12 Months and Beyond

The issues workers and employers face are often the same or similar to those of their treatment providers and doctor.  The obstacles outlined and strategies suggested may help you better understand what may be happening to stakeholders in the workers compensation system at a given point in time. Ideas are offered for supporting the various stakeholders assisting injured workers recover and get back to work.

What is happening

It is now more than 12 months since your patient's injury claim was lodged and they are still in the workers compensation system. A number of  unexpected challenges are likely to have been experienced as well as unexpected  setbacks. Inevitably, secondary or tertiary health issues are likely to have followed including , social, psychological, financial and employment difficulties.

In the following sections the most commonly experienced challenges are outlined by workers who have been in “the system” for more than a year are discussed. Suggestions are made on ways injured workers can be supported to deal with these challenges including where to find the right types of of advice or support for particular circumstances.

The injury itself - 

Workers who are in the system for 12 months or more are likely to have one or more of the following:

• More serious  injuries – the injury may have required surgery on one or more occasions
• Multiple Injuries  -  affecting a range of areas of the body
• Physical and Psychological Injury Occurring Simultaneously. It was mentioned in the sections Injuries 1 to 3 months that there are some situations where an accident or incident occurs at work where both physical and psychological injuries may result.  These occur typically where there is significant traumatic event.  

What the injured workers need to consider - 

1. Has the  NTD performed and been helpful over the last 12 months?  Did they  assesses accurately, provide good feedback, and know what surgeons or specialists could offer the best treatments services to  get the best possible results?
2. In cases where there is a primary psychological injury or a secondary  psychological condition ( highly likely for any injured worker who has been caught up the "system" for 12 months)  did the  NTD have  a  good understanding and experience in dealing with psychological injuries and health issues while he / she treated  the worker's primary  physical health issue?.
3. Getting other opinions, particularly when there are inconsistencies in opinions about  diagnosis and management,  
4. Educating them selves to research independently about what is wrong with them, and what treatments will and won't be most effective .Encourage patients  to do their own independent research on treatment options including which treatment providers have best reputations.

When surgery didn't do what it was suppose to do - i.e unexpected side effects and complications from the surgery.

What the injured worker and treatment providers need to consider- 

1. The injured worker needs to be encouraged to discuss their post op experiences and get feedback about what should be happening, time frames and options for treatment and self management.
2. The injured worker should also have a similar conversation and get similar types of feedback from the  surgeon
3. If symptoms fail to resolve and / or other strategies of management are suggested which the worker finds unacceptable a  2^nd opinion from another surgeon should be sought.

Side effects and complications from treatments such as medications - e.g. physical dependence, inadequate pain control , liver or kidney problems

What the injured worker and treatment providers need to consider- 

Whether the NTD who is aware of these issues and will explore alternative treatment options  e.g. referrals to therapists who can use alternate strategies that minimise medication  problems.

Secondary Physical injuries - e.g: A significant injury to a left knee or leg may result in changes of posture -  leading to back problems  - it may also result in the injured person favouring the other leg and overuse problems occurring in that knee.  This occurs frequently with leg, knee, arm, hand and shoulder injuries. -  Resulting insurer liability and subsequent treatment problems can be a significant challenge.

 What the injured worker and treatment providers need to consider- 

1. That the injured worker has a good NTD who is aware of these issues and will implement preventive strategies to minimise secondary injuries.
2. Having a good lawyer who will support the injured worker if  liability issues occur.

