<%BANNER%>

Facilitating Injured Workers Return to Work

Permanent Link: http://ufdc.ufl.edu/UFE0022368/00001

Material Information

Title: Facilitating Injured Workers Return to Work Using Job Analyses and Other Select Variables to Prevent Prolonged Disability
Physical Description: 1 online resource (91 p.)
Language: english
Creator: Jackson, David
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2008

Subjects

Subjects / Keywords: compensation, disability, injury, work, workers
Counselor Education -- Dissertations, Academic -- UF
Genre: Mental Health Counseling thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: The objective of this study was to determine if the time an injured worker received temporary disability could be reduced by having the treating physician review a job analysis. Job analyses are customized job descriptions that include the precise physical and mental demands of a specific job. Following the job analysis comparison, age, attorney involvement, direct personal contact with a counselor and body part were examined to determine if those variables could predict disability time as well. A total of 101 injured workers in the construction, logging, oil and gas, structural moving and water well drilling industries were included in the study. All subjects suffered a compensable work injury and had missed at least one week of work. Fifty of the workers had a job analysis performed on their particular job and presented to their respective treating physicians. Fifty-one workers had no job analysis performed and the mean time of disability, in weeks, was compared. Workers over age 49 who had a job analysis presented to their treating physician received significantly fewer weeks of disability than those without a job analysis. A job analysis did not have a significant influence with workers under age 50 however; several limitations of this study may help explain the lack of significance. Other variables were then explored to determine their correlation with time on disability. An injured worker represented by an attorney remained on disability significantly longer than a worker not represented by an attorney. Workers under age 50 who had direct personal contact with a rehabilitation counselor received significantly fewer weeks of disability than those without direct personal contact with a counselor. Injuries to the upper extremity (e.g., shoulder, elbow, wrist, hand or fingers) led to significantly less time on disability when compared to injuries to other body parts.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by David Jackson.
Thesis: Thesis (Ph.D.)--University of Florida, 2008.
Local: Adviser: Sherrard, Peter A.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2008
System ID: UFE0022368:00001

Permanent Link: http://ufdc.ufl.edu/UFE0022368/00001

Material Information

Title: Facilitating Injured Workers Return to Work Using Job Analyses and Other Select Variables to Prevent Prolonged Disability
Physical Description: 1 online resource (91 p.)
Language: english
Creator: Jackson, David
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2008

Subjects

Subjects / Keywords: compensation, disability, injury, work, workers
Counselor Education -- Dissertations, Academic -- UF
Genre: Mental Health Counseling thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: The objective of this study was to determine if the time an injured worker received temporary disability could be reduced by having the treating physician review a job analysis. Job analyses are customized job descriptions that include the precise physical and mental demands of a specific job. Following the job analysis comparison, age, attorney involvement, direct personal contact with a counselor and body part were examined to determine if those variables could predict disability time as well. A total of 101 injured workers in the construction, logging, oil and gas, structural moving and water well drilling industries were included in the study. All subjects suffered a compensable work injury and had missed at least one week of work. Fifty of the workers had a job analysis performed on their particular job and presented to their respective treating physicians. Fifty-one workers had no job analysis performed and the mean time of disability, in weeks, was compared. Workers over age 49 who had a job analysis presented to their treating physician received significantly fewer weeks of disability than those without a job analysis. A job analysis did not have a significant influence with workers under age 50 however; several limitations of this study may help explain the lack of significance. Other variables were then explored to determine their correlation with time on disability. An injured worker represented by an attorney remained on disability significantly longer than a worker not represented by an attorney. Workers under age 50 who had direct personal contact with a rehabilitation counselor received significantly fewer weeks of disability than those without direct personal contact with a counselor. Injuries to the upper extremity (e.g., shoulder, elbow, wrist, hand or fingers) led to significantly less time on disability when compared to injuries to other body parts.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by David Jackson.
Thesis: Thesis (Ph.D.)--University of Florida, 2008.
Local: Adviser: Sherrard, Peter A.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2008
System ID: UFE0022368:00001


This item has the following downloads:


Full Text
xml version 1.0 encoding UTF-8
REPORT xmlns http:www.fcla.edudlsmddaitss xmlns:xsi http:www.w3.org2001XMLSchema-instance xsi:schemaLocation http:www.fcla.edudlsmddaitssdaitssReport.xsd
INGEST IEID E20101202_AAAACZ INGEST_TIME 2010-12-03T04:06:18Z PACKAGE UFE0022368_00001
AGREEMENT_INFO ACCOUNT UF PROJECT UFDC
FILES
FILE SIZE 74581 DFID F20101202_AABXLA ORIGIN DEPOSITOR PATH jackson_d_Page_41.jpg GLOBAL false PRESERVATION BIT MESSAGE_DIGEST ALGORITHM MD5
bef3485745d9e7efe71d415405167b62
SHA-1
e3422e2a6cb2f5ead00a57c19f9be33c41e5b68f
114624 F20101202_AABXNZ jackson_d_Page_62.jp2
b9c516587d16bf718f5b0788c37d6658
56e86e51e7e5f4c284d323faf20417e23acdeada
72545 F20101202_AABXGD jackson_d_Page_22.jpg
a940e418f605c8fed17c8e2b72d447ac
248fbf7d4672f431281b018966860c665c55caf1
6742 F20101202_AABXSW jackson_d_Page_31thm.jpg
2e14f79bce2ce6b5f628d7f246c1b966
85601b41e2f003ddfd0bf059874bd3ce5596f2f8
97081 F20101202_AABXGE jackson_d_Page_55.jp2
74fce7ef455fcb156ea2b69c5b475f24
7fe25a7e3baa944a71cd895c37465b6f56201fd2
24966 F20101202_AABXSX jackson_d_Page_32.QC.jpg
01614d1fa47a33ffc65653ce60adb8bf
586cb9fecce86ff815a5653dc62cd075eb8fdb0c
74358 F20101202_AABXLB jackson_d_Page_43.jpg
2e345ea06670f1850064b517db0a58f2
a73e0e4f1f2b3cf85044d061c2829cbde2da439b
24557 F20101202_AABXGF jackson_d_Page_76.QC.jpg
126ac13e8d4a7edd60c7c28d3cff069c
167e7780eb94bd814ab14ef0f1d583b3c609d908
1053954 F20101202_AABXQA jackson_d_Page_52.tif
bd0318d1e8d740b90b3c696c4cc4d086
eb9f0b53204f693e0a965eedf616e71adb47bd7c
6841 F20101202_AABXSY jackson_d_Page_32thm.jpg
48561c58c78b38f85f6daaf4dadca133
237f57aafe4487720e680d643b92e9ecfb123920
75630 F20101202_AABXLC jackson_d_Page_45.jpg
d355b720ef685b4d4dc05993beaca1dd
76afbabdee229e7c6e1a8a4d546334bcd07f0f25
F20101202_AABXGG jackson_d_Page_88.tif
28ad2391d9c61b75783824c3011042c7
08cb5466713a26afe7b5f7f1827258ef55b2eaa8
24543 F20101202_AABXSZ jackson_d_Page_33.QC.jpg
143302218e1f0ded2fb74cb6eb646dbe
b2c9494c48ca10c4dac690141baca0ecf1821998
72201 F20101202_AABXLD jackson_d_Page_46.jpg
63a1dfab3d604397b92ff1e1587e59c3
203ac3ab8cd7f2f20e64139bf174d3f94b620f94
1051976 F20101202_AABXGH jackson_d_Page_06.jp2
b6fde6ce97376b7cde26b902eac9e363
65d853ec47a8efca8f5e24fd6fed67fc073a43fa
F20101202_AABXQB jackson_d_Page_53.tif
6e33a9d23b21c405d6f3531dca07b0ef
c9acf69310dd0062ea24576a30ec735e1cb473c6
75015 F20101202_AABXLE jackson_d_Page_47.jpg
19e974bec27c189e5c2b0a2d7e5821fa
d7eb0a8bf0213750c70d257d581d99d63d9e3423
7493 F20101202_AABXVA jackson_d_Page_68.QC.jpg
5df62ab6d2148f5e1d2df68a3c83d56a
43f58e149645557ccffd95cf1f599101ad2a1270
25994 F20101202_AABXGI jackson_d_Page_29.QC.jpg
6cb408fdc932cacc3d2c1330bbc34b89
a3c3f7fef172ec073b484680a707dd288db63a3a
F20101202_AABXQC jackson_d_Page_54.tif
c92bf7ce61a1d71c38460c6c7ca038f3
e52781cfe8d77d3e92a8553a128bcfe68416afb7
74345 F20101202_AABXLF jackson_d_Page_49.jpg
88ef6dad1667768858ae7c5177b356a1
8e78d12568bf5c75ef078d240d1e1b5f1192ac10
2403 F20101202_AABXVB jackson_d_Page_68thm.jpg
5d9997db0c752c038a790ded30b6b915
e3a038a25da238ea027ed1348649203d22a02531
38499 F20101202_AABXGJ jackson_d_Page_73.jp2
2981c97b84aacee07fbf00d84aec195a
c3b9cfb16880d7659290a214e6fd90c8fad38154
F20101202_AABXQD jackson_d_Page_57.tif
db57ad3db6beae966e8e02001309fec3
ba5eef61aaf42d94c1d14806184e835bc5e6cf11
78568 F20101202_AABXLG jackson_d_Page_50.jpg
e0e99ac542b672b72bdbee4b1f0aef0f
732995d6fcbd65869f9a079d287dc8d582ac2657
2158 F20101202_AABXVC jackson_d_Page_69thm.jpg
4ca1dd2f7f44b61bc32a0ac8af54a90c
0f9de440482d0d48c8e02744ffa55e46d221001b
26002 F20101202_AABXGK jackson_d_Page_79.QC.jpg
89156685ef8b2732684ae71591b34d2c
85d26da646b241bddf303b570c5faebe64a5d16b
F20101202_AABXQE jackson_d_Page_59.tif
87771e3d5066717613af84f3d3a5ad41
c347607ea3a6d18ab59c6a07df08562655212996
63220 F20101202_AABXLH jackson_d_Page_51.jpg
0dadefa71aa77775a1beb0f83a8cba2d
59578292f1a52b6015ebff98cec9ce4aed5c7c77
10702 F20101202_AABXVD jackson_d_Page_70.QC.jpg
d815ab12a105b09d40669297276fee19
6a2508bbf6c66a7107fe8180702faf16e8f2af75
6804 F20101202_AABXGL jackson_d_Page_40thm.jpg
3d2fe78627dd0e47f1d80413b25f352a
48ad3ebfda52a78cf01e8b0758f92b9657375819
F20101202_AABXQF jackson_d_Page_61.tif
92468df2d00aab30aed5a35463b1de05
615e6ce830fe5b1da3a801dc5f340087e551c6d4
74144 F20101202_AABXLI jackson_d_Page_54.jpg
90df45f844c6e3076b95ae92d030ffed
982564719acdac215714df5eb06d16c896952a1a
8986 F20101202_AABXVE jackson_d_Page_71.QC.jpg
595af70d8dc00f6198cd6c42ad92cf12
340b39528536c09ae642d43d069c5fd55f235e28
6992 F20101202_AABXGM jackson_d_Page_14thm.jpg
4c3159d669d583086ff6505d76ce301e
d2dd1e9f50b32cc11b57f6d39e57606b6cfecdca
F20101202_AABXQG jackson_d_Page_62.tif
98d25221775f695c8c4baa7a8996de34
4daca6be2d1aaf075036ccc0e6b0cf5d907e9b51
58628 F20101202_AABXLJ jackson_d_Page_56.jpg
1216d910011494536f18498e4cd87da0
ed50dc519309625955679a4b3bc2cd6fd0084768
3040 F20101202_AABXVF jackson_d_Page_71thm.jpg
510ce93351f3e53cc52aca2202536aed
2f2a82f13eda1a4cf5498f3a6f81606e1ee1b2c7
23263 F20101202_AABXGN jackson_d_Page_74.QC.jpg
3c854ad368b0949ef100b127e827f62c
5ceeeb4ca8c9f769b7ba041c8734de446de1c5ae
F20101202_AABXQH jackson_d_Page_63.tif
80c0aba43e2763f2c5b74ce148f23850
74b2dc9a596c139990ab6cf264bcc68ea6b3272e
64934 F20101202_AABXLK jackson_d_Page_57.jpg
c075a7b7e4892f3f6ef12bd2a0ad9a74
62bab412f2fb2acf5755a2fdeba8132aa66688b8
6509 F20101202_AABXGO jackson_d_Page_27thm.jpg
cae0fc7412e4948dca3314b18d731152
ea0b1213aa7bd762f8661dedbc9fbecf51df3464
F20101202_AABXQI jackson_d_Page_64.tif
4edb8c846d4a1ff0d54c5037b0d09fcd
3838ea9cd9c79956cd82435251c1f3a51ed42fc6
75954 F20101202_AABXLL jackson_d_Page_58.jpg
db11f0303882ec7dfeea5c3de25a1c7f
84c43c5d6a81010acf2d5800ea99c17c67bb6f0a
8196 F20101202_AABXVG jackson_d_Page_72.QC.jpg
93c3e31bd96f5951901e3c7cc0bfa0ff
f5fed5dd49b0282a7248e0f6049faecf1a8f1d97
75618 F20101202_AABXGP jackson_d_Page_18.jpg
0db8df61a038713b95360978dc39d91e
3453626b34026e11ad52afa263df9e21cc20d95a
F20101202_AABXQJ jackson_d_Page_66.tif
f2e43c6356743b38b7bfb58ab67715b2
d7debdb227ade80b4c88da9de94fb996249d10d9
42686 F20101202_AABXLM jackson_d_Page_59.jpg
d9c297fecb6627373032b9631ec5ccf9
f04eb4e2cd3a3a57c140f301247be09cb401f463
6849 F20101202_AABXVH jackson_d_Page_73.QC.jpg
6d5cba019137405f62e906fc3ef2bd30
a0581eb833add518a8c63a83a8382d3fb2b9d14b
6600 F20101202_AABXGQ jackson_d_Page_46thm.jpg
980a4e893f17661ce265f739f4dc5d06
32e61a76844eaa2d9d90a3ec65ac1b13e10311e5
F20101202_AABXQK jackson_d_Page_67.tif
8123cdf404770c5ef7cf26e35cc6ae4b
740184f39c5192a823991c1108da1a720cca3e73
70359 F20101202_AABXLN jackson_d_Page_60.jpg
3c3168e9f0dede89ae21e8dc5497d5e7
c45fe9c83f9982e4434bf9a62759d26c87c3f0e4
6352 F20101202_AABXVI jackson_d_Page_74thm.jpg
98f32189c7e410856b40dafe958c90be
8508eccf560d10858fee8fdcefe60eef3de637f7
1315 F20101202_AABXGR jackson_d_Page_02thm.jpg
c7f87653c46bf6e6ce4719f381f3042a
165fc9df28c207c5fc6b54d0dfffc5a111ec7e7e
1054428 F20101202_AABXQL jackson_d_Page_70.tif
5f75ed396c7d5ff6fe5ced588de20d72
97a0cd69b88baa04c0dcc68f270961e52b28a1e8
75616 F20101202_AABXLO jackson_d_Page_62.jpg
7acb554496ccc39c336f0230e25caf19
2a99dfa80dcac9d2f76ccbe4e9010a29aaf3079d
6722 F20101202_AABXVJ jackson_d_Page_75thm.jpg
09d965e53f6e62e7be73d116312b389a
b529e6c5abc4a1819402af47fe6a3ce21ca67a48
96310 F20101202_AABXGS jackson_d_Page_88.jpg
5f5f34055a488d199f2de89dcc9eade6
250f284fff51dc948eb98b92616a53ae00f127bf
F20101202_AABXQM jackson_d_Page_74.tif
9c9bdc7eeda51c2a9b36fe4b00498876
57fc98c524c76c5c18555318fcd07c37a34d3998
76017 F20101202_AABXLP jackson_d_Page_63.jpg
6b67d8e3db27f162e507b40309d82967
d725ff22f93ad011157e5aeca9f6f5f8ea2d09af
24517 F20101202_AABXVK jackson_d_Page_77.QC.jpg
75292102cb5be019134a1a4c26387755
e90ed3f7f9abba11da96e71426de047bf7c544bc
F20101202_AABXGT jackson_d_Page_19.tif
cd91c8890f97ed1ef7641584b18dfb36
161495084467ad5e7e3b8b255a928dbe3f07b012
F20101202_AABXQN jackson_d_Page_75.tif
405a1135ab8a1a228ffbf0758390dc49
d52da02cfc05910ce42a8b71e3bef3e997fefe1e
76424 F20101202_AABXLQ jackson_d_Page_64.jpg
f66e98f976de106b1a9773a39f5abd1d
f62f663560137472a3bbff56f32e4a8101923b22
6966 F20101202_AABXVL jackson_d_Page_77thm.jpg
d6e76a274988f15b1733c5032e1d7018
f716060bad7e0d5b333830191a472e76a72871ed
77602 F20101202_AABXGU jackson_d_Page_42.jpg
ee237d1db54d2750e3bc2bbbe7c048ca
8136b6740d83765b856764613f4940f39fb38d7e
F20101202_AABXQO jackson_d_Page_76.tif
aa6ece03a3acde5e7b50c4b9ecd4643c
65731900089f3b720d8264dece363bb39886d5f3
76995 F20101202_AABXLR jackson_d_Page_65.jpg
eabb4294aff793bdf235f37cdb7cee38
c62ae6f676fbab660623acf8cb0ec4986b6ea9d0
6467 F20101202_AABXVM jackson_d_Page_78thm.jpg
0aa20b62abf0d5d3ddd997bd3b6d5a7f
d3c1809dacedbe9fa457d288d4ff06017af478d3
71640 F20101202_AABXGV jackson_d_Page_23.jpg
4734d54be107ff7068415733179f558b
d23f97d9d02063745d71048f4257f097fbe466b7
F20101202_AABXQP jackson_d_Page_77.tif
252fb95f3a8982a55b6a5f528c82f936
a81f070b0040cb38a7ccda6d23599022ac8bca2b
73289 F20101202_AABXLS jackson_d_Page_66.jpg
588198893fa05cf2ceb9af1613dc5279
4e0349c30580336b014e445fbc4a9fb6239f549d
7175 F20101202_AABXVN jackson_d_Page_79thm.jpg
240288b70ce998fdb56f9655f7e281ba
e03ad4a39f8cb2add262545fa341e49a4844b636
25612 F20101202_AABXGW jackson_d_Page_17.QC.jpg
125c914ef0baf25bdfe42d302dd6d878
9d33284c395e93b6cf09e1ccb627c1c863493e94
F20101202_AABXQQ jackson_d_Page_79.tif
e7a79f93f5b1fa4eeae4f37d964773e8
cd1cd3cafb1c0010d2847d43a4a8c2f9143d2872
22916 F20101202_AABXLT jackson_d_Page_68.jpg
91704cba444c3bc5bd325d713a810ad9
42a703a1c440b554dddb186e500c5654f0837fce
24083 F20101202_AABXVO jackson_d_Page_80.QC.jpg
473b2612147f8418749e9f070fcc9cfd
ee1d475b90a90820caa176c308f4199fb906ae4d
F20101202_AABXQR jackson_d_Page_80.tif
54cccd7e2ad8c1c9fc6e0e7ab559aea0
84776b086b50548fbe996c5f6d6b955e2dd9926a
18634 F20101202_AABXLU jackson_d_Page_69.jpg
b5684c5e1fd849bcd7e15372d0f1294a
576af8abebbed65525f0cdc48958583f1f9c17a2
6595 F20101202_AABXVP jackson_d_Page_80thm.jpg
9a39d5e9de8bc3515324fc0472ba532c
9c31a6702b828764c94c306781b7938b515b815c
94304 F20101202_AABXGX jackson_d_Page_87.jpg
815769f660802cb8b8519006db77e323
6e2e64433c8bc14d2a7c1e68b8bde10299e9ada9
F20101202_AABXQS jackson_d_Page_81.tif
e032446e17365aced04173cbbfe54ea7
2ebf8fcd8e58bf90191f332a0d7c86d776bb8544
31571 F20101202_AABXLV jackson_d_Page_70.jpg
e53637ec247b0a308dc4ff1a4e0b9e7a
03bcbbe96e2688ccf88fd9a37915c59d67455dab
25827 F20101202_AABXVQ jackson_d_Page_81.QC.jpg
6ff34dcfa2d0f5e0ca9d8ed9a3c1b9e9
7d0fcfa04fff8f0cd694460b40024a907c3b9e94
115403 F20101202_AABXGY jackson_d_Page_47.jp2
f34293a01829668c0d5df244c0648836
ba9140014bb534a1badb88a47c3cdd87d8e57a7c
F20101202_AABXQT jackson_d_Page_82.tif
a49d9125812f642d99903a5a71cdf9b4
6effdfa66bfccc3f0984c1c7970356db39e45347
28219 F20101202_AABXLW jackson_d_Page_71.jpg
dbb15950d047acb334588a7b18b3898b
c8d605106a8a993e55a77918501571b96672b0b9
11403 F20101202_AABXVR jackson_d_Page_82.QC.jpg
43b3b731c5042070361aea02e97076a8
33aba5d284856163928f4c4327feca4411b26b76
115534 F20101202_AABXGZ jackson_d_Page_76.jp2
ba9b7e1462726b0ee8f8e5970d7dda76
8916da48517ccf7016435ed35b667f38eb910b16
F20101202_AABXQU jackson_d_Page_83.tif
f40e6c7190c7a59b59c0d29db2038869
f1dba138e411f0c0f7abc1f728a4cc1112642562
20735 F20101202_AABXLX jackson_d_Page_73.jpg
5f9dd3fa9079dd90c43d4467a19b5a83
667bde614c3b9577de9a1c1afa60922816537122
3579 F20101202_AABXVS jackson_d_Page_82thm.jpg
e423d146223b4515f9732ec167e7e14e
255ad622a6984b6f76b405a9275331d95ecb0c89
25271604 F20101202_AABXQV jackson_d_Page_84.tif
adae8ae116319b80b072cd0d98dc7f9b
1fd660e5cd5a9c6f8f97823823c5458ff47c9fa3
71554 F20101202_AABXLY jackson_d_Page_74.jpg
5d7d8474acd390af1b1ab8251f92cc06
2e7035dabbec5c0d8bedf16b8bec3a2ffa85960e
26885 F20101202_AABXVT jackson_d_Page_83.QC.jpg
0e6b593e4677829d3900759ae8480cf8
3fdfc9bb2cdbbd14eb44657f478f9a586ee45ffc
F20101202_AABXQW jackson_d_Page_85.tif
25e35c786f6995b779b544d5f0b0d611
0c4967e88808084fd1c4b7e0923a1e28ec994e69
27627 F20101202_AABXJA jackson_d_Page_88.QC.jpg
c499cc65fd5ee60d4019d9129bb79b90
96f561524fa892c0abfcd4345cba412923c41571
76087 F20101202_AABXLZ jackson_d_Page_75.jpg
e7126ed700241945ad6980c113f8785c
cac6e49c64798911cc1a3b8ab4985ec3259a2e1f
7075 F20101202_AABXVU jackson_d_Page_83thm.jpg
db847dc460d502685c1e92d32029610e
bf5e93db2a96b53d0f5511fd1106bf699419ef02
F20101202_AABXQX jackson_d_Page_87.tif
48d067d1d7e95f16211cae006c7253fa
a2336d210aa102aa1ff0c008205c7d2d466b00a6
101405 F20101202_AABXJB jackson_d_Page_21.jp2
b8b03905b54fd577224e3a736d0dc399
e21f33ae169d0e6db96c033090b466e2ff237ce1
29949 F20101202_AABXVV jackson_d_Page_84.QC.jpg
85843dca7ec177911ff612b224994898
27f4562046b284d3edbe0eaa105b3cccb0e9c6a6
F20101202_AABXQY jackson_d_Page_89.tif
d4187865b6bcf5550d50f841d0c79536
71086f996e899e7b0138ecf1c9a7fe71eac42abc
6196 F20101202_AABXJC jackson_d_Page_60thm.jpg
1b2b835d7c6e27a31bf6d5c8954df7d4
3014e3fabf7d770d20888d50ea8754bc609fb708
7900 F20101202_AABXVW jackson_d_Page_84thm.jpg
9bebd64617e3c6e12114920210e4f6ed
8bc562220717e174305b9535d134b8b9a9f11357
F20101202_AABXQZ jackson_d_Page_90.tif
65c2a5028ab252397cfadbdc34fd0519
be338350aea0af666877e681e3648443c1db978c
23531 F20101202_AABXJD jackson_d_Page_78.QC.jpg
979710af41b32e28903516156d2d8f84
d2ab1c0c0a84ad1feeb29438c7a6f6400a058194
116367 F20101202_AABXOA jackson_d_Page_63.jp2
b517742c20faa07bbf584b95514196c5
22fb323b976891a06d215560d4241d8238e09b6d
27071 F20101202_AABXVX jackson_d_Page_85.QC.jpg
519f099273cc68730a433c66c9fbbbf5
1e5fd99576d7b1ca6fbb43bda71cdf79564c7b5a
78779 F20101202_AABXJE jackson_d_Page_79.jpg
e2355d5f86162925520c595e6c0cec76
6c08e00c625bbf8b6d0808c0c0b7f30bf32791a9
116278 F20101202_AABXOB jackson_d_Page_64.jp2
6c05f4e87206ee353be6b22d08aa029c
a3ab23b0d1f358b72a7f3b84dac8b5c0db985b48
27534 F20101202_AABXVY jackson_d_Page_86.QC.jpg
88c4633340ca6251946c48621595fc1d
eecd2345dccad575ee328ea48b24db8077ba55c1
