REWARD Report Tasked With a Cure That Medicine Doesn't Have

Catch–22: Issues with How to Help Injured Workers Return to Work

by James B. Talmage MD, Robert B. Snyder MD, and Jason Parker, B.HK

Merriam-Webster defines a “Catch-22” as “a problematic situation for which the only solution is denied by a circumstance inherent in the problem or by a rule.” “Catch-22” originated as the title of a 1961 novel by Joseph Heller.

In workers’ compensation, sometimes injured workers are able to return to work but are reluctant to do so, for many reasons. It can be a problematic situation. But research has revealed successful strategies. This literature review will attempt to clarify what physicians and other Health Care Providers (HCPs) can, and cannot do, to help injured workers return to work.

Recently published scientific review articles highlight the problems employers encounter in helping their employees return to work (RTW) after a workplace injury or a work-related illness.

WHAT THE EVIDENCE SAYS

The American College of Occupational and Environmental Medicine (ACOEM) publishes evidence-based treatment guidelines, which are presumptively correct for treatment of injured workers in California, Nevada, and New York. Their revision to their “Workplace Disability Prevention and Management” guidelines are summarized in a recently published article in ACOEM’s publication, the Journal of Occupational and Environmental Medicine. Their methodology was to search seven electronic databases for studies on this topic. Sixteen authors reviewed 4,249 published studies, and they list 275 articles as references.

They concluded that psychologists delivering cognitive behavioral therapy has evidence of efficacy, and surgery for some specific diagnoses may be helpful when return to work is the outcome studied.

They “recommend” a number of medical interventions to improve return to work, even though they classified these as “Recommended, Insufficient Evidence,” (i.e. “Recommended” by consensus, even though there is not scientific evidence of the intervention being effective). This category included Screening Questionnaires to predict which claimants will have prolonged time off and/or fail to return to work (evidence consistently failed to show predictive ability), Education, Exercise, Nurse Case Management, and Vocational Rehabilitation.

They noted the use of two medications--opioids or benzodiazepines--appear to increase disability--the opposite of facilitating RTW. [see for example Hunt, 2019]

Their third category is “NO recommendation, Insufficient Evidence.” This category included Medical and Psychological Treatments for Symptom Reduction (symptoms includes pain).

They noted “passive” treatments of Electrical Therapies, Heat or Cold therapies, Massage, Manipulation, Acupuncture, Injections, and some surgeries have little value for return to work and may inadvertently increase work disability by “externalization” (relying on others for treatment while avoiding active patient involved rehabilitation strategies).

THE CURRENT OBSTACLE

Pain is one of the most frequently encountered barriers keeping injured workers from returning to work. Injured workers who could return safely (acceptable risk of reinjury – no need for restrictions) and who could do the work tasks (have the motion, strength, etc. to function – no limitations) would appear to be fit to work but fail to RTW.

What they lack is the tolerance to do work tasks despite pain. They may have the ability to do the task but not the ability to do it comfortably. An Australian review [Wegrzynek 2020] of interventions for chronic pain patients to improve return to work searched eight electronic medical databases for studies and concurred with the subsequent ACOEM 2025 review, concluding “There is no conclusive evidence to support any specific tertiary RTW intervention for workers with chronic pain…”.

Again, pain is THE issue most frequently hindering RTW, and a different 2025 Systematic Review of interventional procedures for chronic, non-cancer pain [Wang 2025] found no evidence doctors could reduce chronic pain. Additionally, tolerance is not objectively measurable which just makes the issue more complicated to manage.

Pain is common. The U.S. Centers for Disease Control 2023 survey [Lucas 2024] indicates 24% of U.S. adults have chronic pain, and 8.5% have high impact chronic pain. Many of these individuals go to work every day. A 2022 Systematic Review of published studies on the prevalence of chronic pain [Zimmer 2022] found significant variation in the prevalence of chronic pain in 52 countries, varying from 9.9% to 50.3%. In the “Americas” (North and South American continents), the surveyed countries had on average 26% of the adult population with chronic pain. Both articles noted the older individuals had an increased prevalence of chronic pain.

A SYSTEM IN GRIDLOCK

A Canadian review of the role of Healthcare Providers in Return to Work [Kosny 2018] points out that the population of injured workers can be subdivided. Those with “visible, acute, physical injuries” are not generally a problem for employers, or health care providers. However, Healthcare Providers (HCPs):

faced challenges when they encountered patients with multiple injuries, gradual-onset or complex illnesses, chronic pain and mental health conditions. In these circumstances, many (HCPs) experienced the workers compensation system as opaque and confusing. A number of systemic, process, and administrative hurdles, disagreements about medical decisions, and lack of role clarity impeded the meaningful engagement of HCPs in RTW. In turn, this has resulted in challenges for injured workers (IWs), as well as inefficiencies in the workers compensation system.” [Kosny 2018]

So, the conclusions of the “Medical” review can be stated as:

• • One group of injured workers recovers at the same rate as those with similar non-work-related injuries. Return to Work is not an issue for these workers.
• • The other group has a low risk of reinjury, a self-limited capacity for work, typically has chronic pain, and their pain tolerance is the factor preventing return to work. Doctors will generally not solve this group’s pain problem or improve RTW rate.

