2014

 Injured Worker

functional deficits following an injury are

useful in assessing recovery and setting fea- Table 2. Psychosocial Factors Affecting Recovery
sible treatment goals. from Work-Related Injuries and Potential Treatments
Medications (prescription and over the
counter), illicit substances (e.g., marijuana), Psychosocial factors Potential treatments
and alcohol can contribute to work-related Excessive stress Fear avoidance behavior
injuries or hazards and impair recovery. This Family, friends, or peers receiving training
is the impetus for the postaccident drug and disability compensation Inpatient pain rehabilitation
alcohol testing required by many employ- Fear avoidance behaviors (e.g., self- Medical management of anxiety
imposed limitation in spine range and depression
ers. When documenting the medication
of motion) Neuropsychological assessment
regimen, special attention should be made
Heavy labor position Pain counseling
to dosing schedules. Medications used while
Job dissatisfaction Physical activity
away from work (e.g., at night only) do not
Legal representation
necessarily affect work safety.
Mental health conditions
Psychosocial risk factors may be associated
Monotonous work
with work-related injuries and can affect
Poor relationship with supervisors
recovery.6,13,14,21-23 Psychiatric comorbidities and fellow employees
and maladaptive pain coping behaviors are
associated with delayed recovery from low Information from references 6, 13, 21, 23, and 25.
back pain.24 A stressful work environment
has been associated with increased risks
of shoulder injuries and pain.18 Guidelines information is the job analysis. Job analy-
from the American College of Occupational ses provide details of work tasks, physical
and Environmental Medicine describe psy- requirements, necessary skills, and potential
chosocial factors that should be assessed6 exposures to hazardous materials or envi-
(Table 2 6,13,21,23,25 ). The presence of these fac- ronments. The employer is also a valuable
tors warrants consideration of additional resource for work information, and consul-
treatment options, such as fear avoidance tation is recommended if permitted.27
behavior training, and a neuropsychological
evaluation. It is important to note that psy- Treatment
chosocial factors may operate consciously There are a variety of common work-related
and subconsciously, and their presence does injuries; a discussion of specific treatments
not equate to malingering in cases of delayed is outside the scope of this article. Consen-
improvement.23 sus guidelines, such as those published by
the American College of Occupational and
OCCUPATIONAL HISTORY Environmental Medicine,6 can be consulted
Occupational history is an often overlooked for treatment details. However, there are
component of the medical history. Only tenets of care that can be applied across a
28% of patients have their work history variety of injuries to maximize recovery.
recorded by physicians.26 An understand-
PATIENT COMMUNICATION AND ENGAGEMENT
ing of a patient’s work and occupational his-
tory is critical for clarifying how related the Uncertainty of the treatment course and
injury is to work, preventing future injuries, prognosis can impair and prolong the recov-
and maximizing the return to work pro- ery process. Efficient and succinct patient
cess.27 Typically, the most accessible source education on diagnosis, expected time to
of occupational information is the patient. improvement, and long-term prognosis can
Although obtaining an occupational his- improve outcomes.23,29,30 Setting a return to
tory can be time-consuming, this can be work date and informal education on how
alleviated by the use of patient-completed to prevent reinjury were both associated
forms administered before the evaluation13,28 with early return to work.31 However, some
(Table 36,13,25). Another important source of written education materials such as “back

January 1, 2014 ◆ Volume 89, Number 1 www.aafp.org/afp American Family Physician 19

Injured Worker

books” have not been shown to produce monitoring of recovery and the effectiveness
consistent improvements.32 In the absence of treatment modalities.6,23
of serious pathology, the patient should be
RETURN TO WORK
reassured of a likely favorable outcome.6,29
Treatment goals, including functional Work participation helps maintain physi-
abilities, should be clearly stated. Frequent cal conditioning, self-confidence, quality of
reassessments are recommended to facilitate life, and function.6,27,33 Absence from work

Table 3. Brief Occupational History

Inquiries Rationale and use

Screening questions regarding how related the injury is to the patient’s work
Do your symptoms change between work and Symptoms that do not vary with work hours may
home? indicate a non–work-related etiology.
Have you had symptoms like this at other jobs?
Did you have symptoms while on vacation?