118033 F20101202_AABXJF jackson_d_Page_32.jp2
2c840f9ac90748f14fb65b4e4ac74ee3
e81b86ecac1f7283b4dfaf12c7bb2fbaf7b9aebd
6689 F20101202_AABXTA jackson_d_Page_33thm.jpg
3e34e395e870ddb5fb7e55307601b15a
56c2727cbc335d61f82144f61f56d3934074ae20
115759 F20101202_AABXOC jackson_d_Page_65.jp2
6692ddf8ad6407babf712846c44144c8
2e28cbefaeabcc6e0088e8afb6849812d0142178
7362 F20101202_AABXVZ jackson_d_Page_86thm.jpg
d854bc1198e25d59b3734dcae743592e
fe2ed0afaf28e4f7c2a773bd9f330f6798fb24ad
F20101202_AABXJG jackson_d_Page_60.tif
c0472137ccf74dac8940010961a7bdff
e02b8c75acec5b1ae125ce23f7afc5373cfd3733
6688 F20101202_AABXTB jackson_d_Page_34thm.jpg
74d78e8fd1ebb0d5defc10e3241d7470
5f7ce2165238272a68634d6edc11cce0abe42b79
47551 F20101202_AABXOD jackson_d_Page_68.jp2
b872ed96484a40f7c84008cfe3c4ce36
1de300a512f3ec52ed89f67b1321f9ae93223e58
151078 F20101202_AABXJH jackson_d_Page_88.jp2
3cfadb677863c2a78856bfb88aa6cdc0
3aedf2edbe686c0621629d5f71512cd856e83354
6848 F20101202_AABXTC jackson_d_Page_35thm.jpg
42aa1e9b2a945fcad7f969e8a2773fc6
676fb856ad979f3a6138ef4d32899e4c2834941b
58149 F20101202_AABXOE jackson_d_Page_71.jp2
58a02b29dbf9f838475e1e7fb8f16d52
9e60e1af3c0716608edf2e8030c153b864103d76
74579 F20101202_AABXJI jackson_d_Page_16.jpg
47924ba00ee29a8bafeefe8e36b697c6
91e7b59c483d7b3172f8c95102304dd137dc9cb0
24982 F20101202_AABXTD jackson_d_Page_36.QC.jpg
87c395e07155ec27f08beb71d03cad11
b783c0d555f22544904af3989ec15f9d2e3b984c
105308 F20101202_AABXOF jackson_d_Page_74.jp2
1fcb42eddfc719a01b048bb34cf27ac8
2c5765d021cde3b8478aeedaf8ea9a72e4f408e7
77209 F20101202_AABXJJ jackson_d_Page_61.jpg
536d4fd1bcd6322ba3a0ac22e9724f41
a0c49d9020d953579ac013b85cc9ffee04246bd4
116243 F20101202_AABXOG jackson_d_Page_75.jp2
f5053f19098bf6190de89046e4bc9d71
5f788afbafaa1d9d1244edeec762d9d6b63fe576
118782 F20101202_AABXJK jackson_d_Page_42.jp2
966463c3f40123a83897d812f8aa9f3b
6ed97638632dd065e94ed6db123d3c2c103be2bc
6857 F20101202_AABXTE jackson_d_Page_36thm.jpg
6d061e59cc176146f43723ec8c9608e1
99eea315568d773a8c6a5f93daecb389d952cf38
111640 F20101202_AABXOH jackson_d_Page_77.jp2
228fdfac1f9846b5316e706c2ebd62b3
e9e719d58fe6efb67bb20abbf006bec36a9514da
F20101202_AABXJL jackson_d_Page_26.tif
7e0ad1ee48546bea7f13a2a2a2e75cd7
9c4c34214c11e1d9c1b7af1f907bddf6b580192a
6687 F20101202_AABXTF jackson_d_Page_37thm.jpg
491c86cd82bc204a80d5e254c3e444f3
e989ef50d48e38e889e6956a2673c66d64797695
7220 F20101202_AABXEO jackson_d_Page_85thm.jpg
74a40bcf2bea20342d9c7a68e057989d
d1f54130c1ba1a64c70e08dd29deb60fb57c8d9e
106622 F20101202_AABXOI jackson_d_Page_78.jp2
46d2d4f39d0c5c7cf350273332fb7b95
02f79a1daf809d64c47a87dfd53cfa7ac4ad2ba7
5680 F20101202_AABXJM jackson_d_Page_91thm.jpg
633474b434f2e49e6126d5a79616c92c
7b2e3a9bf0a14375c0df737731fa669ad885c1ba
24876 F20101202_AABXTG jackson_d_Page_38.QC.jpg
308d06251b9d2a1985f49d82a9f03f42
7f5d6c41d81ee6f4e58fc8bcdeaa7a75026632db
24667 F20101202_AABXEP jackson_d_Page_25.QC.jpg
e807638269eb9c6725807188cf09bf9e
032eedcdb926582796e0af52ac0ceb91304981a9
118692 F20101202_AABXOJ jackson_d_Page_79.jp2
22edbd02f3660b253bc0eacce5bce98a
c2f2a65871c5c64ea65070e60eefc260aaa2d765
68344 F20101202_AABXJN jackson_d_Page_24.jpg
996fb2754ececc78fc89d93b79432045
7ebe26b86109cb9de586eeaddbe33d6ddf718c44
26562 F20101202_AABXTH jackson_d_Page_39.QC.jpg
68195843a7351b60b016175b1daf2a7f
dd52092a872108eae7a196c49648339e2c3be3cb
64509 F20101202_AABXEQ jackson_d_Page_55.jpg
6b5d308984d095639450bed5c9d2bbd9
837e9fa02612c73797448f98d0711808d2a1e1f8
110940 F20101202_AABXOK jackson_d_Page_80.jp2
3736d28a745e728348af1a414a75c07e
e0d670694879c52628c25235e411a1f5701d7eda
110179 F20101202_AABXJO jackson_d_Page_66.jp2
8fb5428f768b8ac1925a3aef206d654d
e38a1a638d980cbda1875caef06db2bcb0bea0e6
7113 F20101202_AABXTI jackson_d_Page_39thm.jpg
e2582a12ffebb6bc7a24569543e0f647
6a7fe2953552899c75471a3b8c95911f2f09d10f
6726 F20101202_AABXER jackson_d_Page_16thm.jpg
f80e43cb2132fffbaabf22d50c6c13ae
8f2786273897270e8bfd29ed1f499d5c5e2fd008
118052 F20101202_AABXOL jackson_d_Page_81.jp2
a246e2f92ce7de8fc22cf7a551ce7ba8
34c8fbe93c84a71473fb7f41c50838425e5f6ec5
6787 F20101202_AABXJP jackson_d_Page_19thm.jpg
a0aba2ec3ad5d0022bc08a84d1d7eb4b
7ae51b8d400c97c5cfcfb2c48eaf129ca2a2cc2e
25366 F20101202_AABXTJ jackson_d_Page_40.QC.jpg
ff1e8ecd59f2edde5aaf1bbb768aa2c6
a97172e4f968e5d71c74c2423e89354fb59364be
74876 F20101202_AABXES jackson_d_Page_17.jpg
1797f9891c63a3f520d5a9c80ee24bc3
39258499cd76be03fa82e13cd5982d78efe654cf
42800 F20101202_AABXOM jackson_d_Page_82.jp2
286cc23d7c112bb3f8a97b3ee531aa70
1380a4ef64eb797a3878c978acd7a79b124d8990
75054 F20101202_AABXJQ jackson_d_Page_33.jpg
42107de0f2dd8051915abb8a51555067
ece27c2c6afb1c826cfacc780c312b506d161e5f
24199 F20101202_AABXTK jackson_d_Page_41.QC.jpg
ccb55f3d4d572809a72980d5530e26c4
3c8edebb2a851bbf7300e3a48798b601f7fff6d2
25420 F20101202_AABXET jackson_d_Page_75.QC.jpg
e9ad65569c04b50599cf4c7382f75fa7
694f0338eeb20d2a90bb40b78f262082700f020c
141331 F20101202_AABXON jackson_d_Page_83.jp2
a3e70626fe14dd0da0877939e9758643
4b5728bef5c961f0c01b9d191ef2435e61b05b99
F20101202_AABXJR jackson_d_Page_68.tif
7d023b92f90601cb7998e9708ec6f5c4
9807355f0ee5cfa3c0d80c9709cbd3d41eb22ff8
6779 F20101202_AABXTL jackson_d_Page_41thm.jpg
f5e3894f55aedca33aeddba624f6f237
fc5438609a19c167b1c2f81f5cd206d218896d8d
F20101202_AABXEU jackson_d_Page_06.tif
d14ee05e970debf086494758c8cb0710
4feeaece493b757dc62a7f15f4e3ec4405f9701d
143878 F20101202_AABXOO jackson_d_Page_85.jp2
841ae32c4ffdf878c3e909a8ac26e65d
0bcc49eee672fedcbe91fbb0ccc1e7d78427ab21
F20101202_AABXJS jackson_d_Page_22.tif
e8538b75f201af17351b8b8d1c60e009
f1f4cf4ccb88a5498a11b0a9daf97b0b28d490c4
25180 F20101202_AABXTM jackson_d_Page_42.QC.jpg
f02353b19f97c932cab36e241bd87edb
d85cc8c1120a9f77aa9e73a76011ee2a45e4bc3d
146659 F20101202_AABXOP jackson_d_Page_87.jp2
89a2e0eaf1e6741c7ea765c94207f896
ea3f2da21cbe3d74e285e53507478b9acb4f78a7
24492 F20101202_AABXJT jackson_d_Page_72.jpg
b2f6b5f7a2b86647114b7d3174a51eb0
2315b01655613c53ea8ae09d6caa213311c88094
6888 F20101202_AABXTN jackson_d_Page_42thm.jpg
16fabcc43cd2f2097831ec8ab0c156c3
3fd1400c94aca0072d696c9417f9fa123f10f6d4
F20101202_AABXEV jackson_d_Page_58.tif
ffda24700bc768db5a1a102e0340cee4
37d396d4b99820058982c65a551d1e447fadb6a3
145181 F20101202_AABXOQ jackson_d_Page_89.jp2
653a84d2be4aad94c2b472052b16b7e8
f4e8690bb692cd04e52335bf15fd2f1c2e3283f5
F20101202_AABXJU jackson_d_Page_41.tif
9e2f28c965e09a9bf692763162c532c2
2f5b7f5ca451bf1f0319ca8a4af0e4074aaa4924
6671 F20101202_AABXTO jackson_d_Page_43thm.jpg
045cc35ccb503b6b018c816c54eca67a
c400e6c3b82b059d8e446e686e556c7570ec4dba
126472 F20101202_AABXEW jackson_d_Page_53.jp2
e88131ea221a91e6a1e6e97030195374
12d1f28410ba3c41f4a2a1032829fdb204d74d96
140574 F20101202_AABXOR jackson_d_Page_90.jp2
5d29ef1e101a5bfac2448a9644ca3ba7
7858c6f5220a8f559b146d9c20336af87dcc6cef
100090 F20101202_AABXJV UFE0022368_00001.xml FULL
859ace46ea9bff0ea444be8b1ddb8cc8
28de481e1a70848e6105dfd6a4576cc2f514f6f0
25284 F20101202_AABXTP jackson_d_Page_44.QC.jpg
a28012bf77e7ec986abdf85c5c452b85
f687fc8cbfc219c85ce94b8ca04efeba5b1ddf10
2643 F20101202_AABXEX jackson_d_Page_72thm.jpg
01e2460ebc17d629cd8193487a3ab629
a2b4f936bb2471792250b563b53c0947a5cdcd3e
93870 F20101202_AABXOS jackson_d_Page_91.jp2
49448ca2edd0513927ce9d5c73e77af8
91447db1a8c54127ca67e7c243551295cbeb3d55
6919 F20101202_AABXTQ jackson_d_Page_44thm.jpg
6c1cbe5f6c0d46efff7e2a968c03263b
178fda8c93e0b576e4cb9789dcdd931127285f72
24300 F20101202_AABXEY jackson_d_Page_10.QC.jpg
47fff3876456cb52d6ffb12dc0a89e22
352474514fac3a9a9d06029d261391d710828c7d
F20101202_AABXOT jackson_d_Page_02.tif
352a35a49bd6cb0af595fb1980b13775
8b2a77610d1160559a5949f5987f2802e34348b8
6763 F20101202_AABXTR jackson_d_Page_45thm.jpg
5b265cbd152a02632f43152ce02fb82f
6fa390ed05c1601f88bd7719304d34a938666894
146708 F20101202_AABXEZ jackson_d_Page_86.jp2
0890a7572f136f7d4e80b7d5ce39734a
19ce7ec0cdb1fc9ff256773dc2c58edd390e53a4
F20101202_AABXOU jackson_d_Page_03.tif
1cfbeaf6459f268c96e5e6e597b9aace
10c8ecedb6ce195568f88d16f1a660eae4d42f6a
25227 F20101202_AABXJY jackson_d_Page_01.jpg
3671733d3e10577a457f3713bfddedf9
623a87eb6e56cdb6487fc504e8a828587563ba0b
23994 F20101202_AABXTS jackson_d_Page_46.QC.jpg
ca814e1297eb70b93b765bfdea9d7cb2
0ef80b9b0719ff4960cd8c972abe07dcd61cab7b
F20101202_AABXOV jackson_d_Page_04.tif
633aeeace7a48d17c45d325fbaaa6d66
4f28a4c6db78c24d739e3367e29b8bb73044aec1
9611 F20101202_AABXJZ jackson_d_Page_02.jpg
41ddc9722841f719397c2c7e2ab692de
6e56059f25456046e154288651a698994d172009
24673 F20101202_AABXTT jackson_d_Page_47.QC.jpg
816c0d17b1f7eb11c74b5bcc81908a95
8bdb0d94839bf51a89da6068cd1b478b12544e0c
F20101202_AABXOW jackson_d_Page_05.tif
cab3fca09a3e56becc35173445de2cbc
96daeae72c4b5454ee0211fc3cc39671f0e032d5
73163 F20101202_AABXHA jackson_d_Page_25.jpg
a4c57765679bee6290cc1b87c7eccdd0
b789c9be853143ed7e10786d3e8ce38e25112225
6632 F20101202_AABXTU jackson_d_Page_47thm.jpg
97e8ead6cff16187ab135b2b77deba0c
ca5d639fd6b10aa6042122f91356858d85bcb2be
F20101202_AABXOX jackson_d_Page_07.tif
345fc60e3bfba02608bf49cc66eb603f
abf04e3f083c29b74695b928f5976c96bcfab876
6018 F20101202_AABXHB jackson_d_Page_69.QC.jpg
02f8efd9b92965cf87db4200be7b1dd2
7272386e8e65fb9dca9c8a297d09c777090a2cb0
26398 F20101202_AABXTV jackson_d_Page_48.QC.jpg
1f10ceaa6318abd3ebb433c3a6498e68
d6aa04ed266eb7395c3fd2852a995f96761ad737
F20101202_AABXOY jackson_d_Page_08.tif
d8b1c389575ae66346a12294129a29db
5404bf20a840988dd21a423af728752d8632e0c5
6026 F20101202_AABXHC jackson_d_Page_57thm.jpg
104f0e490cf6a6162c9d1acc171101e8
f1762498a759893a270f3a1ac2974cd76efe13a6
7067 F20101202_AABXTW jackson_d_Page_48thm.jpg
3908301ef3a3ecf40caf2d35e66127c9
f5c868bc6c605046ba0574e48654054d7b20766c
75351 F20101202_AABXMA jackson_d_Page_76.jpg
1289d16afef935d8b1632858b9b97981
ddc1382c8859b24694dce890b0b364f127256961
F20101202_AABXOZ jackson_d_Page_09.tif
06146f4904bc55397cfa0b1bb928102a
e3f1c2aa31af172f892c76b94ad9a2449b8dd04e
85647 F20101202_AABXHD jackson_d_Page_56.jp2
8b9ed864136e03c4a9e6c6cf77d483c7
3b30357fc5f134637bb811e72ce99024c735e386
24480 F20101202_AABXTX jackson_d_Page_49.QC.jpg
4a48ba88ea43fc61a70fe2648934f444
0c038df358dae4818899cbbc53b9bd9fce2b9759
73869 F20101202_AABXMB jackson_d_Page_77.jpg
4159c7acf58ba9ebb52bfbc79b2ebc6a
d0a914d67d67c6759cdc4391cafab5e2b4a1d51d
48899 F20101202_AABXHE jackson_d_Page_72.jp2
ef92236f9addd6b427430168a35e6135
d3badb4eea4a75dc7ae5ce19956bb55558d06e0f
6685 F20101202_AABXTY jackson_d_Page_49thm.jpg
fb4534b88b9599d7abde24b7c194e730
33969cf6f6068c5a758356cdba928fe9dc88c576
69061 F20101202_AABXMC jackson_d_Page_78.jpg
d08e3ddf13841e65dbeac50e0e9a3a37
b3bb1685aa5931ea4d15aa339d74787de37c4225
113461 F20101202_AABXHF jackson_d_Page_34.jp2
5eed04d932a9417447b1fd729f35cd95
6b23cce4bec7201b3c5b6c4f21777bb325b08f3c
F20101202_AABXRA jackson_d_Page_91.tif
2cb22bd0af02da7fdabdc467bc84b246
e302207982a9cf2d307bed116af4923f6981985e
26034 F20101202_AABXTZ jackson_d_Page_50.QC.jpg
254e6a2e1d422d0ae465f48c03b79e15
17c5870b71f2c61186f053cd692f5db463a2b2fd
73831 F20101202_AABXMD jackson_d_Page_80.jpg
a6f78646578cd26c7deb165772a19871
a8fb386301a9865a021a4ddbe3e8d2cc67facabc
4528 F20101202_AABXHG jackson_d_Page_67.QC.jpg
b35e81cdba2e9d759fee7adffa01b1dc
79641460ee5792c7d4a020ba2a558001fa41327e
428826 F20101202_AABXRB jackson_d.pdf
d26207d585cc92ccaf8b46b6eb1ed150
2747606f6cbc600de6792f913f16ac72a9f9af4c
77923 F20101202_AABXME jackson_d_Page_81.jpg
20ebabf941c10268920b4ebf6c668357
387dec17c3181bcc2dab1975e252dcd34aa3a9e1
3511 F20101202_AABXHH jackson_d_Page_70thm.jpg
96f2e0cc69c73a1c402ea00aba4992d1
6dffb5b07c55d09355e20e8c64c5df529e7ee9af
27284 F20101202_AABXWA jackson_d_Page_87.QC.jpg
2e0d4e036bc874fbaf5dd41aa52da4ee
0816212e625a5c005633885bae5d8eec469deda8
32339 F20101202_AABXMF jackson_d_Page_82.jpg
ca232cb1879e12f05ff219efc4fe8e8e
f099d164aad998c4ad976cd3c5e6f0facd06c74a
F20101202_AABXHI jackson_d_Page_73.tif
1bcd6247111c4a619ce7bee11de21454
e248302afea0cccace03b9c338239c321076493a
2316 F20101202_AABXRC jackson_d_Page_01thm.jpg
d1b2945d97d2a66449e558f5ef5aa249
a19cf278b14be45be85932137186597fd5ff8c7c
7271 F20101202_AABXWB jackson_d_Page_87thm.jpg
76c3aa706de09e8f6285331409ae58af
9ec4dd0931786d68209d38b2e5a4210643eb8524
94833 F20101202_AABXMG jackson_d_Page_83.jpg
e441c39871c16cba66243237b313fe2e
baa08b86abcd235dafa67432c1abe973b46a66ac
F20101202_AABXHJ jackson_d_Page_14.tif
68cd327355647b96bcdeb973fd6ff71a
70dcdcab0e51ceaf4ff9b8ad474d40c7a705e73c
7963 F20101202_AABXRD jackson_d_Page_01.QC.jpg
0d804f584651ee965ca6814624837978
74f37921ecfdc16a86e79e90198420fcd1c59d76
27270 F20101202_AABXWC jackson_d_Page_90.QC.jpg
9078aac1e4934c3fdab968b6e432d441
571859f336bc5b1df4ea73be3d008cb1f1d47d74
108049 F20101202_AABXMH jackson_d_Page_84.jpg
8983e88bb2a6c0b46586d89af6bb3171
25633550bf205f01c6a907edb2dd8bb681cdbb93
5283 F20101202_AABXHK jackson_d_Page_02.jp2
419f1d58181294ddbaa9971312d32be3
6d7ac1fb8d29628606ec14f29e2f34c18737c2fb
3042 F20101202_AABXRE jackson_d_Page_02.QC.jpg
4bdfdf8b020d06d99980afca2e64b1f8
90e58c61fbc564fda404c1361bbcfbf1c3a0f0ed
7020 F20101202_AABXWD jackson_d_Page_90thm.jpg
f3133798fdd2f6438cb5e637ec6a67a6
b1dd245223a48e7c6d91dffe4c9c89a73b7b2a84
93474 F20101202_AABXMI jackson_d_Page_85.jpg
8072ca75c4f13561a9c1b95cc152c18b
dcee4180269a54085405ed4c9f2d22b69e6726a6
98887 F20101202_AABXHL jackson_d_Page_57.jp2
ed6c016b388bce721a34da9a08eb1023
e529602958a9f5c575339bcbe95274a66e3ee87c
3319 F20101202_AABXRF jackson_d_Page_03.QC.jpg
08070977ec1c94f5ce6150982d519c2d
7b56e53a6d24c9df261e611ab4be5773009cde28
20846 F20101202_AABXWE jackson_d_Page_91.QC.jpg
5af8f911f5dd74d8b158c5373769599a
878aa50fd5e8380d0388aa966df5c418ab247c36
95808 F20101202_AABXMJ jackson_d_Page_86.jpg
fe33e7a1cb3d4851b6ab87528c9f0796
58acb3630004a26655d9d381a61be63018a2cae6