The Catch 22: Employers may expect the physician to solve the RTW issue for these workers, and physicians can’t do that. Nor can they objectively answer questions about tolerance.

THE SOLUTION

What should employers do with the second group of injured workers?

First, “Ask the patient.” Likely the first study to document the usefulness of this was in Sweden and was published in 2006 [Heijbel]. 508 off-work patients were asked how likely it was they would return to work. Only six out of the 135 who predicted they would not return to work actually did return to work (odds ratio of correct prediction = 8.28). A later systematic review [Carrière 2023] of 30 published studies of 28,741 patients found single question surveys “Do you think you’ll RTW?” had strong evidence of predictive value.

For those workers interested in RTW, a recent systematic review has documented published evidence that employers can do what doctors can’t do [Jansen 2021].

On supervisor level, strong evidence was found for an association between work accommodations and continued employment and return to work. Moderate evidence was found for an association between social support and return to work.”

Physicians as a group have not been trained in assigning work abilities/restrictions, and many are uncomfortable with that role, especially when the patient resists RTW overtures. And, realistically, physicians generally do not have the means of objectively measuring capacity (i.e. lifting, pushing, pulling, standing, etc.)

A STEP-BY-STEP GUIDE

Jason Parker, B.HK Centrix Disability Management Services Inc., taught the October 2024 REWARD Employer session, and his slides can be viewed at the following link AIM4RTW_october_v2_handouts.pdf. His method is likely to be both the most efficient and the most effective for those injured workers who express interest in RTW but who appear to be lagging behind the expected recovery curve. Rather than assume the physician can objectively provide information on tolerance and function or take physician “restrictions” and try to figure out a transitional duty job, he suggests employers and employees follow a sequence called called Lead-->Add-->Mix.

1. Lead with the voice of the worker,
2. Add the voice of the employer,
3. Mix together to reach agreement and then provide that “agreement” to the physician to review for safety concerns.

The conversation should involve the employer Return to Work Coordinator, the injured worker, and the worker’s supervisor.

To help facilitate the RTW discussion, “Lead” with the voice of the worker by completing the following steps:

1. Identify (the most concerning parts of the job for the worker). Simply ask the worker, “What parts of your job do you think you will have the most challenge with?” Once the worker identifies these parts of the job go to the next step.
2. Remove (take them off the table and signal a willingness to accommodate). Simply ask, “If you didn’t have to do those parts of your job, do you think you might be able to be at work?” By removing the most challenging parts of the job from the worker’s perspective you are fundamentally changing the worker’s perception of their tolerance resulting in the worker will most likely say yes. Once you have confirmation the worker perceives they “can” be at work if these items are removed go to the last step.
3. Shift (from disability to ability). Simply ask, “What parts of your job do you think you can currently do?” When the worker identifies what they can do they are a signaling they have the capacity AND tolerance to perform those various parts of their job.

This sequence, Identify-->Remove-->Shift effectively “Leads” with the voice of the worker. It validates what most workers are concerned with (various parts of their job), without inadvertently dismissing them by a desire to use “abilities language.” It quickly signals to the worker that employer is willing to accommodate. And finally, it engages the worker to be an active participant and identify parts of their job that they think they can do and fundamentally addressing the most contentious issue in RTW discussions, Tolerance.

The employer then can add their voice regarding challenges they may or may not have. Together the worker and employer jointly “Mix their voices” together to reach agreement.

Once agreement has been reached it is now the time to go to the physician and confirm that the worker and/or employer have not overestimated safe transitional work. The Return to Work coordinator can confidently draft a letter to the treating physician asking him/her to “sign off” that the worker, at this stage of recovery, can safely do the job in question.

Confirm to the physician the outlined “plan” that the worker thinks they can do. This signals to the physician you are addressing any tolerance issues. And, most importantly, it confirms that their patient and the employer are in agreement of the plan.

Then simply ask, “Are there any risks of harm or safety concerns that would prevent your patient from participating in the above plan? If yes, please explain.

When phrased this way, physicians think reinjury risk at this stage of recovery. Rarely do they fail to certify RTW in the job because they are more willing to support the plan that has already been agreed to by the worker and the employer they have deemed safe.

CONCLUSION

The persistent challenge in return-to-work (RTW) scenarios lies not in medical incapacity, but in pain tolerance and system-level barriers. Physicians cannot resolve chronic pain or guarantee RTW, yet employers often expect them to do so. For injured workers who express willingness to return, the most effective strategy involves collaborative planning between the worker, supervisor, and RTW coordinator—followed by physician confirmation for safety. Empowering workers in this process shifts the focus from disability to ability, offering a pragmatic path forward in cases where medicine alone cannot provide the solution.

ABOUT THE AUTHORS

James B. Talmage MD

Dr. Talmage is a graduate of the Ohio State University for both undergraduate school and medical school (1972). His orthopedic surgery training was in the United States Army.

