Many practitioners avoid the evaluation and treatment of injured workers for 2 main reasons: (1) some practitioners do not like taking the extra time needed to complete the necessary paperwork or the extra time required to communicate findings to the numerous parties involved in an industrial injury; and (2) some patients seen in a workers' compensation setting do not respond to treatment in a predictable fashion.
The second reason noted above presents a dilemma for the physician, because patients often do not get better with the interventions commonly prescribed for a specific injury. When this occurs, enormous effort can be required to tease out specific reasons why patients are not getting better.
The initial scope of involvement in an industrial injury case includes the employee, employer, insurance adjusters, and physician. This list of involved parties eventually can grow to include nurse case managers, medical consultants, ergonomic consultants, physical therapists, occupational therapists, applicant attorneys (representing the employee), defense attorneys (representing the insurer or employer), vocational rehabilitation specialists, disability raters, and workers' compensation judges or referees.
The involvement of so many professionals can quickly complicate matters, because these parties may have differences of opinion and different agendas. Moreover, each party can have a positive or negative effect on the outcome of the case. Being aware of how each party can affect outcome can greatly enhance a physician's management of an industrial injury case.
According to the US Bureau of Labor Statistics (BLS), in 2014, for each 10,000 full-time workers, there were 107.1 cases of nonfatal occupational injury or illness in which days away from work were needed for recuperation. This was an improvement over 2013, in which the incidence was 109.4 such cases per 10,000 full-time workers. As calculated for a combination of private industry and state and local governments, the BLS reported a total of 1,157,410 days-away-from-work cases for 2014, with sprains, strains, and tears being the leading cause of these (420,870 days-away-from-work cases). 
A 2013 report by the National Safety Council estimated the overall cost of unintentional injuries at work to have been $188.9 billion in 2011. 
When treating an injured worker, the clinician must be aware of factors that can affect the duration and outcome of an injury. Addressing these factors results in more effective treatment and a more favorable outcome.
Work-related musculoskeletal disorders occur when there is a mismatch between the physical requirements of the job and the physical capacity of the human body. More than 100 different injuries can result from repetitive motions that produce wear and tear on the body. Specific risk factors associated with work-related musculoskeletal disorders include repetitive motion, heavy lifting, forceful exertion, contact stress, vibration, awkward posture, and rapid hand and wrist movement.
Specific aspects of the injury must be addressed when obtaining the history, because this information helps a practitioner to be knowledgeable about concerns that have medical and medicolegal implications. The answers to these questions provide information regarding industrial injury cases, including causation and work restrictions. In addition, this information can help to determine an individual's prognosis and, if needed, apportionment and disability. 
Complicating factors, while potentially numerous, are present in only a small number of cases. Helping workers with injuries is rewarding, because most workers wish to receive help in recovering from their injuries or illnesses so that they can return to work.
Often, a patient's failure to improve is attributable to reasons that a practitioner cannot affect or influence, causing frustration on the part of the physician. This is especially true when an additional report or a disability rating is required on an individual who, according to the practitioner, would improve under other circumstances (for example, a patient who might have improved if circumstances were different with regard to external influences on recovery and return to work). [4, 5]
This article discusses specific questions that should be asked when first meeting an injured worker and when conducting continued follow-up. In addition, several diagnostic musculoskeletal categories that require special attention in an industrial setting are addressed.
The Practice Guidelines Committee of the American College of Occupational and Environmental Medicine (ACOEM) has developed the ACOEM Occupational Medicine Practice Guidelines.  This book is considered to be the criterion standard for effective occupational medical practice. Presenting essential consensus- and evidence-based information, it provides step-by-step guidelines and practical aids to help busy practitioners manage growing caseloads. In 2004, California instituted a requirement that its utilization review in workers' compensation cases be consistent with the second edition of the ACOEM Occupational Medicine Practice Guidelines. 
Getting to know the injured worker is imperative. In addition, knowledge of the kind of work in which the patient is engaged, along with an awareness of the individual's workstation, current work situation, relationships at work, and degree of job satisfaction, is necessary when assessing the validity of the patient's report of a job-related injury.
