Why Some Workers Don’t Heal

That 20% of patients struggle and fail with recovery is a problem that is easily fixable once it is identified. Virtual reality plays a key role.


It’s well-known in workers’ compensation that 20% of cases account for 80% of costs. It’s been a mystery why four out of five cases progress fairly routinely, and why that fifth one is an outlier. Struggling to find the answer, we’ve continued to do versions of the same things over and over again for these patients, without success – the very definition of frustration and insanity. If it were easy to define who the 20% of patients were, we would have done it years ago, but the problem has essentially eluded us.

As an industry, we have spent countless hours and dollars looking for extrinsic causes to the problem. Could we build a better healthcare delivery network? Perhaps we need to change our drug formulary. Maybe the problem lay with the individual adjusters approving or denying care. All of these are viable and appropriate question, but they place the locus of control for the problem on the world around the patient. I submit that the reason 20% of patients struggle and fail with recovery is purely an intrinsic problem and the solution to the problem is easily fixable once it is identified.

The Real Reason Why That 20% Languishes

The core problem is twofold: Patients do not respond the same way to treatment, and they experience trauma and suffering in very different ways.

A one-size-fits-all approach simply does not work for everyone, because their symptoms and suffering are different. 

The nature of an injury is not just a broken bone or a laceration. While the physical manifestation of trauma is easy to see and treat, trauma expresses itself in emotional ways, as well. So far, our approach to treating injured workers has been primarily biologic – and pharmaceutical. Only recently have we begun to identify the ramifications of mental and emotional health on an injured worker’s recovery and ability to return to work. 

These emotional wounds and physical suffering express themselves differently in different individuals. We need to recognize these variations and develop customized and innovative ways to treat them on an individual level that are cost-effective and long-lasting and can provide patients with a truly positive experience.  

Why Are the Psychosocial Factors So Powerful? 

In 1997, George Engle introduced the bio-psycho-social construct for understanding the human condition as it relates to medical conditions. By identifying the fact that humans are much more complex than biologic creatures, he opened the door to detecting the underlying reasons why some people persevere in the face of grave illness or injury while others languish. To address this interplay, it is critical to understand two constructs.

First, there is a direct relationship in the brain among pain, trauma, depression and anxiety. They are inextricably tied through the neural pathways of the brain. When someone suffers from one of these issues, the others are directly correlated. In physics terms, for every action there is an equal and opposite reaction, and those reactions are not always positive. 

Second, a work-related injury is a life-changing event. Consider what the patient is facing:

  • Anxiety about continuing in their job and being able to support themselves and their family.
  • A loss of sense of self – will I ever be the same again?
  • A loss of identity – our jobs, our professions, our roles in the family and the community are representations of who we are. With an injury, those identities may permanently change.
  • Fear of the unknown – success in treatment is not guaranteed to restore full function.
  • Time to ruminate and worry during the recovery process.
  • A loss of control for their own healthcare – patients are reliant on their adjuster and payer to grant access to care for their problem.

See also: Impact of PTSD on Workers’ Comp Costs

If you consider the biologic connectedness of trauma and mental health and then factor in the emotional impact of a workplace injury, it’s no wonder that anxiety, depression and other mental health problems are present in most cases that drive volatile claims cost and poor patient outcomes.

When the injured worker is in pain, as most are, the recovery is longer, discomfort persists on a daily basis and emotional problems are exacerbated. Sleep is interrupted, delaying the healing process and increasing anxiety and depression. This downward spiral is clinically referred to as the fear-avoidance cycle, and it continues, often ending in permanent disability and addiction, because patients, and oftentimes medical providers, do not know how to break this vicious cycle. 

As noted, pharmacology has been the traditional answer for both pain and emotional/mental health issues. These medications were the only resource available to us clinicians, so they became the proverbial “hammer” and everyone we treated became the “nail.” We’ve seen what long-term reliance on painkillers can cost in terms of addiction, more suffering and even death. A pharmacological solution alone doesn’t work. Not only does it fail to resolve the source of the pain, but it also fails to treat the array of psychosocial symptoms that are related to pain. If anything, narcotics and pharmacology have the potential to make these problems worse. 

Science Leads to a Solution

Fortunately, recent breakthroughs in technology, science and clinical care offer alternatives to effectively treat the 20% of outliers that have long stymied us for their lack of response to the current biologic treatment paradigm. The innovation is understanding that the brain has the ability to promote neuroplastic change when given the appropriate clinical cues for the right frequency and duration. This neuroplastic change promotes a biologic re-wiring of the brain to create permanent resiliency to the symptoms related to the traumatic event. It is imperative that the biologic changes be coupled with social and psychologic training and education to provide an individualized level of support for the patient. The ability for a clinician to use a single therapeutic modality to address all three of these humanistic pillars is unparalleled.

This disruptive approach consists of four components: 

  1. Virtual reality technology: This technology is used to immerse the patient and to distract from the maladaptive sensations. The brain’s ability to create new pathways (neuroplastic change) reprioritizes these signals to create resiliency in the patient. Using the immersive technology, patients report an immediate decrease in their symptoms as well as a residual, or legacy, effect. This equates to acute relief from their symptomology with continuing relief even when they have removed the VR platform. Previously, similar results could only be accomplished with prescription drugs. The results using VR are obtained in a purely non-pharmacologic and safe manner. In addition to the reduction in symptoms (pain, depression, anxiety or PTSD), patients are also reporting a dramatic increase in the quality and quantity of sleep, which is essential to healing following any traumatic event – physical or emotional.
  2. Individualized behavioral counseling and coaching: The coupling of masters-level behavioral health specialists to coach and guide the patient through the virtual reality platform allows for an extremely customized and individual therapeutic experience. These weekly encounters help maximize the protocols within the virtual world as well as drive engagement and behavioral change skills in the real world. The coaches have been charged with helping traumatized patients return to their version of normalcy in their lives or helping them identify and adapt to a new version of normal as they move forward.
  3. An exceptional patient experience: Digital engagement in a virtual setting means that patients don’t need to leave home to engage in therapy. Patients receive direction as to when and how to use their platform from their personal coach, and then it’s available any time of the day or night. When a person is injured at work. there is a loss of control in their life, as their daily routine is interrupted. With this unique therapy, traumatized workers have complete control of one aspect of their healthcare—this is an extraordinarily powerful tool that helps engage these patients and gives them some ownership in the treatment plan. 
  4. A time limit: The 90-day duration of treatment is designed to promote the necessary neuroplastic change, coupled with behavioral change and goal-setting education. The goal for any therapy should be to create change in a timely manner. Furthermore, a true biopsychosocial program needs to drive the patient toward a graduation event—accomplishing a series of goals promotes positive behavioral change.

See also: Why to Provide Life Insurance for Workers

Through this combination of virtual reality technology and customized behavioral counseling, we now have a solution to effectively bring relief to injured workers in a holistic and patient-centric manner. The goal is to be synergistic and complementary to other therapeutic modalities, while promoting a safer and more efficacious treatment pathway. Simply put, this treatment modality delivers on the notion of the triple AIM – better patient outcomes, lower financial burden, and exceptional patient experiences.

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