He is Board Certified in Orthopaedic Surgery and was board certified in Emergency Medicine 1987-2017. He retired from clinical practice in April 2016 after 36 years as a treating physician in Cookeville.

He was a chapter contributor to the AMA Guides, 5th and 6th Editions, and he was Assistant Editor of the Guides Newsletter 1996 2023. He does peer review of article submissions for 3 orthopaedic journals. [The Spine Journal, Journal of Bone & Joint Surgery, JBJS-Reviews].

In 2013 he was Acting Medical Director for the State of Tennessee Division of Worker’s Compensation. In 2014 he became the Assistant Medical Director.

He has taught in Physician CME courses for IAIME, AAOS, ACOEM, SEAK, and the TN BWC. Since 1992 he has given over 900 lectures to physician audiences. He was core faculty for the AAOS Workers’ Compensation Course for 24 years.

Currently with the Bureau, he serves as peer review consultant to the Drug Free Workplace Program the Medical Impairment Rating Registry. He is a member of the Medical Advisory Committee and contributes lectures to the Certified Physician “Best Practices” Course, lectures and articles to the R.E.W.A.R.D. program and articles to the AdMIRable Review. He assists Dr. Snyder with Utilization Review Appeals.

Robert B. Snyder MD

Dr. Snyder was appointed Medical Director for the Bureau of Workers’ Compensation in January, 2014 after 37 years of Orthopaedic private practice.

A graduate of Wayne State University School of Medicine in Detroit, he completed two years of general surgery training at the University of Pittsburgh before coming to Nashville to complete a residency in Orthopaedics and Rehabilitation at Vanderbilt University.

Special activities have included Associate Team Physician for Vanderbilt and Tennessee State University Athletics, Volunteer Orthopaedic Consultant at Fort Campbell during Desert Storm, Orthopaedics Overseas (an affiliate of Health Volunteers Overseas) in Peru, church related mission activities in Honduras, and the 1996 Hospital Strategic Planning Symposium in Prague, Czech Republic. He served as President of the Medical Staff at St. Thomas Hospital in Nashville from 1997 through 1999, and on the Medical Care Cost Containment Committee for Workers’ Compensation from its inception in 1992 until 2014.

Dr. Snyder has presented lectures for the American Academy of Orthopaedic Surgeons, Arthroscopy Society of Peru, the American Orthopaedic Society for Sports Medicine, the National Workers Compensation and Disability Conference, the National Association of Workers Compensation Judges, and in Tennessee: the Tennessee Chiropractic Association, the Tennessee Orthopaedic Society, the Tennessee College of Occupational and Environmental Medicine, the Tennessee Pain Society, the Tennessee Neurosurgical Society, the Tennessee Medical Society, and Tennessee Attorney Memo. He has made numerous other presentations to attorneys, case managers, employers, adjusters, and insurers. He is the course director for the Bureau’s physician education program and an instructor for the Certified Physician Program and WorkComp College.

His activities with the Bureau include Medical Treatment Guidelines, Utilization Review, Case Management, Fee Schedules, Certified Physician Program, rules, physician/provider communications and staff support for the Medical Advisory Committee and the Medical Payment Committee.

Jason Parker, B.HK

Jason Parker is the President and Senior Work Disability Consultant of Centrix Disability Management Services. Jason is the creator of Motivation and Action Planning, which is a unique behavioral, worker-centric approach to work disability prevention. Jason has extensive experience in Work Disability Prevention and Stay-at-Work/Return to Work programs with over 24 years of experience covering almost every employer group. Over the years, he has developed a specialty in work disability prevention, worker engagement, and RTW outcomes that is evidence-based and worker-centric.

Jason was a finalist for the 2018 Comp Laude Awards and recognized for excellence in advocating for the injured worker, collaborating for improved outcomes, and leadership within the work comp field

Jason holds a Bachelor of Human Kinetics from the University of British Columbia.

Jason oversees the leadership of Centrix focuses on helping Insurers and Employers improve RTW outcomes by transforming the worker experience.

R.E.W.A.R.D. PROGRAM: RETURN EMPLOYEES TO WORK AND REDUCE DISABILITIES

Appropriate assignments benefit all involved. They contribute to the employees’ recovery by keeping them productive, engaged, and active. Transitional assignments help shift everyone’s focus from the injury itself and job duties that can’t be performed to their recovery and job duties that can be performed if accommodations are made. For more information, download the toolkit.

MEET WITH LIKE-MINDED EMPLOYERS

Pre-register to join us on August 5, 2025 at 1 PM Central via Microsoft Teams in a talk with last issue's author, Mollie Kallen, MS, CRC, CCM. Mollie is the VP of Business Development at Mollie Kallen Case Management, Inc. (MKCM)/An IMA Group Company.

Disclaimer: Views expressed in the REWARD Report are solely those of the authors and may not reflect the official policy or position of the Tennessee Bureau of Workers’ Compensation, the Tennessee Court of Workers’ Compensation Claims, the Tennessee Workers’ Compensation Appeals Board, or any other public, private, or nonprofit organization. Information contained in the REWARD Report is for educational purposes only.