When first assessing an injured worker and obtaining a history, the physician must address several aspects of the injury. [8, 9, 10, 11] Determination of the cause of the injury can be influenced by many factors in the medical history, including the following:
Date and time of the injury or when the symptoms first began
History of prior injuries or underlying disease
Location where the injury occurred
Mechanism of injury
Whether or not the injury was witnessed
When the injury was first reported
The initial evaluation of injured workers with psychiatric disorders varies significantly from the above-described evaluation. Refer to the National Guideline Clearinghouse for more details. [12, 13, 14]
Differentiating work-related injuries from non–work-related injuries
Causation pertains to whether or not the injury actually was associated with work.  For injuries "arising out of employment" (AOE) or incurred in the "course of employment" (COE), examinations can be directed specifically at answering the causation question. The answer to the question of causation determines responsibility for treatment of the injury. If the injury is associated with work, then treatment is provided and paid for by the employer's workers' compensation insurance carrier.
In addition, if the injury is due to work, lost time from work is compensated for, and the employer often accommodates for work restrictions. If the employer is not willing to make special accommodations, the individual has to take sick time. Prolonged recovery time often can exceed available sick time and can lead to termination of the employee.
Despite inconveniences, individuals accrue certain advantages in reporting that an injury occurred at work or was due to work. Because of this possibility, causation must be determined accurately to avoid requiring the employer to assume the responsibility for an injury or illness that actually is not work related.
Although physicians are not trained as detectives, no other professionals can compile information obtained in the history with the findings on physical examination to determine the probability that the injury is work related. One distinction that must be remembered is that under workers' compensation, it is probability, not possibility, that is accepted in determination of which injuries are considered subject to compensation. Is the probability high, or at least greater than 50%, that symptoms originated with an incident that occurred or activities performed at work? If doubt exists and further investigation will be needed in the future, document specific dates, times, and locations, as well as the mechanism of injury and the presence or absence of witnesses who can corroborate accounts of the injury.
Companies that have pending layoffs or seasonal workers at the end of the work season show a higher number of reports of work-related injuries. In addition, individuals who recently have had poor evaluations of their work performance have a higher incidence of work-related injuries. Be cautious when determining causation in cases with unwitnessed injuries that are reported early Monday morning or upon an individual's return from vacation.
The injury should correspond to the given history. Prolonged typing does not correlate with a wrist fracture in a healthy individual. A wrist contusion should not cause ankle pain. Performing sedentary work without a history of specific injury should not cause lumbar disc herniations. Injuries reported as having occurred hours earlier should not be associated with greenish-yellow bruising at the site of injury, indicating a longer time since the injury's onset. If there is any uncertainty, ask the insurance company to obtain additional information, such as statements from supervisors and coworkers, as well as prior medical records.
Causation can be quite confusing. When an employee has a motor vehicle accident while going to an office supply store to pick up office stock for his/her supervisor, should the injuries sustained be considered work related? What if the employee had taken a small detour to pick up personal dry cleaning on the way back from the office supply store? What if an employee comes in on his/her day off to catch up on paperwork at the office and trips and falls? What if, while on the clock, a mechanic at work decides to change the oil in his own car and has chemicals splash into his eyes? Because the physician will be asked to comment on causation, the medical opinion must be based on specific aspects of history and examination. The physician's opinion is the basis for adjudication when a disputed case goes to court.
Past medical history can be very important when determining causation and apportionment. Apportionment of disability is the determination of the percentage of disability that can be placed on prior injuries or on underlying, preexisting disease. Often, apportionment can occur only if there was preexisting disability. If an individual sustained a previous back injury but made a full recovery without symptoms and was able to return to work without any limitation or disability, no apportionment can be made to that prior injury; however, if disability is associated with a previous back injury, with reduced capacity or reduced tolerance having occurred, then apportionment should be determined.
Apportionment should also be considered when there is a preexisting disease; however, this determination can be made only if the natural course of the disease would have caused disability through its own progression, without work-related activities. For example, the examiner cannot apportion disability in a case in which an individual with osteoarthritis fell and sustained a wrist fracture that healed with reduced range of motion (ROM) at the injured wrist.
Assessing the Extent and Validity of Symptoms
Evaluation of industrial cases requires the practitioner to determine if symptoms are real. This process is very difficult and extremely tricky. Some workers with injuries underreport. Underreporting may occur when individuals want to return to regular work and therefore falsely state that they are better. Underreporting places these individuals at risk for further injury. Some patients overreport, making symptoms seem greater than they are.