Secondary Psychological Injuries- Anyone who is caught up in the workers compensation system for more than 3 months, irrespective of the type and extent of injury is likely to have faced challenges they may have never had to deal with before. After 12 months it is likely that:

• Individual or family income level will have reduced and they will have had difficulties making ends meet.
• Activities previously enjoyed such as hobbies and sports won’t be able to be carried out as before or at all. Frequently new ones haven’t been taken up.
• There are likely to be difficulties with doing at least some activities of daily living such as house work, mowing lawns, gardening, cleaning or food preparation tasks
• There will have been, or still is conflict in households about new roles required to accommodate a person with a disability
• Physical fitness will have decreased and there is will be an overall loss of strength and fitness in other areas of the body, as well as the area where the injury occured.
• Chronic and acute pain episodes are likely to dominate or at least influence a person’s general sense of well being
• Sleep problems are likely 

All these challenges inevitably lead to increased levels of stress, even in people who manage the demands of everyday life very effectively.  Many of challenges outlined cannot be “solved” easily if at all. This can result in frustration, anxiety and anger that may flow on and result in depression, and anxiety, particularly when the person's life situation does not seem to be improving and  there are numerous difficulties being faced on a day to day basis..  Secondary psychological injuries (put another way, psychological and social health problems) are almost inevitable after 12 months for most people if they do not have the right support and progress isn’t being made.

What the injured worker and treatment providers need to consider- 

1. That the injured worker has a  NTD who has an equally good understanding and experience in dealing with psychological injuries and health issues as they do with  treating physical health issues
2. Getting  a referral to a psychologist
3. Getting another treating professional to discuss health concerns with the injured workers NTD and make recommendations for specific referrals. Referrals can be made to a psychologist, physiotherapist, chiropractor, or exercise physiologist/program.
4. Encouraging the injured worker to undertake their  own independent research on treatment options and service providers with the  best reputations.

12 MONTHS AND BEYOND -  A DIFFERENT APPROACH IS NEEDED TO INJURY MANAGEMENT

At 12 months there needs to be a fundamental shift in approach to injury management with most injuries and most workers.  The emphasis needs to change from finding the best treatments to one where the focus moves to adjusting to living with permanent residual restrictions and pain. Psychological counselling / and or pain management counselling is often very helpful with this.  (See Pain Management and Injury Adjustment Interventions and Pain Management and Injury Adjustment Interventions)

Twelve months after the worker's initial injury there are usually  multiple stakeholders involved in a claim.  Issues involved in both the claim and injury process are often complex and conflict is common. In the following sections the most common problems are overviewed and strategies suggested to minimise or resolve the issues.

Industrial and workplace issues can be a major barrier to an injured worker returning to full or near full capacity in their preinjury work place.  In the information file 1-3 Months - What is happening / should be happening the following issues were mentioned as common workplace barriers:

• The employer is reluctant to accept that an injury is work related (despite liability being partially or fully accepted by the insurer) and therefore also reluctant to support the restrictions made on the medical certificate.
• An employer not being aware or being unwilling to accept their obligations to provide suitable duties  for an injured worker
• An employer agreeing to provide but then not accommodating the restrictions or hours of a medical certificate.
• Lack of management and co-worker support - an attitude that the injured worker is a malingerer, weak or not pulling their weight and “dragging the chain”.
• Subsequent problems with the injured worker being fearful of returning to work 

Twelve Months down the track most employers will have accepted that the injury is work related  (even if they have continuing suspicions that it is not) and will be aware of the their obligations to provide suitable duties. It is also likely that the employer will have had advice about their legal and injury management responsibilities at this stage and will be attempting to provide at least token levels of support. The vast majority, particularly if they are being provided with good information and support from an external rehabilitation provider and their insurer will be active participants in the return to work process.  

After 12 months many small to medium size employers will be finding it costly to have had to make a workers compensation in terms of time, money, and unexpected considerations addressing staffing and business requirements.  Employers are required to provide suitable duties for their workers. For a small employer  -  i.e. less than 20 staff their obligations can seem onerous.  The personality of the manager and business owner, the circumstances of injury, their experiences with the worker since injury, and the general health of the business  are all factors that can strongly influence the attitude of the an employer to the injured worker, to the treatment team and to injury management experience generally.  Where there relationship and attitude with the  injured worker is poor, additional barriers to a successful return to work outcome are likely. These include:

• suitable duties not being offered at all
• duties being offered that are not consistent with medical restrictions
• discrimination by the employer
• an unhelpful attitude from the worker about  returning to work -  e.g. avoidance, hostility, taking regular leave, arriving late , leaving early.
• pressure being placed  by the employer on the agent to have the worker re-assessed as "work ready" or generally, anything that will lead to the claim being declined and their obligations ending.