Current or recent job description

Title Toxic exposures must be considered. In addition,
Time at job poor compliance with safety devices, such as
respirators and hearing protection, can lead to
Shift work details
injury.
Tasks
Products made
Potentially hazardous exposures (environmental,
substances)
Assistive devices/protective equipment used

Work changes/events
Changes in materials or products made Changes in tasks can lead to new exposures.
Occurrence of unusual events Similar symptoms among employees can help
pinpoint a work-related etiology.
Symptoms in other employees

Work history
Previous jobs and time of employment Conditions may be related to a job different than
Previous work-related injuries the worker’s primary position. A history of similar
symptoms can provide useful treatment options,
Part-time or secondary jobs
as well as establish a functional baseline.

Questions regarding psychosocial factors

How are your relationships with supervisors Stress at work and poor work relationships can
and fellow employees? affect return to work and recovery.
How stressful is your job?
Do you enjoy your job?

Nonoccupational factors to consider

Hobbies (e.g., hunting, carpentry, painting) Although patients may assume their condition is
Sports activities related to work, activities such as hobbies and
sports must be considered as possible causes of
Alcohol and illicit drug use
symptoms.
Home activities and projects (e.g., yard work,
home remodeling)

Information from references 6, 13, and 25.

20 American Family Physician www.aafp.org/afp Volume 89, Number 1 ◆ January 1, 2014

 Injured Worker

is associated with poor outcomes, includ- insurance representatives, and family

ing increased morbidity, financial loss, and members. Before communicating with an
increased workers’ compensation costs.6,27,33 employer about a work-related injury, it is
To maximize outcomes and minimize pro- imperative that the physician understands
longed disability, prompt and safe return to what information may be transmitted to
work, even if duties are modified, is critical. an employer. Typically, only information
Of those patients who have remained off necessary to describe work restrictions and
work for more than three months, only 50% capabilities should be disclosed. Regulations
return to employment.23 regarding the sharing of work-related injury
Motivated by their desire to support the information vary between jurisdictions.
patient, many physicians place unnecessary Local policies should be clarified with the
work restrictions on injured workers.34 Thus, applicable workers’ compensation insurance
successful return to work requires a para- representatives or legal counsel before any
digm shift. Effective return to work begins at information is disclosed.27
the initial visit by stressing the importance Activity recommendations for the return
of work in the treatment process.27 Physi- to work should include a detailed descrip-
cians should also emphasize that pain is part tion of abilities, restrictions, limitations,
of the healing process and that returning safety concerns, schedule changes, neces-
to work in some capacity, even at a reduced sary assistive devices, and duration of rec-
activity level, should not be delayed until ommendations6 (Table 4).27 In addition,
pain has resolved.6,27 Thus, employers should describing social and environmental limita-
be encouraged to provide temporary alterna- tions or restrictions may be necessary with
tive or reduced duties and workplace accom- some injuries. Such information may be
modations to facilitate a prompt return to communicated in a variety of ways, includ-
work when patients cannot perform their ing through letters and standardized forms.
usual tasks.
MEDICATIONS
Effective communication and collabo-
ration between the physician and various With the high prevalence of musculoskel-
stakeholders are of paramount importance.30 etal conditions in patients with work-related
Stakeholders can include the employer, injuries, the management of acute pain is a

Table 4. Return to Work Prescription

Component Description Example

Capabilities Activities the patient can do safely May lift up to 25 lb from floor to waist
height occasionally
Restrictions Activities the patient cannot do Restricted from driving until impairing
without possibly causing harm to medications are not required
themselves or others
Limitations Activities the patient is unable to do Cannot lift with the right arm above
shoulder height (because of a rotator
cuff tear)
Schedule Changes required in the patient’s Begin reduced work hours at four hours
modifications schedule per day, five days per week
Duration Time frame in which recommendations Above restrictions in place until next
are expected to last (e.g., three appointment on 3/21/14
weeks, permanent, temporary)

NOTE: An example of a medical status form can be downloaded at http://erd.dli.mt.gov/med-status-form.html.

Information from reference 27.