The physician must exercise care, because some individuals sent to a doctor wish to appear as if they are coming with a significant problem. They believe that they must validate the reason for coming to see the practitioner. However, some patients make poor efforts, wincing and grimacing with benign physical examination maneuvers.
The physician evaluating the case has to assess the true level of weakness and loss of function, as well as the amount of subjective pain. This type of examination is vastly different from examinations for patients who are not seeking evaluation of work-related injuries. Although all physicians do this type of assessment at an intuitive level, the examiner seldom is asked to comment on whether the subjective complaints are realistic.
Assessment of the genuineness of injury complaints can be made only by close observation. Observe the patient as he/she enters or leaves the examination room and, at times, within the clinic itself. Observe how the patient moves from the chair to the examination table and how the individual removes his/her jacket, shoes, and socks. Compare the patient's behavior, attitude, and movements when speaking with office staff to those during the examination. Note the time it takes the patient to change into an examination gown. Note also how the examinee reaches for a purse or grips a pen. These observations can provide clues to the validity of the patient's complaints.
Observational signs can be a great help, especially in dealing with patients who have low back pain (LBP). Waddell signs of nonorganic back pain also should be documented. An effort should be made to observe the patient further if there is some suggestion that complaints do not correlate with the amount of injury. The physician may identify various things during the evaluation that do not correlate, such as the following:
When the patient is walking from the waiting room to the examination room, are the individual's pace and gait pattern different from those observed when the patient is asked to demonstrate his/her gait during the physical examination
Does the patient easily bend over to remove shoes and socks but then display a markedly limited range of motion (ROM) of the lumbar spine on examination
Does the patient display wincing and guarding even with superficial palpation
Does the same wincing and guarding persist with distraction
Is motor weakness really due to a lack of effort or does it correlate with changes in reflexes and muscle atrophy
Is the motor weakness consistent on multiple trials
Is the ROM different at each clinic visit
Is the area of tenderness different at each clinic visit
All observations cannot be made during a single patient visit, because they require special effort and consideration, as well as clear documentation, from visit to visit.
Work restrictions, if needed, must be determined at the conclusion of the evaluation of an injured worker.  To establish appropriate work restrictions, the clinician must consider the injured body part, activities that would exacerbate the injury, and the patient's job requirements. Restrictions should be clear and must be tailored to the type of work that the patient does.
Restrictions are established primarily to prevent the employee from engaging in activities that may exacerbate the injury or illness; however, activity restriction is also recommended to guide the employer in finding alternative work that is suitable for the injured worker. Therefore, it is important to communicate with the employer about the activities that the injured worker can do. For example, if a counselor at a behavioral medicine unit is seen for a shoulder strain, restrictions regarding the use of the injured shoulder (such as limits on lifting, as well as on activities involving reaching, pulling, and pushing) should be implemented. If the patient's line of work might require him/her to engage in the takedown of violent individuals, the clinician should make it clear that the individual should be restricted from performing this activity.
Knowing what a patient does, as well as how and where he/she works, allows for proper determination of causation and suggests appropriate work restrictions. Understanding the work situation of the patient also provides insight into the possible source of injury, especially in cases of repetitive or cumulative trauma.
Prognosis in work-related injuries is a question that concerns everyone. The injured worker wants to know how soon he/she can recover and, in some cases, how much recovery time is expected. The employer, along with the workers' compensation insurance carrier, wants to know this information as well. 
If there is significant injury and it is obvious that the individual is not able to return to his/her usual and customary work activities, this information should be communicated to all involved parties as soon as possible. Proper communication expedites the initiation of reasonable accommodations or of vocational rehabilitation, if necessary.
Most medical prognoses for recovery from injuries and illnesses are predicated on the basis of proper treatment and rest. Individuals should rest the injured body part until there is sufficient recovery to reengage in activities with minimal risk of reinjury. What if an individual who works as a loader at a warehouse presents with an ankle sprain? If this individual continues working in circumstances that exacerbate his/her injury, what is the prognosis? If the individual wishes to continue at his/her regular work and does not wish to take time to allow the ankle injury to heal, the patient may have a delayed and limited recovery. This reality should be considered and reflected in the prognosis.
In a prospective study, Benjamin et al addressed early predictors of occupational back re-injury. Male gender, constant whole body vibration at work, a history of previous similar injury, 4 or more previous claims of any type, possession of health insurance, and high fear-avoidance scores were shown to be significant predictors of re-injury. Increased knowledge of early risk factors may lead to interventions to reduce the risk of re-injury. 