26928 F20101202_AABXHM jackson_d_Page_89.QC.jpg
26cefd3532145eb77c8507fcf65ba5a8
4203460681164f89a53d4d5e8c90a421477a211d
15069 F20101202_AABXRG jackson_d_Page_04.QC.jpg
e163b855def24352fdca75cebd4554e4
8a45c3288cbeec50381d2721b20ad744c3e298ab
68902 F20101202_AABXWF UFE0022368_00001.mets
a75d82ec53a571f0b57891f8778f6df7
de8bdea8952ab0f66a2e0e6d6f0c05106b20a7c1
94081 F20101202_AABXMK jackson_d_Page_89.jpg
c41149bfbdb52963c705f26f2d6efca1
3a56875a294972e572ff6d6000f0b25f30a6c849
F20101202_AABXHN jackson_d_Page_86.tif
a9881c9b5350c77b6abb6cfe63adce14
020ecbdb808c891657b0cbd694fb4f4ad66a9b60
4369 F20101202_AABXRH jackson_d_Page_04thm.jpg
a47bb2973bd4e7f0635f7b0126025c97
fd071e815b11758dc0c161e98ced9ef1e97ef0b6
64778 F20101202_AABXML jackson_d_Page_91.jpg
c3e4a30724a5723d49571c7f0dc12849
4dfb747a1b5991003f4094e7a185ada196053949
23678 F20101202_AABXHO jackson_d_Page_08.QC.jpg
a6125fe859e82bf200f50371810b9e94
ec8b3bc79096feaa80366e5973f0678de259ea56
20641 F20101202_AABXRI jackson_d_Page_05.QC.jpg
00fcb057e110a9a3cdb1d411d6914a36
19cf88a759462c2d1ecd4ed7e212d0fb4e398217
6933 F20101202_AABXMM jackson_d_Page_03.jp2
a7a87f17de48517c73f7236789103c42
f679dc4864e12167b59c9437f26c7e3371f00ea0
F20101202_AABXHP jackson_d_Page_78.tif
0043b3855fd1645991fbf8ab25d21d47
d662d9f757bec0ef4397731204a300df303e4d21
5460 F20101202_AABXRJ jackson_d_Page_05thm.jpg
cd8601e96a418e71f7646abcf0df5efe
e30487e143ace7d1cfa7e361abccfc704b427bac
64121 F20101202_AABXMN jackson_d_Page_04.jp2
0d1ec38cd3a72855c12efd6e97897543
dfc5711512f68bc140d833fd7c72ee780444032e
1051965 F20101202_AABXHQ jackson_d_Page_05.jp2
6e96fb38934450598ddc9024cc84c6bd
5557dfff21196b67921af2fbb93e317d5193bc4a
12576 F20101202_AABXRK jackson_d_Page_06.QC.jpg
743eba8e82532b2ea1b5da0778275bd1
72aaf0cfdf4216a84bb882d66b83158a58966852
337069 F20101202_AABXMO jackson_d_Page_07.jp2
37339d2af9c8e4e2d3761fadadef5c6a
6a61b7168094903cd627df5fb29eb6c5e6552f8e
5943 F20101202_AABXHR jackson_d_Page_55thm.jpg
c91a821aa8fe0a8cb5cf541bc9d06299
342e7f00f8a07c1aea1258ddf7d94e8f03ba693c
3606 F20101202_AABXRL jackson_d_Page_06thm.jpg
4b30a0ccc4d989bb6cd38697a2a9ba9f
0d235c8bb71591e8f6e476a7447344352eef822c
109111 F20101202_AABXMP jackson_d_Page_08.jp2
401c8c861ef6b5814a5877b7f93dfcc3
e859a8fb71a27e19b8b6beeedc7025e92c756d75
7007 F20101202_AABXHS jackson_d_Page_65thm.jpg
b5b333a10410a3e7e401ecbe8cbc118b
f43fc877876c463ecfb3812880fa7cb4f1ec171b
6250 F20101202_AABXRM jackson_d_Page_07.QC.jpg
6a50d3c042ac26701370d05f55c23d42
e8792c0ba2f360a48c7fee26ad841aeeeb033b8c
110502 F20101202_AABXMQ jackson_d_Page_10.jp2
c0d4041d70e57f75bf29a2eda2047577
21f9b78a5f0410705a265b53d944147f54f84b2c
34755 F20101202_AABXHT jackson_d_Page_69.jp2
c841226dc0bcdd45d500d4cde0e8ec20
733d326d776144be6562f65d20193062e5895a0f
2018 F20101202_AABXRN jackson_d_Page_07thm.jpg
df0462d897d559ea701784cd75af46d3
ea85dc7ab979f038f33196ace8f95c551db5286a
119421 F20101202_AABXMR jackson_d_Page_11.jp2
535e774258b52fb2d7548d3449bed9b3
b7e9f4acfa54d86c4f8a31ae43685ab52bf05bd4
F20101202_AABXHU jackson_d_Page_55.tif
10e2c705818c0bccf1406cdd3905d9a6
3e1846c93e8c6c596f1edd539355372da91a5420
7151 F20101202_AABXRO jackson_d_Page_09.QC.jpg
79aaba163bc347160f1d766c0daa4b71
a9eb5955f9b73befc3d3f200cb82e07e4f314285
116397 F20101202_AABXMS jackson_d_Page_12.jp2
6dc44acb9aae8007ef2d75f5ec568e3b
9908ccd70a6ee2e3fbf5e4b9c9d7fdcd60c61348
20010 F20101202_AABXHV jackson_d_Page_07.jpg
97cfa55e39335fb24cad9e295cb81694
f388c7fc9df05abbb30ef11f69df9f0a327ae839
2416 F20101202_AABXRP jackson_d_Page_09thm.jpg
4081efe85bcfc655e9ab9af1dfe852bd
21d5179fba70908c6d0acf4d0363097ea19188b3
119800 F20101202_AABXMT jackson_d_Page_14.jp2
a6bc48bc181f9d013d9967f51396a3ca
db383eb5a19335c6e8c1a023f101c836c6ec579e
6965 F20101202_AABXHW jackson_d_Page_38thm.jpg
60e560d4a8ebe2c5613daa72e42cd732
b7a1c239fb10f63e2fb7399b92cbe4955c2df4f7
25897 F20101202_AABXRQ jackson_d_Page_11.QC.jpg
94783a09cfe3c3c7bf82005e6ec80dcd
58c5d4bfd0c244496b88988d9c3fddb6148af32a
112156 F20101202_AABXMU jackson_d_Page_16.jp2
ba4492807dd64adebacced9a70d06ca0
eb803ea1f412963bb91e1e902e028a3aef674583
F20101202_AABXHX jackson_d_Page_65.tif
a12695b2d793026e05461249127b5494
3c5b1717cb911ab68eceec9274fe833738d5f4e3
6917 F20101202_AABXRR jackson_d_Page_11thm.jpg
4e237236b8dceb376953aa457ad98e09
80c421fd9cae421d158d05f3ef47f22f20f67449
113840 F20101202_AABXMV jackson_d_Page_17.jp2
cad431aa0e82ff74f10bfd25bdf1af50
190509577b883c326993a6428ee201548abaebfd
6751 F20101202_AABXRS jackson_d_Page_12thm.jpg
0cc0a4c01dc286896be102a2f59102be
8d8b20a48d8dfa7dcc351bc83558efe46174bbe3
F20101202_AABXFA jackson_d_Page_15.tif
3f1e5b3fc912fa382dc31f102d2ab9fe
5fa9f704be7b6504109798cde8db46b2ae2b86d6
F20101202_AABXHY jackson_d_Page_56.tif
de14ac90bb0eb058480933c1aa44c3e4
b472b78d3f9c8a31c4c9cb353567e11b46021112
26225 F20101202_AABXRT jackson_d_Page_13.QC.jpg
5c9f8f1598f08fdc17569b83651a25c7
3885b951cc23f276b6243b4f7106fe0b48bc47d9
114686 F20101202_AABXMW jackson_d_Page_18.jp2
1a2fd36e95cc346c319a3fd7860e0cd0
9ba5e423a86fccdc3ecbd315405f8dccb2fa655a
F20101202_AABXFB jackson_d_Page_35.tif
2deef924f91a7ce3029af5280e962f94
58de3c2d391a61e1f9f3be2afb7617a8510c1cf8
F20101202_AABXHZ jackson_d_Page_38.tif
4c8d5735f56c63766eadd746ecfd95d5
2757837d5f431b4218476a45ea9adf010dd82374
7122 F20101202_AABXRU jackson_d_Page_13thm.jpg
7854a35333bbc087f3dcfc56ed0900eb
18e2b8fd92c2664aa7fa4913c186379c1e1d5bc8
44006 F20101202_AABXMX jackson_d_Page_20.jp2
c3408a2e16008de1b7bd439f44e85f00
37d1752b47be8692ab7153ebedc5a12a53f91581
F20101202_AABXFC jackson_d_Page_71.tif
05a59e4ec0ee2c9287a5d38c400953f7
ce12633cd5a2b979a007b2abe418d35049c31b01
25404 F20101202_AABXRV jackson_d_Page_15.QC.jpg
c4d4600c3e887c977b9e74675086a334
99bba5d5e2b70ca530c7ea58cee6a69d13c23422
107368 F20101202_AABXMY jackson_d_Page_23.jp2
8e385f0dfd2ad4632e2ce5b0008806f8
9550bde1a441a93964ae0cd24a7017cfc7d7e402
6931 F20101202_AABXFD jackson_d_Page_81thm.jpg
04a5b9cd80c48d69b3863ccaeb79378e
3d36dbf1c29839d28272d016927b12c85227ac99
6728 F20101202_AABXRW jackson_d_Page_15thm.jpg
91999a69f5046c51d82347f925d7ef17
572ce35419c7a2e8a167e2e92e54d593a6a2f7ff
10943 F20101202_AABXKA jackson_d_Page_03.jpg
d252be1dd1bc15405cb2014a18829327
d5cd2a531fb055cfeab2ffdbdc4fc247bfb5e9b8
103377 F20101202_AABXMZ jackson_d_Page_24.jp2
13a217648e350a7cd6bd7e4de5b5d070
0bfb9f67d109296bd0f3fb230682259dd2478c92
25896 F20101202_AABXFE jackson_d_Page_14.QC.jpg
e29d0c220edcf28e43b38f734a6945f8
c8cc9571992fc8204db3aaa2234d37bfed4c447a
F20101202_AABXRX jackson_d_Page_16.QC.jpg
3aa0a567963e21ec7a91123c0b359b6f
8cfd853aedd31704f1853fe79f81f7875b5eae40
46410 F20101202_AABXKB jackson_d_Page_04.jpg
378918740884de1e315a41517339750d
29a6eea23d5acb4ff2af60a3ff9782a727bee891
19335 F20101202_AABXFF jackson_d_Page_56.QC.jpg
38be9aae84c009ce843dfa860dde2450
ce10a117e8a6c586830d55fd6bcabe1af284e7d6
6994 F20101202_AABXRY jackson_d_Page_17thm.jpg
c5a2c8ba37f209a9e003721ec84a680b
a69ad032613ea8b33ad7785715e477a9b000715c
80637 F20101202_AABXKC jackson_d_Page_05.jpg
6931e1b5440ba91e06f0e1b6f554e87c
e9c518e69520181cc330e3591b53ba9ec51cce7c
F20101202_AABXFG jackson_d_Page_72.tif
be0fc1f50210c10456ff09159be90609
c7eae51a317a035bb89b8fea73f485faa8492346
F20101202_AABXPA jackson_d_Page_10.tif
9a255f8e11cd8c04a8de4cfc6307fa5a
b80de24549562daa67485e8d10818b400bcb23b8
25264 F20101202_AABXRZ jackson_d_Page_18.QC.jpg
e8b9a5b9cbc0b91579910c9ea2956eff
27aa4210f6a0c1cfef00a230eb2cf994134101cd
47266 F20101202_AABXKD jackson_d_Page_06.jpg
d7e26b3c1cc699a7a4dd32a1d3d0851d
7ecec290013f5ecc8128350200cb628fccd0ffdb
79617 F20101202_AABXFH jackson_d_Page_48.jpg
3f494135f19198d03775d75dd0710962
006a56cc4eb27d2e1e7e45678428ba25efd37db2
F20101202_AABXPB jackson_d_Page_11.tif
6cebfd65f0f8aa3e7da5706c4246adcb
2e91f3995ea19ebc49ffe6e968e851115a8c8064
21568 F20101202_AABXKE jackson_d_Page_09.jpg
8171e07fcf5c8fdd96d90c7baee1f436
df422ecc480394d0c7d13ef86355afb36f813fa4
21105 F20101202_AABXUA jackson_d_Page_51.QC.jpg
cd671b9be933055b16a351af71d50b7b
bea915d7d7c0ad974ae64ac1d7432b5e0b6af0f3
F20101202_AABXFI jackson_d_Page_69.tif
aab83cacb31358c5d36db2a52cf55fb8
5db1cff61dbb9760591311f98a54f0631809ccbf
F20101202_AABXPC jackson_d_Page_12.tif
695e86db861072d96b4f694b23ed9014
fc6e57f639849e5639b76353252ecea06d174453
74698 F20101202_AABXKF jackson_d_Page_10.jpg
7bf68d208f946ac931e5cbee6a13a5e0
b230d48d8e086beab73270ff1dc260008f8dba42
6006 F20101202_AABXUB jackson_d_Page_51thm.jpg
509d7ebaf56555c69dceefa88a787254
c6e76e87ec9330afb52031ce0e1f6c964e165126
F20101202_AABXPD jackson_d_Page_13.tif
29e533b40b6b3e2a5282caf3aa321861
6d2b7a66593c6bfb79e474e8478cc1de8b402549
79096 F20101202_AABXKG jackson_d_Page_11.jpg
7eecca3616302bddc0f5afc13d9a9a33
ea1226f261a846c801daafd00c825bbe107b1481
1051961 F20101202_AABXFJ jackson_d_Page_84.jp2
7a66e8fe70429952a4e71e2a1a4f1f32
5638efac6771a03c377fa796f72ed3e90cb6b0b0
23726 F20101202_AABXUC jackson_d_Page_52.QC.jpg
251910c35d5f00dce5fd40896e9aa021
3faa4f1b32cc4198ecaf3e8938f2fb53352591a3
F20101202_AABXPE jackson_d_Page_17.tif
c26b058631252e54394f270b1669f3c6
3394dcf42645018a4a49a190227da1e2d0eb6f16
75396 F20101202_AABXKH jackson_d_Page_12.jpg
7a57e2857e55bec02fa0edfd46a48a29
97351664c2f9e0522078af7911c29cba855f31a0
24945 F20101202_AABXFK jackson_d_Page_45.QC.jpg
d3c64329976af2158b447046db0abe57
6e33582459959e188af648f348aab88b43387661
6263 F20101202_AABXUD jackson_d_Page_52thm.jpg
3e4124cb6c7f7e909042d07ef6a98c68
cdd59bfa9e6542a1252310b87d6ac3c3d02a41c5
F20101202_AABXPF jackson_d_Page_18.tif
6987a427484cb0288db020f02d579edc
36642ff57e0fb27f2c547a0bac1e5ebbe70eef86
79212 F20101202_AABXKI jackson_d_Page_13.jpg
9c67fa17d77e35b6d13b618a0882bbb7
4c9cb548ab870b1fbd5c2c7c86778417e03a23a5
77989 F20101202_AABXFL jackson_d_Page_44.jpg
476cc09d35a69107510a057cd671195f
9b74bc2f4baeb0685a05f7b7bfb061641d75a216
7036 F20101202_AABXUE jackson_d_Page_53thm.jpg
50e3f549c5c1311e9e9f5a80669873aa
56018ab2dadafd44cd8b27d7bd8faa045cf33ed5
F20101202_AABXPG jackson_d_Page_23.tif
ce8ac0cef5fefb848ccef22f252d44f4
7e8f239e255e916dfc5c7872dce3515fbf9c9983
79540 F20101202_AABXKJ jackson_d_Page_14.jpg
48ea3bd1eb298cd66aa443118c04072e
c1d7b91c7cb4d5317c63e6a51696f8d74c156b56
13385 F20101202_AABXFM jackson_d_Page_67.jpg
2529133b6f1d2fc9ae194688a0365146
5b609b0665b61ed63cff8c1d259375faf23a7dd4
F20101202_AABXPH jackson_d_Page_24.tif
763b80b6847ed3b0fe334d3ee9998932
afce6d08fcd7b90c408d3492539f6f60df6e528c
75528 F20101202_AABXKK jackson_d_Page_19.jpg
66975eeef73d3f5b15249c0e7652c980
88427344592d9b8dba671df39afa647fd4dc4f0f
6339 F20101202_AABXFN jackson_d_Page_08thm.jpg
89e840c9b1da3d20dcbeaf9caaf552df
3cd0d19a87678012f7226537d321502267802b35
24688 F20101202_AABXUF jackson_d_Page_54.QC.jpg
e2d8b22544c49898f9c2fe1abc591e03
3c84bcc0b7ac00b4fec9f647a78499f1b5272c9b
F20101202_AABXPI jackson_d_Page_25.tif
8fd9e307c79d54e0eb82cace1db5f025
46d0078e3db1c446d8e4ab0cee0eb10ca330a639
33944 F20101202_AABXKL jackson_d_Page_20.jpg
2f4e7bd6c529f01d398db3fc633e01d8
d81a856e234f7939ee0b29eaf7b4ddbcbbcee543
1530 F20101202_AABXFO jackson_d_Page_03thm.jpg
b541afcbb1f691a616ad93a42e5c0b15
b1c5b311e72c35ca914bf1197991443c5c910293
6702 F20101202_AABXUG jackson_d_Page_54thm.jpg
62fbfcc4c5dc0715c5a20802728b9e64
3ddd66409bdb0162b540de0b47c9229f891ce8a2
F20101202_AABXPJ jackson_d_Page_27.tif
f95b1d1bd57a3b551916510d867ed60d
7ffebf885d51836d03261cc931a8d5b4aea2ea3c
67123 F20101202_AABXKM jackson_d_Page_21.jpg
b11d380995ea13116371030ac4c30efc
4034d32533efbd186d3ed6560b73c54bbb8b5e70
75842 F20101202_AABXFP jackson_d_Page_15.jpg
33734cc3aecd76f4b193098d670befda
6c05f89393479db1c7a4cb86b49eb70394bfffb1
21489 F20101202_AABXUH jackson_d_Page_55.QC.jpg
b2e5b950b436cb4411cbf28d1e28e9d6
535daa00aced2b166ce5b0a7a0b66ac7fb613d2b
F20101202_AABXPK jackson_d_Page_28.tif
7bc8be6581a6b4d512d08a490fcfc8b0
07b60579e3280aef8f3859ce0de29f538fe75ff9
80660 F20101202_AABXKN jackson_d_Page_26.jpg
efa587535ddfa1e96152d8b149560005
86db290956ea2700c797c71bfcf1cc46b1edc5f5
66104 F20101202_AABXFQ jackson_d_Page_70.jp2
e136a65ad87c1bb91c3a467168803487
0cec0eb98eb410aca82f9f9c101236f59324f07e
20806 F20101202_AABXUI jackson_d_Page_57.QC.jpg
2ae663b9d409573c27e6064b0f3fe286
d452546caba98ea99c31e46c443d01bb3804d3d0
F20101202_AABXPL jackson_d_Page_29.tif
119a4a0a6ac1926908d17d8e5acb104b
60486b044dad12ddbb3a3d24002bad73152b1beb
74070 F20101202_AABXKO jackson_d_Page_27.jpg
dccf957660ef58013c775924c9a14739
ecfaef217258a52a74e607841c9c62fe909db164
94538 F20101202_AABXFR jackson_d_Page_90.jpg
568033918f93a645584f49a5807f094c
2210eaf625bbd85d6ab3019a7b64d5fe299e078e
24794 F20101202_AABXUJ jackson_d_Page_58.QC.jpg
e2b23936ea2a0821e2dc551ecb958489
af3f16f03d735401f595f5ed3dc5bde737373e0c
F20101202_AABXPM jackson_d_Page_30.tif
7c6caed1602bcac067c19e2543564264
2b84c8263fc5cc1fd05a9797dd228eda20f083a0
73009 F20101202_AABXKP jackson_d_Page_28.jpg
3f08313b5f8046ed91e882ca7d007e49
25b88da02c035aadd65b6cf60e3ca6e66a7dd67f
6964 F20101202_AABXFS jackson_d_Page_50thm.jpg
84766ded69d58374715b6b7769605f36
a190a85889fd0be4407796b6a7242270aade99db
F20101202_AABXUK jackson_d_Page_58thm.jpg
c188f62c41d8e1c32a409b7de454f762
94e588132f73c601c7fc22b4cbb75549ddbbc478
F20101202_AABXPN jackson_d_Page_31.tif
ac69310fb61725888b8762f603d2a162
9f60749eda6db03be7991b269a5a8adf0469370d
79085 F20101202_AABXKQ jackson_d_Page_29.jpg
b6dc9331654fb7912cf41525fe5626bf
806dfa49b0b40fa0067d57e3c0dddce87beaac1b
70150 F20101202_AABXFT jackson_d_Page_52.jpg
7641100e16205110f0628c3e59014ab0
6dbfc74fe342a41d2a668cc9d8df120592c5ff89
14237 F20101202_AABXUL jackson_d_Page_59.QC.jpg
5e50a2b56306345aeded76dd1389ca5e
c86f5cd93af0eaa9fcb3cdc972c9d6da66266f58
F20101202_AABXPO jackson_d_Page_32.tif
c3383c57ca6843e6ef89849f579b150a
f63d46c1aa0b9e10cdb1a62804ac87308ba1df79
79106 F20101202_AABXKR jackson_d_Page_30.jpg
b9440c0fc9efdf824eedbd5040777e06
36302adaabaab5d66939df144e53d02a9d1c816c