What the injured worker and treatment providers need to consider- 

1. The challenges the employer is facing and be understanding of their situation
2. Discussing workers concerns with key staff members.
3. That the worker has experienced rehabilitation provider and experienced case manager who is a good negotiator and mediator.  They can be helpful in explaining the situation and getting support for common goals acceptable to all parties.
4. Formal Mediation 
5. If all else fails discussing alternate work directions with the injured workers NTD and rehabilitation provider.

Problems with Diagnosis and Treatment

After 12 months from date of injury the vast majority of injuries will have healed completely.  For those that haven’t it is likely that the pain and functional restrictions from the injury are unlikely to improve significantly, even with a different approach.  There are exceptions of course such as head injuries - which may take up to 3 years, and some complex injuries where there were unexpected complications.  

There are also situations where the management of the injury has been poor.  Some of the circumstances include:

1. Inaccurate diagnosis from NTD
2. Inadequate Investigations by NTD
3. Inadequate or inappropriate referrals by the NTD
4. Premature certification of "fit for suitable duties" or too rapid an upgrade of hours  resulting in significant injury exacerbation.
5. Inadequate information and feedback from the NTD ignoring significant symptoms - i.e. red flags resulting in complications or exacerbation of symptoms. 
6. An over cautious approach to inury management -  i.e encouraging avoidance  resulting in the injured worker becoming disproportionally fearful of reinjury, and / or becoming deconditioned.  -  Both scenarios can result in slower response times to treatment  and rehabilitation and lower work capacity.
7. The NTD  fails to recognise secondary psychological difficulties that are emerging due to actors such  poor pain management, associated chronic sleep difficulties, family problems, medication issues  prescribed and non-prescribed .  Treatment responses are frequently affected by issues such as anxiety, agitation, poor decision making and memory problems, impaired motivation, and hesitation to attempt a new treatment or upgrade of  duties at work.
8. The NTD  not identifying psychological and social difficulties (see Red and Yellow Flags) and therefore does not attempt to address the issues affecting his/ her patient.  They may not adjust medication or treatment regimes, or refer for psychological assessment and support when it is most  needed.   

Treatment provider problems such as:

1. Inappropriate treatment strategies for the symptoms
2. Treatment irregularity -  appointment scheduled too far apart
3. Abrupt and inappropriate treatment cessation.  Although the emphasis in worker compensation injury management is for “evidence based practices” that are “reasonable and necessary” there is often disagreement between service providers and the agents paying for the treatments as to what is evidence based, “and what is reasonable and necessary”. 

Insurer/ Agent  Issues

It was mentioned in the initial information document that the insurers / agents are the managers, gate keep and bean counters of the NSW Workers Compensation system.  It was also mentioned that the relationship injured workers, nominated treating doctors, treatment providers and rehabilitation providers have with the claims officer managing a particular injured workers claim can and does make an enormous difference to how quickly decisions are made, referrals and treatments approved and payments made.  By 12 months this will havebecome  increasingly apparent to all the stakeholders who are required to deal with an agent responsible for a particular claim.

Positive Agent Experiences

 There are situations where 12 months down the track where:

1. The claims officer appears to have had training in injury management
2. The agent has policies and procedures for rapid processing of all aspects of claims including wages, treatment expenses, and travel and paying wages
3. The agent has adequate staffing levels
4. The agent doesn’t have staff turn over every 2 to 3 months
5. Has a positive culture - where injured workers and treatment providers are not perceived as malingers or rorters of the system
6. Adopts a team and collaborative management of the injured worker
7. Cases are managed with an emphasis on injury management as opposed to claims management,  an approach that is more collaborative and less adversarial
8. The agent has well trained and experienced staff that are making important decisions and supervising less experienced staff.