Collaborative approaches and a broader spectrum of resources and supports are needed to help injured workers and their families in resuming meaningful participation in daily, social, and productive occupations. 
Prevention of Work-Related Musculoskeletal Injuries
The science of fitting the job to the worker is called ergonomics. Employers who have implemented ergonomics programs have had great success in avoiding work-related musculoskeletal injuries, keeping workers on the job, and boosting productivity and workplace morale. [20, 21, 22, 23]
Strategies for the employer to reduce work-related injuries may include the following:
Looking at injury and illness records to find jobs in which problems have occurred
Talking with workers to identify specific tasks that contribute to pain and lost workdays; ask workers what changes they think could make a difference
Encouraging workers to report their symptoms and establishing a medical management system to detect problems early
Finding ways to reduce the need for workers to engage in repeated motions, forceful hand exertions, prolonged bending, and working above shoulder height
Reducing or eliminating vibration and sharp edges or handles that dig into the skin
Relying on equipment, not human backs, for heavy or repetitive lifting 
Simple solutions often work best. Workplace changes to reduce pain and cut the risk of disability need not cost a fortune. Examples of simple, but effective, ideas include the following:
Change the height or orientation of the product; give knives with a curved handle to workers who process poultry so that they do not have to bend their wrist unnaturally to cut the birds apart
In nursing homes, provide lifting equipment so that workers do not have to strain their back when transferring patients by themselves
Offer workers involved in intensive keyboarding more frequent short breaks to rest muscles
Vary tasks of assembly line workers to avoid repeated stress on the same muscles
Work-Related Myofascial Pain Syndrome
Causes of myofascial pain
Employers and employees often fail to recognize that, with time and the aging process, physiologic changes occur. Jobs usually are given to people who demonstrate a capacity to perform the tasks associated with that job; however, as people age and decondition, their physical tolerances gradually decline. On the other hand, as their familiarity with the company grows, they often are assigned additional tasks. This observation is true especially for companies that are forced to downsize because of a change in the economic environment. The increase in workload at some point intersects with the decline in physical tolerances and leads to work-related injuries or illness.
Overuse injuries, such as myofascial pain in the forearms, arms, or shoulders of workers performing repetitive activities, occur when individuals exceed their physical tolerance and have declining physical capacity. Such individuals present to the physician after having performed the same type of work for years; for example, they may have developed pain in their arms without having engaged in any new activity, without having suffered a specific injury, and without any change having occurred in their work area.
Although all potential causes should be considered during the workup, in many cases it comes down to muscles that have become irritable and tight. Pain is perceived not only when tissue damage occurs but also when the potential for tissue damage is present. One form of punishment for children when they misbehave is to have them hold a heavy book out at arm's length. Initially, this position does not cause any discomfort, but within minutes, the outstretched arms can become extremely uncomfortable.
When muscle tissue capacity is exceeded, especially as a result of performing repetitive activity for hours at work, 5 days a week, individuals often have discomfort and pain. The treatment for these problems is similar to the treatment for any muscle strain (ie, relative rest, stretching, improving muscle endurance and strength); however, these problems often persist despite conservative care.
Recovery and prevention
The expectation that these types of problems quickly improve and resolve, as one might expect in acute injuries, often is mistaken, as rapid improvement frequently is not the case. Most individuals with myofascial pain syndrome have experienced gradual onset of pain over the course of several months. This type of indolent development of pain commonly is associated with a prolonged recovery.
Once muscles have become irritable, they behave as if they are contracted, shortened, or in spasm, responding with pain when stretched, palpated, or activated. When treating these types of injuries, the clinician must realize that the irritable musculature is displaying a learned response. Just as the condition took months to develop, it can take months to improve. Eliminating potential causative factors, such as underlying physiologic factors (eg, poor sleep, inadequate rest) or an improper work area with poor ergonomics, is critical.
Adequate rest and sleep are absolute requirements for muscle recovery. A vicious cycle can develop when myofascial pain symptoms prevent an individual from sleeping at night. The lack of sleep prevents the muscles from gaining sufficient recovery and rest from the previous day's activities.