2285 F20101202_AABXFU jackson_d_Page_73thm.jpg
659339e3dda3177eea100b7da19efe34
4dbd70b12ee70405adf4006ec163d01e6a15c664
3989 F20101202_AABXUM jackson_d_Page_59thm.jpg
81e6df49892bcd01fdd391f28124cfe2
1f1c794d92e88202b2088a9d51af32f9ab09ce38
F20101202_AABXPP jackson_d_Page_34.tif
107085634327a22e2897820694ad5c45
4d385e59018426c9bd489973ad3be35717af09fb
76611 F20101202_AABXKS jackson_d_Page_31.jpg
1aa11d5bb1e4198e171cb69293acc862
75b5f84d7c8325588cb6516a949ce1187025c762
F20101202_AABXFV jackson_d_Page_16.tif
db851756fe3e442c740a8cb2f007de5c
ff7d03cad01cd95c6caf3dab197d28cc592df77f
22727 F20101202_AABXUN jackson_d_Page_60.QC.jpg
412fb69e7a405756cebc6db03b15089c
a9a346406b184ee63b608dcd96f3fa61a009074c
F20101202_AABXPQ jackson_d_Page_37.tif
71b182285012d973ca08b538bc7d86bd
49083f93f1fed49eb3119fb3f6f5b4f3e1fb4ecd
76958 F20101202_AABXKT jackson_d_Page_32.jpg
916843408e867e0a31a202aecf5cc958
e70da6bf276f994c89668174fae2d050612c4860
25618 F20101202_AABXUO jackson_d_Page_61.QC.jpg
9a2272695b87f245c76fd96d26294426
4ad7ecfec3ab0ff6f80cc502e7febfeef77472c8
F20101202_AABXPR jackson_d_Page_39.tif
66004c1b482de7bf6b95b4b2939e45e4
cd68ca4d3e558ef836372bdb5e020b7f2f05a1de
F20101202_AABXKU jackson_d_Page_34.jpg
c835cf6d30643715311c5703743406f6
d792fb1e9070c9bdc5e7f00b81b917ac12d6e1e4
76371 F20101202_AABXFW jackson_d_Page_40.jpg
177bc434dad910351ffc2f79e45835ef
458b90a4e459bdc195421849f6f9391a5c59ee2b
6912 F20101202_AABXUP jackson_d_Page_61thm.jpg
a11a637b7b52194077129e7a0ccb6486
3bbd5ea9a4d40d38e869c4f55bad31dfbc53ff7d
77372 F20101202_AABXKV jackson_d_Page_35.jpg
90ad83d2e68a1b59894fdf7af63aba4f
43733ad6f3dcc301669108989fd362b728586727
27673 F20101202_AABXFX jackson_d_Page_01.jp2
3f9d52c259fb4fde4e6c2b71682015c7
21fda4a0cbbacc89a3770e3ec86f7762e7ed33f8
F20101202_AABXPS jackson_d_Page_40.tif
380cb6412d27776ceb098c5b0f9ee3a5
94d649f633bddb021a3c7bc8ef37bd1419b84ccb
25071 F20101202_AABXUQ jackson_d_Page_62.QC.jpg
24c2d0fd06359ff8f58ea1eff88d44bc
f2da4b2c57921e15ce6046cd4880b0267f3e7d3f
76951 F20101202_AABXKW jackson_d_Page_36.jpg
dc8682d12eba55de68ee844f9ef01c9f
e066551b59474a66eb10606a86fd3f647b1590de
F20101202_AABXFY jackson_d_Page_45.tif
f849c0c0e2ccdbc6b3bc116eacadc162
f7dce6ecfb1d9b59dce99171473fa29bcae67361
F20101202_AABXPT jackson_d_Page_42.tif
4d72108f7ff6db3425ddd73403181062
880e6d1bba862bb75a5d6f86bed2ab25fdcd2382
6997 F20101202_AABXUR jackson_d_Page_62thm.jpg
5e0c0195ca92a1740efc8d250a48fb5f
f17457c317ed8ef0fac2abbd2cb85a0899237392
74556 F20101202_AABXKX jackson_d_Page_37.jpg
fd038f2c2dd16080bb5036d8857ae1e1
77b4d2ca5e1322f767a1d34fd574dece54f450cf
F20101202_AABXFZ jackson_d_Page_49.tif
45b228c4941d1ad1f579de030f91ccf7
348a6ba1a4d7eb5cb8b82a535109836c7da23aa2
F20101202_AABXPU jackson_d_Page_43.tif
3ac128062cebb078f5ffef9bd8521923
8c3c73312b1acf8190ee41f17acd394ef02b9032
25704 F20101202_AABXUS jackson_d_Page_63.QC.jpg
0663dcb1924b3543ce0f641c59ed5a27
06137c40d9658376c1b62984c223f11306780b64
75763 F20101202_AABXKY jackson_d_Page_38.jpg
b88772d6037730375fc41fdf9a56dd19
02f209b62bd27a965e229844db634ffc4cbd3ee4
F20101202_AABXPV jackson_d_Page_44.tif
55de6f27eae4c993c7172d6f36ec0155
577badacc6ce3e9206f25485beac2edc67a962fd
7033 F20101202_AABXUT jackson_d_Page_63thm.jpg
ac536ef5c139b6e113ff5d42bff837e9
1f13289bc5f8588db13e97808eeaa39ec02d2e1e
116834 F20101202_AABXIA jackson_d_Page_31.jp2
7ebbe37a62dd213fa9f1abbfe05be6fe
8f301fa2ea53e727789a0b720dbd84f662861938
80363 F20101202_AABXKZ jackson_d_Page_39.jpg
e480e3135a31d0f4fbc22344294f2f4b
8bf3c5494c6233f9f4ba0e85efc2168ff9050465
F20101202_AABXPW jackson_d_Page_46.tif
2fb6494763ebfbea2a4d0c651b9154d9
3691404f9e96e2f621ccad13b977282f96be16e0
25478 F20101202_AABXUU jackson_d_Page_64.QC.jpg
df6e8419e0c7823ff5b77c92913d3d67
bd89d66f27bdc78d73096bcf8051af68d8ef2511
F20101202_AABXIB jackson_d_Page_36.tif
78d61a79763334c8f7fa91e5ebd2f7f2
dc56b8d07be2ba32e5b7237fff1c505643b04b6f
F20101202_AABXPX jackson_d_Page_47.tif
c389a2a83481e3801ac3fc698883f10a
9a13cde549570938281b644fa94bc43e2f9a6713
6940 F20101202_AABXUV jackson_d_Page_64thm.jpg
46884b5c93abb8144c1934f066fc707c
5491210fe1d0cf04d54486a84237c46309d861e9
5495 F20101202_AABXIC jackson_d_Page_56thm.jpg
67c69d33804175ca148ee44660a06a38
3ef875361a4dba691188733eed4dfa8b1e57259e
F20101202_AABXPY jackson_d_Page_50.tif
4610f424ab7cba3f227a18a11948be6e
18666f398d4041a3cbaa1be0ba747d984979de81
25229 F20101202_AABXUW jackson_d_Page_65.QC.jpg
c44baa9250294b651bdb5d260effbdc5
30657bdaf44205132727402bcf15406ab5bf40f6
F20101202_AABXID jackson_d_Page_48.tif
955895362cec068a171fadbc72b0793c
50e3bd06c0839737504d32a72f10eab58fe9141c
111825 F20101202_AABXNA jackson_d_Page_25.jp2
cf63bdfd4772bf69c60f667503d67707
ecb0677ba1f59e30c8b557d2d9e05758166cfe1d
F20101202_AABXPZ jackson_d_Page_51.tif
0d3b3840272d6f8c67f89fcdf4467ea2
57ccf93a223ae943c9424c91f8fe905f74ceca19
23881 F20101202_AABXUX jackson_d_Page_66.QC.jpg
f7afb4a774430a720fd657cc362ff936
bcf9df7c8027f84ec9fbffe63681dbc83a9198a2
25321 F20101202_AABXIE jackson_d_Page_35.QC.jpg
baeddbc9ba5c2bd2bb683064e9ffcc50
e7d82882ddac24e001b2f2bcb8f15c8df780d095
123631 F20101202_AABXNB jackson_d_Page_26.jp2
6cb1e3770ac5fe1e2682b9cab8c874c3
166193ba242d4abc6550aea775105f81667e1653
6778 F20101202_AABXUY jackson_d_Page_66thm.jpg
1c04b87d26b7774d12f0bb5bf7fa2c67
6ed3af333badb61deb643b4006f9aa4e2be602ad
6820 F20101202_AABXSA jackson_d_Page_18thm.jpg
f0a56bff3edbaf29e13e9c15b47d3398
780543407b696aa3d821916d79ea4421e9a2dcfa
111753 F20101202_AABXNC jackson_d_Page_27.jp2
b3117e2ae4e32f36fb0430e2c00f74a6
aeeeb62440a2f75ebe8c3a33d208d67866e9ef2f
F20101202_AABXIF jackson_d_Page_33.tif
ea46ae279b69eee2c42597bb45910dfa
bcbb78efb1cb0641ddff891e2ee11ca5ccfc3fc8
1700 F20101202_AABXUZ jackson_d_Page_67thm.jpg
f21864f9d30ffd627dedb2ba9c3741d5
869e307c01146d6d3f6635f5021638fe3fbbc40f
25173 F20101202_AABXSB jackson_d_Page_19.QC.jpg
b2bc561354fbdc73e5fb25bbb238d264
3bd80fcb5f4ab87128696ccf3e58c5299875b9ed
119013 F20101202_AABXND jackson_d_Page_29.jp2
ab49f9ca8247b154cda85a93ded1b878
88ca3909cecec4bbd069b4c869d331515c33c0ef
115975 F20101202_AABXIG jackson_d_Page_15.jp2
5dd9cc6f5c04b66ece9a20396825ee51
eeb77b3beaecfc75a3bcab4d021ff1c455a06d5f
10602 F20101202_AABXSC jackson_d_Page_20.QC.jpg
0ea619cf8231480f8ac27d14b5b1e35f
32d0c8f00d2a5580f4bf0a11dcb62e1828378e30
119465 F20101202_AABXNE jackson_d_Page_30.jp2
a45908a60445cbdc3c24799fa1511bd6
62cbf75600fc34135f59372aed92b54e004b2141
F20101202_AABXIH jackson_d_Page_21.tif
612aa9eabac9992b19d26b7c6e8e2d6b
f4638015ec6b9841f624acf2c48aa0979293b907
119898 F20101202_AABXNF jackson_d_Page_35.jp2
4a191da125ef9b413f78c45f804c3c0a
c66d5b314608aad261a592a000ff8858b263debe
24950 F20101202_AABXII jackson_d_Page_34.QC.jpg
3fa5272be8bdbb21781260d4e295661b
af6abbb1f96aee69501623698de09e9638a912d9
3174 F20101202_AABXSD jackson_d_Page_20thm.jpg
8ce06482128790dcd2ca23664d5ba3ee
bb7953c4df1eb39b4afa7ce72ccecfd47b8f2cae
117723 F20101202_AABXNG jackson_d_Page_36.jp2
5033c64931b30caf821ec4b98d6deccc
d1f9233f69129cf71c9b0b9f89c45d2cfc1452ba
26104 F20101202_AABXIJ jackson_d_Page_53.QC.jpg
125d35284f2278c802df75b14318b73d
2aca88d7496381da412a8c90ef33220d9864ad51
22383 F20101202_AABXSE jackson_d_Page_21.QC.jpg
ed4bdd53f11b7e20f5f29018f04c830b
0afe331131e140811b9c4957feef0643d24f856a
114264 F20101202_AABXNH jackson_d_Page_37.jp2
910e7e967c64ad9e44ffefd562ca8518
2692e45ed5da167af6d70fe9b143d963ae5412eb
111366 F20101202_AABXIK jackson_d_Page_22.jp2
8b0f4a6504b082ff69484c1bba49452d
29f7d2912bc233c7e31353b3518d6a885ae6fae2
6379 F20101202_AABXSF jackson_d_Page_21thm.jpg
0aff58eee4ef97e2b6a1f42661f0d3b3
1e44beecd1e423b80b9cc5b346cac1ec65ee1308
115891 F20101202_AABXNI jackson_d_Page_38.jp2
6dde15fb93a79b673308be636f4913cb
b3f49125dffbe9d9e909255e536a367a7577ba89
7142 F20101202_AABXIL jackson_d_Page_89thm.jpg
b5ce737d8321fb0c12881e7e4ff7870d
7253a48d20cab241bb8b81401c8bd0d9ace05bff
24498 F20101202_AABXSG jackson_d_Page_22.QC.jpg
e55f35210badaa967494672fee9b6404
69eaec964fa12d91e4fcebafd3e8040860708e16
123907 F20101202_AABXNJ jackson_d_Page_39.jp2
6559668cabf52a0623356e9a28810663
f6c2bc460189e06009046a85f81d655f591b8bc4
F20101202_AABXIM jackson_d_Page_20.tif
81602bd68c77f456a1ac6871ef47a3c4
38e5f4cbe76d127fe16491c1b169571d5051961b
6529 F20101202_AABXSH jackson_d_Page_22thm.jpg
d8aea7617b1fe06b6b2ec5c37d6d89e8
47103f1c8d84e003c7ca6700f528400d8d5a417e
116151 F20101202_AABXNK jackson_d_Page_40.jp2
5ca45b4cf6cf372ab834866dac773223
424afa865116d62790444ada31e187ba3e3d9c20
110394 F20101202_AABXIN jackson_d_Page_28.jp2
28e6170c4054757e838f4e5bbb4b84ba
07f9f2a31943bcb8da53357ac1086172aa951a9e
23495 F20101202_AABXSI jackson_d_Page_23.QC.jpg
ec56a775422a7406614d0e059d4a4866
ec9352d33484fd320ecd818a9155b6e748603830
113300 F20101202_AABXNL jackson_d_Page_41.jp2
97c87a9fd248cf860531b4c7cecef1b6
04fcee6c9bd187a19b93600bfc4f8b644217516d
6952 F20101202_AABXIO jackson_d_Page_76thm.jpg
734a616d3c01850012ad89dc908e605a
08b442e4275d65866f6ead56af604dd00eafb84b
6619 F20101202_AABXSJ jackson_d_Page_23thm.jpg
e4cdcd99f6e51460605ca2824d8a5899
37bbb7595e776187bf8e26f2d378a6d66ec47fb2
113463 F20101202_AABXNM jackson_d_Page_43.jp2
a54f88b41b7e6740bb318983b64b55ac
a0c897331841aafcd0c30551e6ab31543182eca1
6800 F20101202_AABXIP jackson_d_Page_10thm.jpg
1412f7787669dd94a0665a9616221465
4e6ae4ff67d58b27b2aeacf12d88aed17ab42432
22130 F20101202_AABXSK jackson_d_Page_24.QC.jpg
faba165defc36f87b1b910183f57b686
e7800dbbb4fa45f9324566dc74d897ddeeb0f881
117978 F20101202_AABXNN jackson_d_Page_44.jp2
f558c4bc6a2da3e007e4ff78d5366a18
a0cc9e24c00043ee90f40db4fa7dc7d1944a3404
24215 F20101202_AABXIQ jackson_d_Page_43.QC.jpg
f326087bf8ebb1aea33a27e289d3dc08
a7441d1a6b2fb2c85d221ba013cc15ffd86ca8f1
6430 F20101202_AABXSL jackson_d_Page_24thm.jpg
eecb2aee7137e901d7fa3d34f84fe378
19deb1fb789cc83270a04ef5524b7c99470e5173
114171 F20101202_AABXNO jackson_d_Page_45.jp2
1a24c30488332d38620aae3376935c2e
878c2aa182aeed5fdc831ad83b76141d84efbe05
114580 F20101202_AABXIR jackson_d_Page_33.jp2
8503132ed27f71c57b6052132b5a5128
87c4d460e52f52385de3c10c94380fe88cef05a0
6575 F20101202_AABXSM jackson_d_Page_25thm.jpg
f4bb40b0d6cdc91203463fed3618c958
aaf0083a7df39c3c2ee3c21137a08d4533dc1dc6
110420 F20101202_AABXNP jackson_d_Page_46.jp2
3695896365d67bf3b8a5fdc7d529cbcc
97622ded827a692d005f44324984a938e6acf0fb
105356 F20101202_AABXIS jackson_d_Page_52.jp2
023ec4ca7d23ead00def49d0882b8e8a
f9c8cd4f7eda9cca5fe5dc4d478b0150264f3ee3
26746 F20101202_AABXSN jackson_d_Page_26.QC.jpg
5147c65a09a072f79bd02345706f7545
e3ff6f801c51e2cd2773c94540dc08afc4280c76
120872 F20101202_AABXNQ jackson_d_Page_48.jp2
7673ac767d03e106700bbf2641e68251
a72fa2ff078f741aeb05bb305dda17d7b4d0c0dd
115966 F20101202_AABXIT jackson_d_Page_19.jp2
b2641c891496073cddb0dc448233e479
685f4d1b5bb3a48b3835629ae2976a48f77b6358
113057 F20101202_AABXNR jackson_d_Page_49.jp2
197bbd4f3c0183423754184f2171f676
06c88b41b0dd9923d5f7f45a701c0ff2a2a95b64
F20101202_AABXIU jackson_d_Page_01.tif
21166d61ee95898804d605c8366f9388
63fc5dfc8611946b7673cce5ef3090ba2ac2bffd
7021 F20101202_AABXSO jackson_d_Page_26thm.jpg
12d46865e1e494543e8cfdb9580814e1
258899311d7f4251fef79911fef63ba8f3dd89f3
119910 F20101202_AABXNS jackson_d_Page_50.jp2
08f6b7ebb021374048731dfb9777c757
68ef16dcd22b616fbfbb038a537e571ac76e0ad7
74870 F20101202_AABXIV jackson_d_Page_08.jpg
e1cf833a667737f1fe9e447cdbed002f
128117988c664b97040ac1972bcff2dc14edcddb
24202 F20101202_AABXSP jackson_d_Page_27.QC.jpg
bb0b8cb783957c6f1d1151d79931deba
aa665460fd0afb45382f3de8066c4098bb03dc93
94890 F20101202_AABXNT jackson_d_Page_51.jp2
0d8d8f6823e5ea145770324592b48db6
d4c1b511e81df2ff79e99f2b602d34ea3f75b01f
24719 F20101202_AABXIW jackson_d_Page_12.QC.jpg
ffb028fd4e4d0a1bfda1e256eb272df5
215b67f991017cb0f902dbd949d3d8a81f39d5b0
23981 F20101202_AABXSQ jackson_d_Page_28.QC.jpg
d0bede917bc17ee914949ffb6e74b1e2
60170409d81414d58cca87306e02529454695ebb
115010 F20101202_AABXNU jackson_d_Page_54.jp2
b107d4e8a65aa67baaaca137440e01d7
9b3c4cf048a06cd49f278ab4b0557b2297c683b3
82443 F20101202_AABXIX jackson_d_Page_53.jpg
4851e3ad1d7efd5fd1a7c26c17a96290
ea1c91d9e53e11288818e61282e914b814a366fe
6835 F20101202_AABXSR jackson_d_Page_28thm.jpg
7d9cc61cd3d33be4e9bb3d80d30912a7
3fb8a19e39dff187a356c62f734d00cb4b9678a0
114532 F20101202_AABXNV jackson_d_Page_58.jp2
b3f074fb072a9f3cad9805369d299af6
a6d4c0f2cd81dfde061a52a94949576f9c1ee005
7440 F20101202_AABXIY jackson_d_Page_88thm.jpg
9f2d2e092bd86da734cd711f4d72032a
574c58e6664273a277aff12909fc26b974f257eb
6921 F20101202_AABXSS jackson_d_Page_29thm.jpg
f169e9e2c2ce9ce94648bf8983a67b4d
726f47bc4db95c7f14c5fa5204b9959f225ce4c1
60712 F20101202_AABXNW jackson_d_Page_59.jp2
a1550cdf84e8bba77d9ffbcc82ea9ed8
431348060678339b17d8abdb6b4cace610157909
26493 F20101202_AABXGA jackson_d_Page_09.jp2
379bc6bd91b898795d14c56a1781fd1a
504b058e9652976964ff7e363b61f3fd06d307af
25948 F20101202_AABXST jackson_d_Page_30.QC.jpg
8854d3a0a5fa179782bb6697f95e5d42
e812d5b45096f61d5806c298ce583ff0f2b3adc2
103027 F20101202_AABXNX jackson_d_Page_60.jp2
2a5275d4d06a32f38b07b12ad6f93e13
9f69c26a645c2398c593306f5a85e60f65821f78
24829 F20101202_AABXGB jackson_d_Page_37.QC.jpg
76b54a7a0d526ba3bff7ed31b2e2f45e
da969044b80507b5c5d4283f594e1886f888e8a9
11816 F20101202_AABXIZ jackson_d_Page_67.jp2
d9107b3f2ec39ee25fc1390ba4a10b9f
956c3e903b61737dcbd57beab7d0543b76de61a1
F20101202_AABXSU jackson_d_Page_30thm.jpg
1a73798d86b713e5f4c20ade86fdacc7
cc7b5f1db9d154e99ff462df22180a67722cd6c7
117171 F20101202_AABXNY jackson_d_Page_61.jp2
5e79e1c546efbed88efe613f80df93f5
9916e2c804c57f80a83e0fb5c87ee9ef89e18e90
121619 F20101202_AABXGC jackson_d_Page_13.jp2
7c856347bcbc5fb40ff705a7876569cc
622960520c5a62595f72f7132bea591a502f834d
24792 F20101202_AABXSV jackson_d_Page_31.QC.jpg
aa085d947c087bc99540b81bd9ecd772
dd67b09e726d21e2103d0dc4f4f492b688ff3466