The feedback from workers who have had positive experiences includes comments on supportiveness, reasonableness in decision making, paid on time, works in with the treatment team.

Negative Agent Experiences

In the first information doc "Time of injury to 1 month", it was mentioned that the majority of complaints made to WorkCover by injured workers and treatment provider relates to agent related problems.  Unfortunately this remains so through the life of a claim and for various reasons.

The situations where problems develop with the agent is the opposite of "Good Experiences" and can be summarised as:

1. The claims officer DOES NOT appear  to have had training in injury management
2. THE AGENT DOES NOT have policies and procedures for rapid processing of all aspects of claims including  wages, treatment expenses, travel and pay reliably
3. THE AGENT DOES NOT have adequate staffing levels
4. THE AGENT  has rapid staff turnover - i.e.  every 2 to 3 months
5. THE AGENT has a negative culture  -  where Injured workers and treatments providers are  perceived as malingerers or rorters of the system
6. THE AGENT DOES NOT encourage a team and collaborative management of the injured worker; rather they are directive and non-consultative.
7. Cases are managed with an emphasis on an adversarial approach to claims management with ongoing emphasis on reducing liability
8. THE AGENT DOES NOT have well trained and experienced staff who are making important decisions and supervising  less experienced staff.

Some of the typical problems reported by injured workers after 12 months are outlined below:

Time Frames for Approval

Slow responses to treatment and rehabilitation service requests, for specialist’s referrals and for investigative procedures are the area where most complaints are made to Workcover’s Claims Assistance Service. It is important for Injured Workers and treatment providers to know that not all services require agent approval providing there is a valid claim. 

Below is a summary of relevant parts of the current WorkCover Act relating to services needing agent approval, what services don’t and what the avenues of appeal are when there is slow or non response from the agent.

• It worth commenting however that even when a valid complaint is lodged with the agent and/or with Workcover the vigorousness that the matter is pursued, followed up and dealt with will determine how much attention and priority is given to the matter and what the consequences will be if there is breach.  We are interested in hearing about  injuried workers and treatment providers experiences of dealing with agents and Workcover on matters of treatment approvals -  Please refer our Questionnaire on the this subject

WHAT WORKCOVER HAS TO SAY

•  Travelling Expenses

“If the worker has paid for reasonably necessary medical treatment, the insurer is to reimburse the worker within 7 days after the worker requests payment. If the worker has paid for travelling expenses to receive medical treatment or to attend a medical appointment that the insurer has arranged, the insurer is to reimburse the worker within 7 days after the worker requests payment. “

• Non Response to Claim Application

If the insurer does not respond to a new claim or a request for a specific benefit under Part 3, Divisions 2, 3 and 5 of the 1987 Act within 21 days, the worker can seek assistance from Work Cover’s Claims Assistance Service (CAS) on 13 10 50 or their union. CAS will issue the worker with a CAS reference number upon initial contact and then contact the insurer to facilitate a response. CAS will send a letter to the worker within 7 days of the request advising either:

• The insurer’s response (i.e. the action the insurer has taken or will take); or

• That there is still no response.

Once the 7 days has elapsed, the worker may lodge a dispute with the Workers Compensation Commission (WCC) quoting the CAS reference number and attaching the CAS letter. For the purpose of relying on the CAS reference number or letter to commence proceedings in the WCC, the CAS inquiry must be made no earlier than 7 days before the time limit for determining the claim has expired. The worker or their representative may also need to refer to the WorkCover Work Capacity Guidelines regarding payment of weekly payments

• Treatment Services That Don’t Require Prior Approval

Exemptions:  The following treatments are exempt from the requirement for prior insurer approval. (Note: These exemptions only apply where provisional liability for medical expenses or liability for a claim has been accepted).

3.2.1 Nominated treating doctor

Any consultation with the nominated treating doctor in relation to the injury claimed except for consultations for mental health treatment items AA905 and AA910 in current Australian Medical Association List of Medical Services and Fees.