When treating individuals with myofascial pain, explain the nature of the problem to the patient. When running a marathon, an athlete does not sprint the entire race at top speed. Few individuals besides athletes realize the importance of stretching to maintain muscle strength and flexibility. Prevention of the prolongation or recurrence of myofascial pain can be achieved when individuals understand the importance of daily stretching and of pacing activities at work.
Work-Related Low Back Pain
Low back pain (LBP) is common in the general population. Lifetime prevalence of LBP has been estimated at nearly 70% in industrialized countries; sciatic conditions may occur in 25% of individuals experiencing back problems, according to Andersson.  Studies of workers' compensation data have suggested that LBP represents a significant portion of morbidity in working populations. Data from a national insurer indicate that back claims account for 16% of all workers' compensation claims and for 33% of total claims costs. Studies have demonstrated that back disorder rates vary substantially by industry, occupation, and job within given industries or facilities.
Back disorders are multifactorial in origin and may be associated with occupational and non–work-related factors and characteristics. Nonoccupational factors may include age, gender, cigarette-smoking status, physical fitness level, anthropometric measures, lumbar mobility, strength, medical history, and structural abnormalities. Work-related and non–work-related psychosocial factors also have been associated with back disorders. 
The relationship between LBP and employment can be complex.  Some individuals may experience impairment or disability at work because of back disorders, even if these were not caused directly by job-related factors. The degree to which ability to work is impaired often depends on the physical demands of the job. Furthermore, a back disorder experienced at work may be a new occurrence or it may be an exacerbation of an existing condition. Again, it may initially have been caused directly by work-related or non–work-related factors. Patients complaining of back pain may modify their work activities in an effort to prevent or lessen pain. Thus, the relationship between work exposure and the disorder may be direct in some cases but not in others.
Causes and diagnosis
Many conditions in the low back may cause back pain, including muscular or ligamentous strain, facet joint arthritis, and disc pressure on the annulus fibrosis, vertebral endplate, or nerve roots. In most patients, the anatomic cause of LBP, regardless of its relationship to work, cannot be determined with any degree of clinical certainty. Muscle strain is probably the most common type of work-related and non–work-related back pain.
Although a relationship sometimes exists between pain and findings of disc abnormalities on magnetic resonance imaging (MRI) scans (eg, herniated disc, clinical findings of nerve compression), the most common form of back disorder unfortunately is characterized by nonspecific symptoms that often cannot be diagnosed. Include subjectively defined health outcomes in any consideration of work-related back disorders, because they make up a large subset of the total. Defining back disorder with objective medical criteria may be too restrictive.
Risk factors for work-related low back pain include the following:
Heavy physical work
Lifting and forceful movements
Bending and twisting (awkward postures)
Static work postures
Types and outcomes of low back pain
LBP can be defined as chronic or acute pain of the lumbosacral, buttock, or upper leg region. Sciatic pain refers to pain symptoms that radiate from the back region down 1 or both legs. Lumbago refers to an acute episode of LBP.
In many cases of LBP, specific clinical signs are absent. Low back impairment generally is regarded as a loss of ability to perform physical activities. Low back disability is defined as LBP necessitating restricted duty or time away from the job.
Although it is not clear which outcome measure is best suited for determining the causal relationship between low back disorder and work-related risk factors, keep in mind that it is important to consider severity when evaluating the literature.
In addition to the level of severity, outcomes may be defined in a number of other ways, either subjectively or objectively. Information on symptoms can be collected through an interview or via a self-report questionnaire. Back incidents or reports include documentation of conditions reported to medical authorities or on injury/illness logs. These conditions may be signs or symptoms that provoke an individual to seek medical or other attention, perhaps due to acute symptoms, chronic pain, or injury related to a particular incident.
The need for medical attention may be determined subjectively or objectively. Whether an incident is reported depends on the individual's situation and inclinations. Other back disorders can be diagnosed using objective criteria (eg, various types of lumbar disc pathology).
Carpal Tunnel Syndrome
In 1988, carpal tunnel syndrome (CTS) had an estimated population prevalence of 53 cases per 10,000 current workers. Twenty percent of these individuals reported absence from work because of CTS. In 1994, the Bureau of Labor Statistics (BLS) reported that the rate of CTS cases resulting in days away from work was 4.8 per 10,000 workers. In 1995, the BLS also reported that the median number of days away from work for CTS was 30, which is even greater than the median reported for cases of back pain. In 1993, the incidence rate (IR) of CTS cases that qualified for workers' compensation was 31.7 per 10,000 workers; only a minority of these cases involved time off from work. These data suggest that each year approximately 5-10 workers per 10,000 miss work because of work-related CTS.