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Injured Worker

common occurrence. The purpose of pain purposes, such as to review treatment and
management is not just to decrease pain, assess how related the injuries are to work.
but also to improve physical and emotional Another type of examination that may be
functioning.35 In most patients, acute pain needed is the functional capacity evaluation,
can be controlled adequately with the use of which assesses functional ability using one of
acetaminophen or ibuprofen.36 several validated instruments.38 Functional
Occasionally, severe acute pain may require capacity evaluations are usually performed
stronger medications such as opioids. The use by a physical or occupational therapist and
of opioids for the treatment of non–cancer- can provide useful information about the
related pain has increased significantly ability of the patient to undertake essential
in recent years, and a similar trend has job-related physical demands.
occurred in the treatment of An impairment rating is also commonly
The back (36%), shoulder injured workers. For example, performed for work injuries. It is a consensus-
(12%), and knee (12%) are
between 1999 and 2007, opioid based estimation (represented as a percent-
the most common sites for
use increased by 50% in Wash- age) of anatomic, physiologic, and psycho-
ington’s workers’ compensation logical changes in function.38 Also accounted
work-related injuries.
cases.37 Early opioid use in the for is the effect of these changes on activities
treatment of work-related back of daily living.39 Impairment rating assess-
injuries has been associated with prolonged ments are typically performed by physicians
disability, higher medical costs, increased and utilize the American Medical Associa-
risk of surgery, and long-term opioid use.36 tion’s Guides to the Evaluation of Permanent
Opioids may also limit an injured worker’s Impairment. There are six editions of the
ability to return to work. Opioids, as well as guides, and different jurisdictions use dif-
benzodiazepines and muscle relaxants, are ferent editions.39 Impairment ratings can
associated with reduced alertness, sedation, provide useful information about functional
and cognitive limitations. Although current abilities and medical history, but it should be
research is inconclusive regarding the poten- noted that impairment does not necessarily
tial impairments on function associated with correlate with disability.39
opioids, numerous employers have adopted A neuropsychological examination can
policies that prevent employees from work- provide information on psychiatric disor-
ing while using impairing medications.35 Job ders, personality traits, and psychosocial
tasks should be considered when prescrib- factors that may affect treatment and recov-
ing medications. Any potential work safety ery. This examination includes an array of
concerns secondary to the use of impairing tests to help develop a detailed psychological
medications should be discussed with the profile of a patient. It is usually performed
patient and, with adequate permission, the by a clinical psychologist or psychiatrist over
patient’s employer. several hours.6,39

Specialized Examinations Documentation

The management of work-related injuries, Significant legal and financial ramifications
especially in the setting of workers’ com- can be associated with a work-related injury,
pensation, can often require the input of and it should be expected that documenta-
additional clinicians. Such input can consist tion pertaining to the injury will be scru-
of unique examinations and reports, many tinized by multiple stakeholders including
of which are unfamiliar to primary care nurse case managers, claims adjusters, medi-
physicians. One common evaluation is the cal peer reviewers, and attorneys. Clinical
independent medical examination. It is an documentation is used by claims adjust-
extensive one-time evaluation performed ers and insurance providers to determine
by a clinician or a panel of clinicians not the extent of medical coverage. Failure to
involved in the care of the patient. Inde- adequately document an injury can severely
pendent medical examinations serve several limit a worker’s legitimate access to care.