PAGE 1

FACILITATING INJURED WO RKERS RETURN TO WORK: USING JOB ANALYSES AND OTHER SELECT VARIABLES TO PREVENT PROLONGED DISABILITY By DAVID JACKSON A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2008 1

PAGE 2

2008 David Jackson 2

PAGE 3

To my wife Jennifer, son Quinn and daughter Amelia. 3

PAGE 4

ACKNOWLEDGMENTS There are several individuals I would like to thank. I would first like to thank my wife Jennifer for her incredible patience during the diss ertation process. There were many times I was overwhelmed with my dissertation and work and sh e managed our two infant children by herself. I would also like to thank Dr. Pe ter Sherrard, my committee chair, for his guidance and support. I would like also to thank my other committee members, Dr. Sondra Smith, Dr. Linda Shaw and Dr. Jamie Pomeranz. I would also like to tha nk my other mentors Dr. Robert Hosford and Dr. Paula Lovett for their guidance throughout my gradua te school studies and professional work. I would also like to thank Cyndi Garvan for her st atistical assistance and SAS consultation as well as Dr. David Miller. I owe very much to Su san Hartwell Johns for her willingness to provide data for my dissertation. I would like to thank my editor and sister in law Jessica Hathaway for her assistance in editing. I w ould also like to thank my parent s, David and Mary Jackson, for their love and support throughout my life. 4

PAGE 5

TABLE OF CONTENTS page ACKNOWLEDGMENTS...............................................................................................................4 LIST OF TABLES................................................................................................................. ..........7 ABSTRACT.....................................................................................................................................8 1 INTRODUCTION................................................................................................................. .10 Introduction................................................................................................................... ..........10 Statement of the Problem....................................................................................................... .11 Rationale of the Study............................................................................................................13 Definitions and Operational Terms........................................................................................16 Impairment and Disability...............................................................................................16 Temporary versus Permanent..........................................................................................16 Partial versus Total..........................................................................................................17 Temporary, Permanent, Partial and Total........................................................................17 Job Analysis.....................................................................................................................18 Indemnity...................................................................................................................... ...19 The Research Questions......................................................................................................... 20 2 LITERATURE REVIEW.......................................................................................................21 Rising Costs............................................................................................................................21 Pain of Unemployment...........................................................................................................22 Disability and Depression.......................................................................................................25 Physicians Role............................................................................................................... ......28 Risk Factors for Prolonged Disability....................................................................................34 Interventions to Preven t Prolonged Disability........................................................................44 3 METHODS...................................................................................................................... .......52 Hypotheses..............................................................................................................................52 Independent Variables............................................................................................................53 Dependent Variable............................................................................................................. ...56 Participants.............................................................................................................................57 Data Collection.......................................................................................................................57 Data Analysis..........................................................................................................................58 4 RESULTS...................................................................................................................... .........60 Descriptive Statistics......................................................................................................... .....60 Independent Variables.....................................................................................................60 Dependent Variables.......................................................................................................62 Initial t-test Comparing the Job Anal ysis to the Non-Job Analysis Group............................63 5

PAGE 6

Backward Multiple Regression Analysis................................................................................63 Comparison of Individual Independent Variables on the Dependent Variable......................65 5 DISCUSSION................................................................................................................... ......74 Overview of Significant Findings...........................................................................................74 Job Analysis.....................................................................................................................74 Direct Contact..................................................................................................................75 Attorney Involvement......................................................................................................76 Body Part Injured............................................................................................................77 Age..................................................................................................................................77 Limitations.................................................................................................................... ..........78 Job Analysis.....................................................................................................................78 Comparison of Individual Independent Variables...........................................................79 Suggestions for Further Research...........................................................................................79 Implications for Practice and Policy.......................................................................................81 APPENDIX: QUESTIONNAIRE.................................................................................................82 LIST OF REFERENCES...............................................................................................................83 BIOGRAPHICAL SKETCH.........................................................................................................91 6

PAGE 7

LIST OF TABLES Table page 4-1. Chi-Square Comparison of Independent Variables for Correlations......................................68 4-2. Multiple Regression Analysis.............................................................................................. ...69 4-3. Comparing the Sub-Groups on Ti me on Disability Individually...........................................70 7

PAGE 8

Abstract of Dissertation Pres ented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy FACILITATING INJURED WO RKERS RETURN TO WORK: USING JOB ANALYSES AND OTHER SELECT VARIABLES TO PREVENT PROLONGED DISABILITY By David Jackson August 2008 Chair: Peter A Sherrard Major: Mental Health Counseling The objective of this study was to determine if the time an injured worker received temporary disability could be reduced by having the treating physician review a job analysis. Job analyses are customized job descriptions that include the precise physical and mental demands of a specific job. Following the job an alysis comparison, age, attorney involvement, direct personal contact with a counselor and body part were examined to determine if those variables could predict di sability time as well. A total of 101 injured workers in the construction, logging, oil and gas, structural moving and wate r well drilling industries were included in the study. All subjects suffered a compensable work injury and had missed at least one week of work. Fifty of the workers had a job analysis performed on their particular job and presented to their respective treating physicians Fifty-one workers had no j ob analysis performed and the mean time of disability, in weeks, was compar ed. Workers over age 49 who had a job analysis presented to their treating physicia n received significantly fewer w eeks of disability than those without a job analysis. A job an alysis did not have a significant influence with workers under age 50 however; several limitations of this study may help explain the lack of significance. Other variables were then explored to determin e their correlation with time on disability. An injured worker represented by an attorney rema ined on disability sign ificantly longer than a 8

PAGE 9

9 worker not represented by an attorney. Workers under age 50 w ho had direct personal contact with a rehabilitation counselor received signifi cantly fewer weeks of disability than those without direct personal contact with a counselor. Injuries to the upper extremity (e.g. shoulder, elbow, wrist, hand or fingers) le d to significantly less time on di sability when compared to injuries to other body parts.

PAGE 10

CHAPTER 1 INTRODUCTION Introduction For all living organisms, experi encing an injury is unfortunately a common experience. Living organisms are fragile and sus ceptible to illness, injury and inevitably death. Most injuries are not severe or then fully heal with no long te rm residual limitations, pa in or other effects. However, some injuries lead to chronic pain, impairment and/or disability. The distinction between injuries that heal a nd those that lead to a disability may be accountable to more than a factor of physical h ealing alone, there may also be a psychological component. Of the research in this area, one ar ticle written nearly 40 years ago provided impetus to this particular project. While examining a population of people with a work related injury, McGill (1968) noted that if an injured person rema ined out of work more than six months, he or she was much less likely to ever return to wo rk. Others have found si milar results (Crawford, 2004, May 18; Hashemi, Webster, Clancy, & Volinn, 1997). In 1973 the US Congress passed The Rehabilitation Act and the modern vocational rehabilitation era was born (Rubin & Roessler, 1995). Although rehabilitation services had been provided for disabled soldiers since the 1918 So ldiers Rehabilitation Ac t, the 1973 law provided substantial funding for programs to help people w ith disabilities return to work. In 1974 the Commission on Rehabilitation Counselor Certification (CRCC) was establis hed to regulate and set standards for rehabilitation couns elors. In their efforts to help people with disabilities return to work, rehabilitation counselors attempt to match the person with a disab ility to a job for which he or she possesses the experience, skills and ed ucation and can meet the physical and mental requirements of the job. One of the many t ools rehabilitation counselors employ is a job analysis. Rehabilitation counselors can perform workplace assessments, or job analyses, to 10

PAGE 11

document the mental and physical requirements of the job to determine if their client possesses the residual functional capacity to perform the job. Job analyses commonly follow a format developed by the Department of Labor, utilizing definitions, descriptors and categories that guide the rehabilitation counselors report and help ensure that both the counselor and treating specialist(s) utilize th e same nomenclature. The report is commonly reviewed by the physician, employer, risk manager, insurance representative or other specialists. In the case of workers compensation patients (specifically those that have been restricted from returning to work by their doctor), this report is typically designed sp ecifically for the doctors review. The physician, using specialized knowledge of the environmental limitations associated with the diagnosis as well as the severity of the di agnosis and resulting impairme nts, decides if the physical requirements of the job are within the physical capacitie s of the injured patient. Although there are numerous re asons why a physician may w ithhold a partially injured worker from returning to work, one of the hypotheses guiding this pr oject is that many physicians treating partially disabl ed workers 1) do not take the time to sufficiently learn about the physical requirements of their patients job, 2) are misled, either deliberately or not deliberately, by the workers description of the workplace environm ent; or 3) err on the side of caution and keep the worker, who is capable of safely returning to work, from returning to work. If temporary disability conti nues for a prolonged period, the chan ces that the worker will ever return to work diminish substantially. Statement of the Problem As of June 2007, 6.9 million Americans under age 65 were recognized by the US Federal Government Social Security Administration disability program as being totally disabled and were receiving income and healthcare benefits from SSA (United States Social Security Administration, n.d.). Sudden household accidents, motor vehicle accidents, workplace injuries, 11

PAGE 12

cerebral vascular accidents and diseases commonly result in injury, impairment and disability. In all of 2004, nearly 800,000 Americans were awarde d disability benefits by Social Security. According to SSA, musculoskeletal conditions are the most common body systems to be associated with total disability. Musculoskeleta l injures were also asso ciated with the longest periods of disability for work ers compensation patients (Unite d States Department of Labor Bureau of Labor Statistics, n.d.). The SSA awards disability benefits to Am ericans only if they cannot engage in any substantial gainful work because of a medically determinable physical or mental impairment (Social Security Administration Office of Hearings and Appeals, 1990, February). An applicant is denied disability if there is any work, anyw here that exists in the country in substantial numbers that the applicant could engage in, usua lly including entry level jobs, even if the job does not exist in the local economy or there is not an opening (United St ates Social Security Administration, n.d.). Since one requirement for the receipt of disability benefits is not earning income, individuals are unlikely to have been earning any wages for the months and years before and during the application and appeals process. When the federal Social Security system rec ognizes an individual as being disabled, he or she is usually declared by an adjudicator or admi nistrative law judge as having a total disability that prevents him or her from working in a ny capacity. The Administration does not have a category to cover partially disabl ed workers. The philosophy is that partially disabled workers can work in some capacity, that is, their disability is not total. According to the Rehabilitation Research and Training Center on Disa bility Demographics and Statistics Disability Stat us Report (2005), over 22% of working age Americans with a disability were working full time all year in 2005. This is comp ared to the 56% of working age 12

PAGE 13

Americans without a disability that worked full time all year in 2005. If part time workers are examined, the figures are 38% and 78% respectiv ely. The average annual household income of persons with a disability is $26,000 less than their non-disablied counterparts and the difference in the poverty rate is 15.3%. Nearly 25% of all Americans w ith a disability live in poverty. The percentage of working age Americans repo rting a disability increased from 12% in 2003 to 12.6% in 2005. However, only 15.4% of th ese individuals were receiving Social Security Disability. Among the 16.9 million peop le age 21 to 64 who described themselves as having a severe disability, 56% were not receivin g disability payments (Steinntz, 2006, May). Of this population, 35.5% were not employed in a ny capacity for the preceding 12 months. This represents nearly 3.37 million Americans with a disability that are unemployed but not recognized by the federal government as disabled or did not qualify for disability benefits. The Social Security Disability Insurance (SSDI) application and appeals process takes months and occasionally years to complete. Approximately 70% of applicants are denied after their first application and 90% are denied durin g the appeals process ( Disabilitysecrets.com n.d.). These applicants that are denied repr esent the numerous Americans who have become convinced at one time after the onset of their injury or illness that they were unable to work, but according to the SSA, were capable of working. Rationale of the Study After a worker is injured, it is important to receive timely medical care and return to work as quickly as possible. In 1968, McGill reported that after six months of being on workers compensation disability, a worker has only a 50% chance of ever re turning to gainful employment and after one year of being out of wor k, the possibility of ever returning to work is 25%. Other research shows that injured workers out of work for more than six months have only a 25% chance of ever returning to gainful employment (Crawford, 2004, May 18). Hashemi, 13

PAGE 14

Webster, Clancy, and Volinn (1997) studied the costs and time out of work for 106,961 injured workers with low back pain and detected a pattern. Of the injured workers who were on disability at the end of n weeks, only 50% would be off disability at the end of 6 n weeks. However, their study only included active workers compensation claims. There was no follow up to determine what happened to the injured workers after their disability ceased or why it ceased. There was no exploration to determine if the injured workers returned to work, their indemnity benefits expired or if they were a pproved for SSDI or Supplem ental Security Income (SSI). Considering that only a small pe rcentage of this population will ever qualify for disability income, the first few months after an injury repr esent a critical time to introduce return to work options for people with partial or non-catastrophi c disabilities. There may be several explanations for th is phenomenon. Although clinical guidelines underscore continuing physical activities during most kinds of back pain, many patients with back pain may suffer from kinesiophobia. They are fearful that physical activity will worsen their pain or injury, causing more disability th an warranted by their pain and injury alone (Linton, Vlaeyen, & Ostelo, 2002). The inactivity causes debilitation or weakening of the body and makes them more susceptible to pain. Anot her theory may be that because most physicians are trained only in physical medicine and many focus only on physical dysfunction to the tissues in the back, they convince thei r patients that recovery can only be achieved by medical provisions to the spine despite findings that much of back pain is biopsychosocial and reflects no physiological damage to the spine (Mahmud et al ., 2000; Loisel et al. 200 5). Another possible explanation is that patients reflect the fears of their doc tors. When physicians hold misconceptions about the etiology of their patients pain and activity level, so will their patient (Linton, Vlaeyen, & Ostelo, 2002). Other explanations involv e the secondary gain from 14