The literature relating occupational factors to the development of CTS has been reviewed extensively by numerous authors. Most of these reviews have reached a similar conclusion, which is that work factors are one of the important causes of CTS.  In a 1992 study, Moore found the evidence to be more equivocal, but he nonetheless stated that epidemiologic studies have shown a fairly consistent pattern of observations regarding the spectrum and relative frequency of CTS among jobs believed to be associated with risk of CTS. 
Complicating Factors That Delay Recovery
Many factors, some surprising, can delay recovery for patients with work-related injuries.  Whatever the source of delay in recovery, signs that a patient is not committed fully to recovering and to returning to work can easily be missed.
Lack of patient commitment
A lack of commitment to recovery can be seen when a patient does not pick up prescriptions or lets them run out between appointments. When a patient begins to miss therapy appointments or demonstrates poor compliance with home exercise programs (for example, if he/she proves unable to demonstrate home exercises that were taught at prior visits or by therapists), the physician should be aware that the patient may lack the desire to recover fully. Frequently missing follow-up appointments or showing up very early or very late for appointments is an indicator of this type of attitude. The patient may come to the clinic and state that he/she is very busy and may leave if not seen right away. Others may state that they cannot return to work even when extensive restrictions are implemented for relatively minor injuries.
A sign that is most uncomfortable for practitioners is that in which an injured worker blames his/her situation on others. This laying of blame even may be directed at the physician. When the individual is able to return to work, he/she often tells the employer that the physician was responsible for the late return to work.
The practitioner can be deemed less than caring if he/she does not acknowledge the patient's pain and discomfort, despite normal examination findings and negative diagnostic studies. When returning to the job as recommended, the individual may insist that if further injury ensues, it will be the doctor's fault and responsibility.
Other patients can return to the practitioner time after time, stating that there has been no change in their condition. These patients report that none of the interventions have helped and that they continue to be in considerable pain and discomfort. Yet, when asked to localize the pain or identify activities or times of day when the symptoms are most bothersome, they remain vague and their responses are generalized (eg, reporting that they feel pain all the time or feel it all over). Statements such as these may be indicative of other reasons for continued symptoms. For example, overgeneralization may be due to the worker's unrealistic expectations or result from unresolved conflicts with coworkers, supervisors, or bosses.
A large shift in thought regarding the use of sick time or sick leave has taken place. In the past, days were set aside to be used when an individual was ill and could not work. If the employee did not get sick, sick leave was not used. This concept has changed to the extent that many workers perceive calling in sick as a way to take a day off work. The slang term "mental health day" is used to rationalize this type of action.
Misuse of work-injury claims
Each company decides whether this is an acceptable practice; however, some individuals have come to use work-injury claims as a means of obtaining extra days off from work without using their vacation or sick leave days. Physicians often find themselves drawn into this fraudulent action. Processing each individual claim takes numerous hours of work on the part of the employer, physician, clinic staff, and insurance carrier. When a patient requests a couple of days off to recover, the question of whether this is a reasonable request corresponding to the severity of the injury must be considered.
Misuse of workers' compensation
Some workers have a sense of entitlement that leads them to feel that, because they have dedicated a career of work to a company, the company should take care of all of their health-care needs. Although most companies have programs set up to provide their workers with health insurance, some individuals feel that all health issues should be covered under workers' compensation. This misconception is very difficult to change and often leads the individual to feel that the company does not appreciate his/her years of job dedication.
Job dissatisfaction and workplace conflicts
Unhappy workers seldom are eager to return to the work environment. If the patient hates his/her job, recovery can be delayed, because the individual does not become a willing participant in the recovery process.
In some cases, conflict at the work place must be recognized and addressed before recovery can occur. Supervisors or coworkers who are understanding and supportive, especially when a worker has work restrictions in place, can be very helpful in helping an individual to recover from an injury or illness. On the other hand, supervisors or coworkers who are unsympathetic and who tend to belittle the patient can make an individual not want to get better. In addition, a supervisor who ignores work restrictions and assigns workers to tasks that continue to exacerbate their symptoms can be a barrier to recovery.