22 American Family Physician www.aafp.org/afp Volume 89, Number 1 ◆ January 1, 2014

 Injured Worker

In addition, accurate documentation can 2. Nonfatal occupational injuries and illnesses requiring
days away from work, 2011 [news release]. Washing-
help control rising workers’ compensation ton, DC: Bureau of Labor and Statistics, U.S. Depart-
costs by better conveying how related an ment of Labor; November 8, 2012. http://www.bls.gov/
injury is to work.34 news.release/osh2.nr0.htm. Accessed March 14, 2013.
3. Leigh JP, Marcin JP. Workers’ compensation benefits
Documentation must include a list of and shifting costs for occupational injury and illness.
potential injuries and sources of pain, and J Occup Environ Med. 2012;54(4):445-450.
detailed physical examination findings. For 4. Michas MG, Iacono CU. Overview of occupational
acute injuries, the location, date, time, and medicine training among US family medicine residency
programs. Fam Med. 2008;40(2):102-106.
mechanism of injury should be recorded
5. Won JU, Dembe AE. Services provided by family phy-
clearly. The necessary history elements in sicians for patients with occupational injuries and ill-
an acute work-related injury can be recalled nesses. Ann Fam Med. 2006;4(2):138-147.
by using the American College of Occupa- 6. American College of Occupational and Environmental
Medicine. Occupational Medicine Practice Guidelines.
tional and Environmental Medicine’s four 3rd ed. http://www.acoem.org/practiceguidelines.aspx.
W’s (where [location of event], when [time Accessed October 15, 2012.
and date], who [witness and other persons 7. Census of fatal occupational injuries–2012 [news release].
Washington, DC: Bureau of Labor and Statistics, U.S.
involved], and what [mechanism of injury
Department of Labor; August 22, 2013. http://www.bls.
and circumstances]).6 gov/news.release/cfoi.toc.htm. Accessed November 26,
2013.
Data Sources: A search in PubMed was conducted using
terms such as evaluation of work injuries, work injuries, 8. Geoghegan JM, Clark DI, Bainbridge LC, Smith C, Hub-
opioids and workers compensation, return to work, and bard R. Risk factors in carpal tunnel syndrome. J Hand
Surg Br. 2004;29(4):315-320.
occupational evaluation. Clinical Queries and MESH were
used. In addition, searches of the Agency for Healthcare 9. Karpitskaya Y, Novak CB, Mackinnon SE. Prevalence of
Research and Quality evidence reports, Bandolier, Clinical smoking, obesity, diabetes mellitus, and thyroid disease
in patients with carpal tunnel syndrome. Ann Plast Surg.
Evidence, the Cochrane database, Database of Abstracts
2002;48(3):269-273.
of Reviews of Effects, the Institute for Clinical Systems
Improvement, the National Guideline Clearinghouse 10. Hakim AJ, Cherkas L, El Zayat S, MacGregor AJ, Spec-
tor TD. The genetic contribution to carpal tunnel syn-
database, and UpToDate were performed. Search date:
drome in women: a twin study. Arthritis Rheum. 2002;
October 1, 2012; reviewed on September 15, 2013.
47(3):275-279.
11. Barcenilla A, March LM, Chen JS, Sambrook PN. Carpal
The Authors tunnel syndrome and its relationship to occupation: a
meta-analysis. Rheumatology (Oxford). 2012;51(2):
GREG VANICHKACHORN, MD, MPH, is the medical direc- 250-261.
tor for the Occupational Health Services Clinic at Kalispell 12. National Institute for Occupational Safety and Health.
(Mont.) Regional Healthcare. Preventing slips, trips, and falls in wholesale and retail
trade establishments. http://www.cdc.gov/niosh/docs/
BRAD A. ROY, PhD, FACSM, FACHE, is an administrator/
2013-100/pdfs/2013-100.pdf. Accessed March 5, 2013.
executive director at Kalispell Regional Healthcare. He is
responsible for the Summit Medical Fitness Center, Occu- 13. Taiwo OA, Mobo BH Jr, Cantley L. Recognizing occu-
pational illnesses and injuries. Am Fam Physician. 2010;
pational Health Services Clinic, and a number of other hos-
82(2):169-174.
pital departments.
14. Webb R, Brammah T, Lunt M, Urwin M, Allison T, Sym-
RITA LOPEZ, MSN, APRN-BC, is a nurse practitioner in the mons D. Prevalence and predictors of intense, chronic,
Occupational Health Services Clinic at Kalispell Regional and disabling neck and back pain in the UK general pop-
Healthcare. ulation. Spine (Phila Pa 1976). 2003;28(11):1195-1202.
15. Videman T, Battié MC, Parent E, Gibbons LE, Vainio P,
REBECCA STURDEVANT, MSN, APRN-BC, is a nurse
Kaprio J. Progression and determinants of quantita-
practitioner in the Occupational Health Services Clinic at tive magnetic resonance imaging measures of lumbar
Kalispell Regional Healthcare. disc degeneration: a five-year follow-up of adult male
Address correspondence to Greg Vanichkachorn, MD, monozygotic twins. Spine (Phila Pa 1976). 2008;33(13):
MPH, Kalispell Regional Healthcare, 205 Sunnyview 1484-1490.
Ln., Kalispell, MT 59901 (e-mail: gvanichkachorn@krmc. 16. Jarvik JG, Hollingworth W, Heagerty PJ, Haynor DR,
org). Reprints are not available from the authors. Boyko EJ, Deyo RA. Three-year incidence of low back pain
in an initially asymptomatic cohort: clinical and imaging
risk factors. Spine (Phila Pa 1976). 2005;30(13):1541-
REFERENCES 1548; discussion 1549.
1. Workplace injuries and illnesses–2011 [news release]. 17. Silverstein BA, Bao SS, Fan ZJ, et al. Rotator cuff syndrome:
Washington, DC: Bureau of Labor and Statistics, U.S. personal, work-related psychosocial and physical load
Department of Labor; October 25, 2012. http://www. factors. J Occup Environ Med. 2008;50(9):1062-1076.
bls.gov/news.release/osh.nr0.htm. Accessed November 18. Pope DP, Silman AJ, Cherry NM, Pritchard C, Macfar-
15, 2012. lane GJ. Association of occupational physical demands

January 1, 2014 ◆ Volume 89, Number 1 www.aafp.org/afp American Family Physician 23