3.2.2 Specialist medical practitioner

The first consultation for the injury with a specialist medical practitioner, on referral by the worker’s nominated treating doctor.

3.2.3 Pharmacy

3.2.3.1 Pharmacy items prescribed by the nominated treating doctor or specialist medical practitioner for the injury in the first 3 weeks post injury, to a maximum of $500.

3.2.3.2 Pharmacy items excluded from the Pharmaceutical Benefits Schedule to a maximum amount of $100.

3.2.4 X-Ray

All plain x-rays performed on referral from the nominated treating doctoror specialist medical practitioner in relation to the injury claimed and provided within one week of injury.

3.2.5 Public hospital

Any services provided in public hospitals that are provided by or consequent upon presentation at the hospital’s emergency department for the injury claimed that is within one month of the date of injury.

3.2.6 Physiotherapy, Osteopathy or Chiropractic treatment

3.2.6.1 The initial consultation and up to a further seven treatment sessions provided by a registered practitioner where:

 a) The injured worker has not previously received treatment for the injury claimed, or

b) The treatment resumes with the same practitioner within a three month period from the last treatment and less than eight treatment sessions were provided originally.

c) The treatment resumes with the same practitioner within a three month period under a previously approved planand deemed as the same episode of care.

3.2.6.2 The initial assessment for a new episode of care where a worker ceased treatment more than three months previously and returns for additional treatment for the same injury. The registered practitioner cannot utilise any remaining treatment sessions that may have been approved under the previous episode of care.

3.2.7 Psychology treatment or counselling

3.2.7.1 The initial consultation and up to a further five treatment or counselling sessions provided by a WorkCover approved practitioner where:

a) The injured worker has not previously received treatment/counselling for the injury claimed, or

b) The treatment/counselling resumes with the same practitioner within a three month period from the last treatment and less than six treatment sessions were provided originally.

c) The treatment/counselling resumes with the same practitioner within a three-month period under a previously approved plan and deemed as the same episode of care.

3.2.7.2 The initial assessment for a new episode of care where a worker ceased treatment/counselling more than three months previously and returns for additional treatment/counselling for the same injury. The registered practitioner cannot utilise any remaining treatment/counselling sessions that may have been approved under the previous episode of care.

3.2.7.3 The preconditions to be met before the exemption will apply are:

a) The psychologist must be WorkCover approved and

b) The injured worker’s nominated treating doctor or treating specialist medical practitioner who is a psychiatrist must make the referral for treatment.

3.2.8 Remedial Massage

3.2.8.1 No more than 5 sessions of remedial massage, where there has been no previous remedial massage therapy for the injury claimed.

3.2.8.2 The precondition to be met before the exemption applies is:

a) The remedial massage therapist must be WorkCover approved.

3.2.9 Hearing needs assessment

3.2.9.1 The initial hearing needs assessment only.

3.2.9.2 The preconditions to be met before the exemption will apply are:

a) The hearing service provider must be WorkCover Approved and

b) The injured worker’s nominated treating doctor is to have referred the worker to a treating specialist medical practitioner who is an ear, nose and throat physician to determine that the hearing loss is work-related and that there is binaural hearing loss of 6% or more. The ENT makes the referral for treatment.

Worker Issues, Social Issues and  Financial Issues

It was mentioned in previous docs that as well as the factors outlined above return to work outcomes can be and often are affected by many factors intrinsic to the worker.  Some of these factors included

• Fundamental drive and need to get back to work 
• Resilience  to the setbacks that are likely to have occurred
• Stress levels and mental health having had a work place injury and being integrated into the worker compensation systems.