PAGE 15

prolonged and disabling pain (Rainville, Sobel, Hartigan, & Wright, 1997) or the adversarial nature of workers compensation leading to the worsening of pain perception because of psychosocial stressors. Patients and doctors may al so only be reflecting th e culture expressed in the media (Buchbinder, Jo lley, & Wyatt, 2001). According to the United States Department of Labor Bureau of Labor Statistics, in 2005 there were 4.2 million reported nonfatal work-related injuries and illnesses in private companies and nearly 30% of those injures caused the inju red worker to take time away from work. Although the median number of days missed was seven, 25% of the injured workers who missed work missed over 31 days (United Status Department of Labor Bureau of La bor Statistics, 2006). Thirty percent of lost time injuries were musculos keletal in nature and n early seventy percent of all musculoskeletal injuries were in the serv ice producing industries the fastest growing industry. The cost of workers compensation is also an important issue. Twenty years ago indemnity payments, or payments made to the inju red worker to replace lost wages, represented the majority of workers compensation costs (I nsurance Information Institute, n.d.). Although by 2003 medical costs were slightly more than half of total workers compensation costs, indemnity payments still represented 45% of total costs. Th is reversal may be due more to the rising costs of medical treatment for work injuries and not falling indemnity costs. From 2001 to 2005 the average rate of increase in workers compensa tion medical care costs was 10%, compared with an annual average rise of 4.4% of the medical care Consumer Price Index (CPI). Workers compensation patients also use more medical care, when compared to non-workers compensation patients. According to the Natio nal Council on Compensation Insurers (NCCI), the increase in medical costs of workers compen sation patients is more than double that of non15

PAGE 16

workers compensation patients is because workers compensation patients receive care longer, more often and use a greater mix of services. At torney involvement, an issue rare in personal insurance, boosts claims costs between 12% and 15%. Definitions and Operational Terms Impairment and Disability Impairment and disability are two terms th at frequently coexist but have distinct definitions. Impairment refers to the loss or abnormality in the psychological, physiological or anatomical structure or function (World H ealth Organization, n.d.). Impairments are the disturbances of the bodily systems, organs or other structures and ar e the specific and obvious consequences of an injury. They are the prolonge d clinical conditions that either temporarily or permanently disrupt physical, mental or affectiv e functioning (Livneh, 1987) When there is an interaction between features of the persons impairment and those of the society in which he or she lives, disability is the result (World Health Organizati on, n.d.). It is a restriction of the activities expected of the average non-disabled person because of the impairment. Workers compensation boards commonly consider a disability as an incapacity to earn, in the same or any other employment, the wages which the employee wa s receiving at the time of the injury because of the injury (Florida Workers Compensation Institute, 2000). Impairments usually, but not always, lead to a disability. Temporary versus Permanent Most insurance programs disti nguish temporary disabilities from permanent disabilities as well as partial from total disabilities (Florida Workers Compensation Law, 2000). Temporary disabilities arise from impairments and injuries that are expected to heal, leaving no permanent functional loss. They are fluid and can change as the patient undergoes medical or behavioral treatments designed to eliminate the illness, thus leaving no impai rment. Permanent disabilities 16

PAGE 17

are what remain and are irreversible. They resu lt from impairments associated with injuries or illness that are not expected to heal. They us ually require the injured individual to make life changes to adapt to the disability. Partial versus Total Partial disabilities commonly al low the injured worker to c ontinue working, although with limitations to some activities. For example, a be low knee amputation is only a partial disability to a telemarketer. Total disabilities however, prevent the injured from any and all types of vocations in which they might be reasonably expect ed to work. Because of the impairment, or a combination of impairments, the person is inca pable of working at even the most sedentary position. As a counter-example, a below knee amputati on for an illiterate fruit picker is usually a totally disabling condition. Temporary, Permanent, Partial and Total There are also intersections be tween partial, total, permanen t and temporary statuses. A temporary status signifies the pa tient is in the process of healing, undergoing medical treatments or expected to improve from their diagnosis a nd impairment. A temporary disability should therefore change, hopefully improve. A temporaril y and totally disabled patient is completely incapable of working, but expected to improve. For example, during hospitalization, a patient is typically not permitted by his or her physician to leave to go to the office and is therefore unable to work in any capacity. He or she is totally disabled. Once discharged, the patient may be allowed to return to work and therefore, duri ng his or her hosp italization, was temporarily but totally disabled. As most injuries do not requ ire hospitalization or even lost time from work, most injures incur no lost time (United States Department of Labor Bureau of Labor Statistics, n.d.). Partial disability status al so considers the injured workers job and the physical and mental requirements. Knee surgery and a requirement to remain on crutches is likely only a partial 17

PAGE 18

disability to a school teacher. Reasonable ac commodations may allow the teacher to continue working. If the patient is exp ected to recover from the surgery, the disability is only temporary and partial. However, the same surgery and impair ment for a fruit picker is likely temporary but totally disabling. The difference between a totally disabled work er and a partially disa bled worker can be better understood by considering the philosophy behind the SSA listing of impairments. When the Social Security Disability program determines if an applicant is disabled, one of the first steps is to determine if the applicant has a medical injury or illness so severe that the impairment alone, regardless of the applicant s education, age or work histor y, would prevent the individual from engaging in any work that exists in substantial numbers in the economy. For example, an applicant who, through documented medical eviden ce, has eyesight equal to or worse than 20/200 in the best eye would meet listing 2.02 in the SSA listing of impairments (U.S. Social Security Administration, 2005). Anyone with an impairment this severe would be considered totally disabled. An individual with eyesig ht of 20/100, although very poor, would not be assumed to have a disability. The philosophy is that not all occupations require good eyesight. The worker could not work many jobs, but he or sh e may still retain the capacity to work some jobs. For example, the worker could no longer work as a jewel inspector, but may be able to work as a fruit picker. Job Analysis According to the United States Department of Labor Employment and Training Administration (1991) a job analys is is a systematic study of a specific job in terms of the workers relationship to data people and things, the met hodologies and techniques employed, the machines, tools, equipment and work aids used, the materials, products, subject matter or services which result and the worker attributes that contribute to successful job performance. 18

PAGE 19

They also include worker traits such as th e physical demands of the job, working conditions, general educational development level, specific vocational prep aration, aptitudes, interests and temperaments (Weed & Field, 1994). Physical demands should include the exertional and nonexertional requirements. Lifting, pushing, pul ling, reaching, handling, stooping, climbing and many other factors incorporate the physical components. Job anal yses usually include aptitudes such as verbal, numerical and spatial requirements or temperaments such as directing others, dealing with others or making judgments and decisions. Job analyses come in many forms, such as written reports, vide o analyses, pictorial analysis and others. Job analyses can be perf ormed using electronic data (Sanchez, 2000) and the purpose of the analyses can vary. As a physicians concern is primarily with protecting against exceeding the physical limitations imposed by the injury, job analyses performed for a physicians review usually have a specific emphasi s on the physical demands of the job. They can be used to identify the essential functions of a job and also the reasonable accommodations that would allow the individual with an impairment or disability to continue working. Indemnity If an injured worker is withheld from wo rk by his or her treating doctor because of a work injury related impairment and subsequently loses income, he or she is usually entitled to wage replacement payments by the workers compensation insurance company. The company typically pays a portion of the work ers average weekly wage until the worker is cleared to return to work by the doctor. The industry and state laws refer to these payments to the injured worker to replace lost wages as indemnity (Florida Workers Compensation Law, 2000). As will be discussed in greater detail in ch apter three, the outcome variable will be more related to the length of time an injured worker received indemnity payment than the time spent out of work. 19

PAGE 20

20 The Research Questions The following questions were addressed during the study: 1. If a doctor reviews a job analysis of a posit ion available by the empl oyer, is the injured worker cleared by the doctor to return to wo rk sooner than had the doctor never seen a job analysis? 2. If the injured worker has hired an attorney, is he or she more likely to remain on disability longer? 3. Is age a significant factor for time on disability? 4. Does the body part that is injured si gnificantly influence time on disability? 5. Does the involvement of a re habilitation counselor, working directly with the doctor, employer and patient, have an influence on this timeline? 6. Is there a combination of variables th at prolong or shorten disability time?

PAGE 21

CHAPTER 2 LITERATURE REVIEW Rising Costs The cost of workers compensation injuri es, and the subsequent premiums paid by employers, are analyzed regularly by various private and non-prof it organizations. Most state Workers Compensation divisions maintain their ow n statistics as well concerning costs. Below are reviews of selected articles. Hashemi, Webster, Clancy, and Volinn (1997) found that 70% of claims cost $1000 or less and, on the opposite end of the spectrum, 10% of inju ries were responsible for 86% of the costs. In 1991, Frymoyer and Cats-Baril (as cited in Hashemi, Webster, Clancy, & Volinn, 1997) estimated the total economic imp act of low back injuries alone was between 75 and 100 billion dollars per year. Hashemi, Webster, and Clancy (1998) review ed low back claims for a large insurance company that insured approximately 10% of the private US workers compensation market from 1988 to 1996 and tried to detect any trends in length of disability and cost. They found that on average, 74% of low back injury claims incurre d less than one week of disability. Of these claims, 23.4% were zero cost, 74% were medical only (no lost time) and 2.6% incurred less than one week of disability. Over the period study, the authors noted that the frequency of these claims increased from 65% in 1988 to 75% in 1 996. Claims that lasted over four months decreased from 12.7% in 1988 to 8% in 1996. A lthough only between 4% and 9% of claims involved more than one year of disability (depending on the year), these few claims accounted for between 65% and 85% (depending on the year) of the total costs of all low back claims. However, these claims decrease d 56% over the period studied. 21

PAGE 22

The authors speculated that the decrease is lik ely due to a combination of factors. State workers compensation laws have become stricter regarding length of disability, employers may be more likely to offer modified duty, managed ca re reduces the fees paid to medical providers and the number of high risk occupations has d ecreased. They also reference a study by the National Council on Compensation In surance that shows the strength of economy may be the single biggest predictor on the num ber and costs of claims. As the economy expands, so does the frequency and cost of claims. However, as the economy slumps, so do the amount of claims and costs. In 2004 over six million injured workers were rece iving social security disability with each individual receiving an aver age of $894 per month (United States Social Security Administration, 2006, February). An additional 5 .7 million people with disabilities received supplemental security income (SSI) from the fe deral government. There were 377,030 disabled workers living in Florida. In December 2004 alone the federal government paid six billion dollars to disabled workers. Pain of Unemployment The value and importance of work is difficu lt to overstate. Employment provides value and satisfaction to workers such as achievement, comfort, status, altruism, safety and autonomy (Dawis & Lofquist, 1984). Achievement typi cally includes ability utilization. Economic independence, security and activity provide comf ort. Recognition for good or hard work, for having authority and social rank provides status. Altruism includes demonstrating and being identified with moral values and social service. Safety includes practicing company policies, supervision-human relations and supervision-tec hnical relations. Autono my can be satisfied by the creativity and responsibility associated with work and financ ial independence. Missing work 22

PAGE 23

would deny these satisfactions and missing an inordinate amount of work may lead to emotional changes that may require psychotherapy. Frese and Mohr (1987) found that even for th e non-disabled population, being unemployed contributes to mental health problems. They studied 51 blue collar workers over the age of 45 and found that prolonged unemployment leads to depression, reduced hope and financial problems. However, they found that none of th ese factors led to unemployment. Once the worker found employment, there was a reduction in depression and financial problems. They speculated that financial problems and disappointed hope played a role in the development of depression. Montgomery, Cook, Bartley, and Wadsworth (1999) attempted to ascertain if the link between depression and unemployment was more due to an association between those more vulnerable to mental illness woul d more easily become unemployed than a cause and effect link. They made adjustments for any subject with a pre-existing tendency for depression, behavior maladjustment, social class and region of resi dence. In this longitudinal study of 3241 British men, their data concluded that unemployment was a risk factor for depr ession severe enough to warrant treatment even in men w ith no pre-existing tendencies. Unemployment not only contributes to depr ession and financial problems, but perhaps marital difficulty as well. In a longitudinal study of 815 recently unemployed job seekers, Vinokur, Price and Caplan (1996) studied the link between unemployment, economic hardship, depression and marital or relationship satisfaction. They found that the financial strain of unemployment had a significant effect on the depre ssive symptoms of both partners, which also led to both partners withdrawi ng social support from one anot her. The reduced support and 23

PAGE 24

increased undermining behaviors had advers e effects on both the sa tisfaction with the relationship and on depressive symptoms. Rodriguez, Lasch and Mead (1997) tried to separate the aff ects of financial strain from the affects of unemployment when comparing depressi on rates of employed to unemployed workers. The authors analyzed data collected from the National Survey of Families and Households of 1987 to 1988 and found that if the unemployed wo rker received unemployment compensation, their depression rates was similar to an employed worker. However, the depression risk for unemployed workers collecting welfare was id entical to unemployed workers receiving no financial support. Their findings remained si gnificant even after controlling for household income. However, Joelson, and Wahlquist (1987) studied shipyard wo rkers over a two year period and noted that even if the workers received unemployment compensation, they still displayed depressive reactions during their unemployment. There was also a growing attitude to be among the job losers. After termination, older workers displayed more of a sick-role behavior than younger workers. Older single men became more is olated, consumed more alcohol and showed more signs of depression. Payne, Warr and Hartley (1984) studied the affects of 6 to 11 months of unemployment on workers and attempted to ascertain if social class insulated white collar workers from the psychological affects. Although th e blue collar workers reported more financial problems, both groups displayed similar amounts of psychological problems. The authors concluded that medium term unemployment appeared to have a homogenizing effect of poor psychological health regardless of income. 24

PAGE 25

Frese ( 1987) found that the depressive symptoms of older blue collar German unemployed workers improved if they transitioned directly in to retirement. Their depression rate became commensurate with employed workers. Frese al so found that depression in unemployed workers was linked to financial probl ems and disappointed hope. D'Arcy and Siddique (1985) studied the ill effects of unemployment on physical health. They analyzed data from the Canada Health Survey of 14,313 Canadians and found that the unemployed showed significantly higher levels of distress, greater short term and long term disability, reported a large numbe r of health problems and had sought and used proportionately more health care than the employed. Unemployed workers also had higher rates of heart trouble, high blood pressure, bone and joint problems, hyperten sion and pain in the heart and chest. Blue collar workers were more vulnerable to the ill physical effects while white collar workers suffered more psychological distress. Low in come unemployed who were also the principle earner were the most psychologically distressed. Asvall (1987) reported that unemployment c ontributes to the worsening of individual health and well being and that it is the most underprivileged w ho are the most vulnerable to unemployment. He noted that unemployment produces stress, reinforces feelings of helplessness and removes opportunities for individual growth and development. Economic, financial and psychological development suffers the most. Disability and Depression Even if receiving disability benefits, the disa bled population is vulnerable to mental and physical health issues. Americans with a di sability are not only impaired by the physical conditions that they report, but many are sufferi ng mental health problems as a byproduct of their disability. Von Korff, et al (2005) surveyed 5692 American s and found that 19% reported 25

PAGE 26

suffering spinal pain that lasted over a year. Of these, 35% had a co-mobid mental disorder. People with chronic spinal pain were significantly more likely to consider themselves disabled. Turner, Lloyd, and Taylor (2006) also studied the link between disa bility and depression and found that 37% of surveyed individuals that met the criteria for a disability also met the criteria for having a psychiatric or substance abuse disorder, compared to only 22% of the nondisabled subjects. Additionally, they also found that Hispanics with a disa bility were more likely to suffer a psychiatric problem than African-Ameri cans or Caucasians. The presence of activity restrictions was also found to be linked to the presence or recu rrence of a psychiatric disorder. Wilk, West, Rae, and Regier (2006) found significantly higher rates of disability and functional impairment in individual s with an DSM IV Axis I disorder as well as alcohol abuse or other substance abuse disorder than those with an Axis I disorder alone. They also found that the rates of work disability for those with a psychi atric disorder and a subs tance use disorder were significantly higher than those without a comorbid substance use disorder. A 2007 study in Louisiana surveyed patients vi siting an Emergency Room for 30 days and found that of the patients who presented with a psychiatric emergency, 32.4% were receiving Social Security Insurance and over half of th at population (51.3%) admitted to abusing drugs (Saran & Patterson, 2007). Additionally, they f ound that of those admitting to abusing drugs, 68.4% admitted to spending their SSI income on drugs. As the monthly SSI rate at the time was $585.00, this would likely place the patient in furthe r financial peril than those not using drugs. The costs of depression alone in the United States rose from $43.7 billion in 1990 to $83.1 billion in 2000 (Greenberg et al., 2003). This includes direct healthcare costs, mortality costs for depression related suicide and absenteeism because of depression. Beyond the healthcare and absenteeism costs of depressed workers, there is an extra, hidden cost to employers with workers 26