Injured Worker

and psychosocial working environment with disabling 30. Anema JR, Van Der Giezen AM, Buijs PC, Van Mechelen
shoulder pain. Ann Rheum Dis. 2001;60(9):852-858. W. Ineffective disability management by doctors is an
19. van der Windt DA, Thomas E, Pope DP, et al. Occupa- obstacle for return-to-work: a cohort study on low back
tional risk factors for shoulder pain: a systematic review. pain patients sicklisted for 3-4 months. Occup Environ
Occup Environ Med. 2000;57(7):433-442. Med. 2002;59(11):729-733.
20. Rotator cuff injuries. Epocrates Online. https://online. 31. Kosny A, Franche RL, Pole J, Krause N, Côté P, Mus-
epocrates.com. Accessed March 2, 2013. tard C. Early healthcare provider communication with
patients and their workplace following a lost-time claim
21. Soklaridis S, Ammendolia C, Cassidy D. Looking upstream
for an occupational musculoskeletal injury. J Occup
to understand low back pain and return to work: psy-
Rehabil. 2006;16(1):27-39.
chosocial factors as the product of system issues. Soc Sci
Med. 2010;71(9):1557-1566. 32. Derebery J, Giang GM, Gatchel RJ, Erickson K, Fog-
arty TW. Efficacy of a patient-educational booklet for
22. Shaw WS, Pransky G, Patterson W, Winters T. Early dis-
neck-pain patients with workers’ compensation: a ran-
ability risk factors for low back pain assessed at outpa-
domized controlled trial. Spine (Phila Pa 1976). 2009;
tient occupational health clinics. Spine (Phila Pa 1976).
34(2):206-213.
2005;30(5):572-580.
33. Roelfs DJ, Shor E, Davidson KW, Schwartz JE. Losing life
23. Derebery J, Anderson JR. Low Back Pain: An Evidence-
and livelihood: a systematic review and meta-analysis
Based, Biopsychosocial Model for Clinical Management.
of unemployment and all-cause mortality. Soc Sci Med.
2nd ed. Beverly Farms, Mass.: OEM Press; 2008:61-77.
2011;72(6):840-854.
24. Chou R, Shekelle P. Will this patient develop persis-
34. Newman LS. Occupational illness. N Engl J Med. 1995;
tent disabling low back pain? JAMA. 2010;303(13):
333(17):1128-1134.
1295-1302.
35. American College of Occupational and Environmental
25. Nguyen TH, Randolph DC. Nonspecific low back pain
Medicine. ACOEM guidelines for the chronic use of opi-
and return to work. Am Fam Physician. 2007;76(10):
oids. http://www.acoem.org/Guidelines_Opioids.aspx.
1497-1502.
Accessed October 1, 2012.
26. Politi BJ, Arena VC, Schwerha J, Sussman N. Occupa-
36. Webster BS, Verma SK, Gatchel RJ. Relationship
tional medical history taking: how are today’s physicians
between early opioid prescribing for acute occupational
doing? A cross-sectional investigation of the frequency
low back pain and disability duration, medical costs,
of occupational history taking by physicians in a major
subsequent surgery and late opioid use. Spine (Phila Pa
US teaching center. J Occup Environ Med. 2004;46(6):
1976). 2007;32(19):2127-2132.
550-555.
37. Swedlow A, Ireland J, Johnson G. Prescribing patterns
27. American College of Occupational and Environmen-
of schedule II opioids in California Workers’ Compen-
tal Medicine. The personal physician’s role in helping
sation. Oakland, Calif.: California Workers’ Compensa-
patients with medical conditions stay at work or return
tion Institute; 2011. http://www.cwci.org/document.
to work. http://www.acoem.org/PhysiciansRole_Return
php?file=1438.pdf. Accessed November 15, 2012
toWork.aspx. Accessed November 1, 2012.
38. Taiwo OA, Cantley L. Impairment and disability evalua-
28. Harber P, Merz B. Time and knowledge barriers to rec-
tion: the role of the family physician. Am Fam Physician.
ognizing occupational disease. J Occup Environ Med.
2008;77(12):1689-1694.
2001;43(3):285-288.
39. Rondinelli RD, Genovese E, Brigham CR. Guides to the
29. Dasinger LK, Krause N, Thompson PJ, Brand RJ, Rudolph
Evaluation of Permanent Impairment. 6th ed. Chicago,
L. Doctor proactive communication, return-to-work rec-
Ill.: American Medical Association; 2008:5.
ommendation, and duration of disability after a workers’
compensation low back injury. J Occup Environ Med.
2001;43(6):515-525.

24 American Family Physician www.aafp.org/afp Volume 89, Number 1 ◆ January 1, 2014