Assuming all has gone well and none of the barriers outlined above are present the internal drivers that will influence a successful return to work outcome include:

• General health and fitness prior to injury
• Previous injuries or illness
• The personality of the worker
• Internal resilience
• What the job meant for the worker before injury and general satisfaction levels
• Perceived satisfaction / dissatisfaction levels with the job.
• Adaptability to making changes in life style and attitude ante accommodate injury

After 12 months in the NSW workers system even the most resilient, motivated workers are likely to find their life situation stressful, particularly if their injury has not recovered or nearly recovered. By 12 months most injured workers are likely to have experienced:

-        Financial difficulties due to pay not arriving on time, pay not taking into consideration real preinjury earnings, upfront costs such as for medications or travel not reimbursed in a timely manner.

-        Delays in approvals for specialist referrals, investigative tests or  new treatments

-        Conflicts between stakeholders over treatment issues  - such as what is “reasonable and necessary”,  work capacity

-        Bullying by stakeholders, or “perception” of  bullying by stakeholders particularly agents, some  rehabilitation providers and some employers

-        Communication breakdown between parties particularly when the desired outcome of increased job capacity doesn’t occur and there is a perception that one or more parties are not working efficiently or encouraging malingering.

-        Resultant stress on the injured worker and other stakeholder

-        Secondary depression experienced in the injured worker

-        Changes and reduction in motivation

-        Secondary physical and mental health problems - anxiety depression, poor life style habits, loss of physical activity, diet, and lifestyle change, social avoidance, relationship conflicts.

• What the injured worker and treatment providers need to consider- 

Unfortunately for most workers who have had injuries that have meant they are still with the workers compensation system 12 or more months down the track there will have been many events and setbacks they have had little or no control over.  For most people in such situations and with uncertainty about the future, there is a high likelihood of worry and associated problems with anxiety and depression. 

Although there are many areas of an injured worker’s life that they may feel they have little or no control, most injured workers DO have more control and influence on their life situation than they may realise.  To regain control however often requires getting support, especially initially and the result will not be instant.  In the following sections the areas where control can be regained and exercised are outlined.

The worker needs a strong team - NTD, specialists, and solicitor.

The Workers compensation system has many stakeholders who have vested interests and hold opinions about the way things should be done.  Some of these are enshrined in legislation or “Workcover Guidelines”. Many of the attitudes and practices of stakeholders however are not so much determined by the rules, but by beliefs, culture,  training (or lack)  of decision makers such as insurers NTD,  specialists.

The healthiest environment for progress is one of team work and collaboration where all parties manage to agree upon and work towards common goals.  The injured worker has some input into this in terms of :

• Who they choose as their NTD
• Who they choose as their solicitor
• How they communicate  to  their support  team-  i.e. advising of problems or difficulties rather than wait until they are overwhelming
• How they attempt to deal with difficulties  that arise  -  i.e. with agents -  by staying patient, communicating  concerns and problems, knowing when or when not to escalate a problem

Teach your patient their  rights - These include right to choose:

• Their NTD
• Treatment providers
• Rehabilitation provider
• Claim for necessary travel expenses to and from appointments you go made via your NTD or organised by the agent
• Get medication and other treatments expenses reimbursed
• Request assessment of your home or workplace to identify aids or support service that can assist you while you recover
• Reasonable cost associated with retraining  -  i.e. courses, some mandatory equipment

 Teach your patient their obligations

These include the need to:

• Attend appointments organised by their NTD or agent
• Attend appointments on time
• Notify of change of circumstances -  i.e. part time work, change in number of dependents
• Notify of their inability to attend an appointment in advance of scheduled date

Teach your patient/ client where to get help and in what situations.

These were outlined in the first information doc "Time of Injury to 1 Month". To summarise who can help for what:

1. The  NTD For general information about the worker's  injury, work readiness, general medical and health concerns  related to their injury
2. Psychologist or Counsellor 
   • For problems dealing with the effect their injury is having on their life socially, psychologically, at work, with relationships, and their future.
   • For primary psychological injuries such as trauma and major depression caused by major catastrophic event of trauma

Know who can’t help your client so they don’t waste your time and energy

The NTD is the first port of call for medical or treatment issues - the patient needs to let them know what is happening and of changes in theirphysical or psychological health.  A doctor with good listening a communication skills is essential.

• The Agent -  In first instance for non-payment issues such as wages, travel expenses, medications not being paid or not on time

• The WorkCover hot line in second (or 3rd instant if problems persist), a call to Workcover has been known to speed up processing times considerably.

• WorkCover Hotline for delays in approval for specialist referrals, surgery,  and for investigative procedures

Solicitors

• For denial of a claim if the worker  believes the claim is valid and declination is unreasonable
• For treatment expenses being refused after efforts made to discuss and negotiate with agent by NTD or other professional involved in service have failed
• To claim for lump sum for impairment
• To make a common law claim if impairment is significant and the employer may have been negligent

Help your patient/ the injured worker look after themself

1.  Physical health

Prescribed Medication Use/Abuse

• After 12 months of injury related symptoms a range of injury related medicines may have been tried to help with pain relief or treatment of associated symptoms.  Some of these medications may cause side effects, adverse reactions or interactions with other drugs. Some medicines can cause dependence and tolerance.  It is important to be aware of what medications are for, desired effects and benefits as well as possible side effects, interactions or adverse reactions.  Encourage patients to  do  their own research,  and discuss usage issues with a health professional  -  particularly when  medications use is  prolonged. .

Non Prescribed Use/Abuse

• There is also a tendency  of some injured workers to use prescribed or legal medications outside guidelines leading to risks of adverse reactions and side effects.   Similarly, some prescribed medications used socially or combined with alcohol and cigarettes are sometimes used excessively by injured workers who are struggling to cope with their situation or injury.  Illicit drugs normally used sparingly by some people may be used increasingly after an injury for their analgesic effect - e.g. marijuana, however drug interactions, dependence are possible and a risk worthy of careful consideration.

Don’t stop physical activity

Substantial Injuries rarely affect only the injured body part. They affect the ease of performing activities of daily living and through problems such as sleep deprivation and associated depression have the effect of lowering motivation and drive to be active. As a result  general physical deconditioning occurs and can lead to  other health issues (such as obesity), particularly when diet and food intake regulation is neglected. 

Although a physical or psychological injury often does affect  the ease physical activities that can be undertaken, it is essential to maintain a reasonable level of health and fitness.  Encouraging discussion with the worker's NTD  or another health professional can be very helpful for coming up with options they  can do despite having an injury.

Encourage your patient not to abandon their social network

People who are injured often find they can’t do things they use to do such as particular  sports.. Frequently new ones have not been taken up.  Hobbies and interests are often a source of meeting new people and friendships.  Many injured workers who aren’t able to participate in activities they use to prior to injury haven’t taken up new activities in the first 12 months and tend to become socially isolated.  Depression and anxiety can compound the tendency to social withdrawal and isolation.

Encourage your patient 

• Not to isolate themselves
• To reach out to people they are comfortable with and who care
• To develop new hobbies and interests

2. Looking after  mental health -  problems and strategies

• Family dynamics - People who have sustained a substantial injury often can’t do things as they use to at home and need assistance and support.  Often the injured person’s way of dealing with their injury is not helpful with family relationships, - irritability, anger, mood swings, with drawl and can put strain on relationships. Psychological and rehabilitation support is often essential when injury symptoms impact on the lives of family members.
• Concentration and memory - people experiencing chronic and acute pain, sleep depression, injury related agitation and depression have problems concentrating and remembering all they need to do. Use of a diary and doing  fewer things over a longer time frame are steps towards accommodating and adjusting to injury and temporarily impaired concentration difficulties.
• Getting the balance right.  The secret to longer term injury management is getting the balance right. Doing too much and therfore reinjuring or becoming overwhelmed v's doing little and losing further function  e.g  reduced confidence and the development of  social phobia
• Accepting the need for help - An injury and changed life circumstance that goes on for a year or more throws up many significant challenges and can  be overwhelming. Support and guidance is often essential to succesfuly navigate through the various obstacles, physically, psychologically and through the system. Encourage the injured worker not to be afraid to seek help and guidance when they need it.

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