PAGE 27

with depression. Even while actively engage d in work, Stewart, Ricci, Chee, Hahn, and Morganstein (2003) found that the lost productivity of workers w ith depression cost employers an extra $44 billion per year. Th ey also found that depression is one of the most costly health related lost labor time condition because it is highly preval ent and comorbid with other conditions. Lerner et al. (2004) studied 246 workers with depression in various occupations and 143 non-depressed workers and found that certain positi ons suffer more loss of productivity when the workers have depression. Workers in positions that required more co mmunication, a high degree of contact with the public and high amounts of j udgment missed more work when depressed. Nurses, social workers, benefits coordinators attorneys, engineers, marketing managers, financial analysts, teachers, customer service ma nagers and salespeople were examples of such positions. Lustig and Vanden Boom (1997) compared 20 employed people with an Axis I diagnoses to 19 unemployed people with similar diagnoses within a community s upport program called the Program for Assertive Community Treatment (PAC T). All participants completed a 45-minute quality of life interview designed to measure their subjective ratings of their own quality of life. After controlling for other variables, they found sm all differences in satisfaction with safety and daily activities, moderate differences in satisfact ion with family, financia l situation, and health and social relations and major differences in gl obal quality of life satisfactions between the unemployed and employed groups. Kessler, Greenberg, Mickelson, Meneades, and Wang (2001) studied lost time from work for all chronic medical conditions and found that 22.4% of workers age 25 to 54 missed at least one day of work per month because of a chr onic medical condition. For those with work 27

PAGE 28

impairments, the monthly average was 6.7 work loss or work cutback days in the previous month. Physicians Role When a physician agrees to treat a patient c overed by workers compensation insurance, a primary concern is the timeline regarding when th e worker can safely resume their work duties (Young, Wasiak, Roessler, McPherson, Anema, & van Poppel, 2005; Loisel et al., 2005). Allowing the individual worker to return to work is in the interest of the worker, employer, health care provider, insurance company and society in general. Physicians are usually the only individuals involved in the inju red workers care that officially determines the workers impairment. A physician in training will spend between se ven and eight years learning the medical aspects of diseases and injuries (University of Florida College of Medicine, n.d.). Physician training does not typically include vocational aspects. Consequently, a physician providing medical treatment to an injured worker li kely does not understand the physical workplace environment of their patient and/or, given the workload and expectations of physicians, do not take the time to learn. Rather than making a vocational decision, idea lly the physician is supposed to, in most occasions, simply indicate in wri ting what physical activities the patient should avoid so as not to worsen their condition or place others at risk (Florida Division of Workers Compensation, 2006). Commonly referred to as work restrictions or work status, these limitations are based on medical factors only. The vocational consequenc e becomes the employers responsibility. That is, it puts the responsibly in the employers hand s, freeing the physician from the responsibility of having to fully understand the workplace dema nds. The employer becomes responsible for determining if the worker can safely resume th eir duties. If the empl oyees usual position does 28

PAGE 29

not require those activities limite d by the doctor, or, in the ca se that the employees normal position does require the activities limited by the physician, if alternative duties can be arranged, the worker can continue working (Florida Workers Compensation Law, 2000). Unfortunately, some physicians may take it upon themselves to make the medical and vocational decision. In the event that the doctor fears returning the patient to work until they have completely recovered, he or she may simply keep the worker totally off work. If the doctor is willing to consider the workplace demands be fore making a medical/vocational decision, they usually must rely solely on their patient for information. That is, the physician must solicit vocational information from their patient. This interaction can be time consuming, but more importantly it requires the employee to articulate a clear and honest desc ription of their work environment. For many vocations, this description is simple. Ho wever, there are two potential hazards to relying on patient information to make a medical/vocational determination. First, the injured worker may not sufficiently communicate the complete details of their job. It may be due to a lack of vocabulary, pr essure to quickly summa rize their duties or an uncertainty of the exact forces present at the j ob site. The patient may provide an answer as honest as possible, but leads the doctor to an incorrect decisio n. Also, a poor or inarticulate description may cause the physician to become conf used or frustrated and, to save time, simply keep the person out of work until the next a ppointment, which may not occur for months. The second potential hazard to re lying on patient information is that it places the physician in a position of susceptibility to deliberate manipulation by the patient. Considering in fiscal year 2005 in Florida alone, work ers compensation fraud cost em ployers nearly nine million dollars (Florida Department of Financial Services Division of Insurance Fraud and Division of Workers Compensation, 2007), manipulation by in jured workers is a significant concern for 29

PAGE 30

employers, their employees and the customers, wh ich inevitably pay higher prices for goods and services. Workers compensation insurance cost s represent nearly two percent of a companys payroll (Insurance Information Institute, n.d.). Derebery, Giang, Saracino, and Fogarty (2002) found that approach ing and educating physicians led to less lost time and less functiona l limitations. They also suggested a more positive attitude by the physician led to a better psychosocial impact on the injured worker. That is, their patients would be less likely to perceive their back pa in as serious or disabling. Hussey, Hoddinott, Wilson, Dowell, and Barbour (2003) found that physicians can deliberately misuse their responsib ilities to determine the functional status of their patients. Some doctors either refused to assign limitations or were overly cautious Their research found that doctors believe determining this status conflicts with the docto r-patient relationship. Mahmud et al. (2000) surveyed 98 low back pain patients that met th eir criteria and found many doctors were not following guidelines for low back pain. They pointed out that spinal imaging is not recommended for the first month of low back pain however, 42% of patients were referred by their doctors for x-rays in the first month. Their caution is that positive findings, even if clinically unrelated or of poor correlation to symptoms, may be interpreted by patients as indicative of a more specific and severe conditi on than actually exists, leading to repeated requests for medical intervention and a delay in f unctional restoration program. This may lead patients to expect a cure or complete recovery. Guidelines recommend that opioids are generally not indicated with low back pain patients and if prescrib ed should be done so for only a short duration. In their study, they found that 38% of doctors prescribed at least two courses of narcotic pain medicine. The researchers f ound a significant relationship between opioid use beyond seven days and prolonged disability. Patie nts who had multiple doctors involved in their 30

PAGE 31

care, had more than five physician visits or rece ived a referral to a specialist remained on long term disability significantly longer. Bishop and Wing (2003) found similar results of doctors in British Columbia. They observed 139 family physicians treatment of workers compensation patients with uncomplicated back pain. Clinical guidelines for the diagnosis and treatment of uncomplicated back pain was distributed to the physicians in advance. Th ey noted the guidelines were developed by the US National Institutes of Hea lth Agency on Health Care Policy and Research, the Industrial Medicine Council of California and the Quebec Task Force on Spinal Disorders and recommended only a short course of narcotic medicine, limited diagnostic studies in the first weeks of an injury, quick resumption of physical activities, including work, and to encourage patient education and exercise. They found that while most adhered to guidelines concerning history, examination procedures and diagnostic testing, treatme nt guidelines were typically ignored. A significant nu mber of physicians r ecommended bed rest, pass ive physical therapies or an early referral to a specialist and only 22% of the physicians followed the guidelines regarding allowing the individual to return to work. McGurik, King, Govind, Lowry, and Bogduk (2001) asked physicians in 13 clinics in Australia to follow evidence based guidelines for treatment of low back pain. The guidelines emphasized patient education and reassurance, empowering the patient to resume or restore normal activities of daily livi ng though simple exercises and graded activity. The doctors included pain medicine and manual therapy only as necessary. Only treatment of non-workers compensation patients were monitored for complia nce and care was administered only to acute back pain patients for a maximum of three months The control group was four general practice units, or geographical regions, in Australia. The researches found that while the treatment 31

PAGE 32

groups physicians examined the patients longer and more frequently, the control group used more physical therapy (as opposed to home rehab ilitation), bed rest, hot packs, medical imaging and opioids. The treatment group had significantl y greater reductions in pain, fewer patients requiring continuing care after 12 m onths and higher ratings of thei r treatment. Remarkably, the cost per patient in the treatment group was near ly half that of the control group; primarily because of over prescribing im aging and physical therapies. All patients in the control group had returned to work after th ree months and all but two in the treatment group returned to work. Alt hough more patients in the treatment group missed work (144 versus 29 patients), the median durati on of lost time for the treatment group was three days compared to five for the control group. Linton, Vlaeyen, and Ostelo (2002) surveyed the beliefs of doctors and physical therapists to determine if the providers po ssessed certain fear-avoidance be liefs. They found that 31% of primary care doctors treating non-specific back pain believe pain relief is necessary for a return to work and 17% worry if a patient reports pain during an exercise. Forty three percent of doctors reported that they did not provide clear information about activities. The authors point out that these beliefs are contra ry to recent recommendations for the treatment of back pain. More than 25% believe sick leave is a good treatment despite most clinical guidelines recommendation that sick leave is not a treatment Encouraging patients to continue activities, even if there is some pain, is underscored by guidelines for treating non-specific back pain. Fortunately, most doctors believed that psyc hological factors might influence back pain. Despite the prevalence of clinical guidelines fo r low back pain as well as the evidence for the influence psychosocial factors have on pain and disability, some doctors may inadvertently contribute to prolonged disabili ty. Benbadis, Herrera, and Orazi (2002) studied 97 patients 32

PAGE 33

referred to a neurology clinic and found that although nearly two thirds of the patients had a nonneurolgic condition, a condition with no treatable underlying cause, th e doctor still believed the bio-medical path alone was the be st course of action. The docto rs, despite the best clinical guidelines, recommended the patients be treated symptomatically with medications, rest, and physical therapy. Interestingly, they made the same treatment recommendations for two-thirds of the patients with a neurological finding. They suggested referral to chronic pain management, physiatry, rheumatology or a comprehensive pain management program. The authors made no mention of any non-medical causes of pain or the relevance of why no objective clinical abnormalities were found in most of the pa tients. Although the study followed only one neurologist, the researcher s concluded that treatmen t of most back pain is best handled by family physicians and not neurologists In a more subjective analysis, Di Iorio, Henley, and Doughty (2000) mailed surveys to general practitioners in Illinois a nd, of the 87 returns, noted that the doctors treatments differed significantly from the clinical guidelines recommended by the US Agency for Healthcare Research and Quality. Similar to the previous studies, the physicians overutilized medications and imaging and underutilized patient education. The doctors also did not recognize red flags representing serious underlying abnormality (i.e.: fracture, infection, tumor, etc.) 50% of the time. Elders, van der Beek, and Burdorf (2000) reviewed 12 articles concerning medical interventions for low back pain after the first 30 days, or commonly referre d to as the sub acute phase, and found support for low back clinical gu idelines after the acute phase. The most successful studies were of interventions introdu ced only after 60 days pos t-injury or during the sub-acute phase of back pain. They used a common temporal definition of back pain: acute 33

PAGE 34

lasting less than 30 days, sub-acute lasting mo re than 30 days but less than two weeks and chronic back pain as pain lasting over 12 weeks. In seven of the eight studies that included exercises, training in working methods, lifting techniques, education and functional conditioning, return to work was significantly better in the tr eatment group. The interventions were referred to commonly by the respective articles as back scho ol and reduced lost time from work between 22-42%. The researches conclude d that these types of active interventions were most helpful during the sub-acute phase of back treatment. Interestingly patients that received case management were excluded. Loisel et al. (2005) also poi nted out numerous reasons w hy physicians do not always follow best practice guidelines. Many docto rs may lack the knowledge based on the time required or accessibility of the information. Ot hers may not agree with the guidelines due to differences in evidence interpretation, their beli efs that recommendations are not applicable to their patients or are not cost beneficial. Doctor s also face the inertia of their established practice patters that are difficult to change. Risk Factors for Prolonged Disability Althoff and Andress (1996) reviewed a coll aborative project of the Gallup Organization, Fortis Benefits Insurance Company and the Menni nger Clinic that studied differences in people who returned to work quickly after an injury from those that did not. Quick returners demonstrated resiliency (ie: refused to feel vict imized by their condition), conscientious (ie: read books or articles about their condition), willpower (ie: positive attitude) and proactiveness (ie: focused on the future). Younger workers were more likely to quickly return to work as were women and those who have never been married. I ndividuals were more likely to return to work after an accident than an illness. They also found that 60% of thos e with a disability that did not 34

PAGE 35

occur at work eventually returned to work, compar ed to 46% of those whos e disability originated from a workplace accident. Atlas, et al. (2006) conducted a 10 year st udy of 394 patients in Maine with a lumbar herniation and resulting scia tica and compared the difference among patients covered by workers compensation (39%) versus those not receiving workers compensation (79%). They found that 81% of the non-workers compensati on injured were employed the previous month compared to 32% of the workers compensati on injured. The workers compensation group was also more likely to have an attorney (38% vs 3%), less likely to be treat ed surgically (41% vs 63%) and, although their physical exam ination findings were similar, were less likely to have a moderate or severe finding on advanced imaging (62% vs. 82%). They also reported longer duration of symptoms and were more likely to repo rt back pain, as compared to leg pain. Also, back specific and generic functional status we re worse among the workers compensation group. At the five and ten year follow up, the workers compensation patients were also more likely to be receiving Social Security Disability (13% vs 3 %). They were also less likely to report their pain had improved (53% vs 72%), were less satisf ied with their current state of symptoms (44% vs 73%) and were less satisfied with their initial treatment decision (69% vs 88%). Although the workers compensation group was more likely to be on Social Security Disability at the five and ten year follow-up, the two groups work statuses was similar. They were also more likely to report poor quality of life. After controlling for th e variables, younger age, physician expectation for surgical benef it and better SF-36 physical functi on were significant independent predictors of workers compensation patients returning to work. Barsky and Borris (1999) reviewed functiona l somatic syndromes, syndromes that are characterized more by symptoms, suffering and disability than by consistently demonstrable 35

PAGE 36

tissue abnormality, and discussed the psychological components when one assumes a sick role. As the patients are convinced that their conditio ns etiology is physical and not psychological as well as their simultaneous distrust of medical pe rsonnel, the article sugge sts clinicians use six steps to treat the condition. In order, they recommended doctors : rule out the presence of a diagnosable medical disease, sear ch for psychiatric disorders, bu ild a collaborative alliance with the patient, make restoration of function the goal of treatment, provide limited reassurance and finally prescribe cognitive behavior al therapy for those who do not respond to the first five steps. Okurowski, Pransky, Webster, Shaw, and Verma (2003) identified four risk factors that were associated with prolonged disability for workers compensation patients. They started out with 23 factors that they identified during th eir literature review (age, appropriateness of treatment, assessment period, attorney involve ment, average weekly wage, co-morbidity, compliance with treatment, current medications, education level, functional capacity level, gender, intensity or dura tion of treatment, job demand level, language barriers, marital status, modified duty available, months on job, presentation of symptoms, prior injuries or prolonged work absences, return-to work motivators, severity of work related injury, timeliness of referral and workplace issues) that they believed could predict prolonged disabil ity. After interviewing 986 injured workers early in their treatment, they found that older age, language barriers, early referral to case manager and neutra l or negative attorney attitude towards return to work were associated with prolonged disability. The author s speculated that the ear ly referral to a case manager finding resulted from the referring agen cy quickly referring severe or complicated injuries. The authors also were surprised that the other factors were not predictors of prolonged disability as they discussed that most had empirical support. 36

PAGE 37

Katz et al. (2005) found that workers compen sation patients, especi ally those with an attorney, were more likely to be out of work six and twelve months after undergoing carpal tunnel surgery. However, they found that self-efficacy was a better predictor of work absence at six and twelve months after surgery than sy mptom improvement. Interestingly, endoscopic release and nerve conduction veloc ities were not significantly asso ciated with work absence at six and twelve months. The authors suggested types of educational pr ograms to improve selfefficacy. Carmona, Faucett, Blanc, and Yelin (1998) al so compared workers compensation versus non-workers compensation patients that underwent carpal tunnel syndrome surgery and found that, after controlling for other variables, workers comp ensation patients were 3585% less likely to return to work earlier than those patients not injured at work. The presence of workers compensation was as well as a predictor of dela yed returns to work as the presences of bending and twisting of the hand prior to injury. They found the median time away from work was five weeks and 39% were out of work more than five weeks. These factors were a better predictor than clinical factors (co-morb idiity, previous CTS). This last finding was exceptionally interesting considering 82% of patient s reported symptoms after surgery. Nathan, Meadows, and Keniston (1993) compared the median time off work for workers compensation and non-workers compensation patient s that underwent carp al tunnel surgery. They found the median time off work for worke rs compensation patients was 21 days compared to 10 days for private/Medicare/welfare patients. The authors speculated the type of coverage was the primary prediction factor. Rainville, Sobel, Hartigan, and Wright (1997) also compared the duration of symptoms as well as disability from work of low back pain patients on workers compensation to low back 37

PAGE 38

pain patients not on workers compensation. In the final analysis, 47 workers compensation patients and 38 non-workers compensation patients were included. The study also incorporated patients who were between three and six months post surgery (discectomy versus fusion). In their study the workers compensation group report ed higher pain levels and other subjective symptoms, were more depressed and reported more disability. Although both groups scored similarly in physical function post-treatment the compensation group had less reduction in disability scores. This led the authors to spec ulate that compensation patients were less receptive to interpreting improved physical capacities as enabling improved daily functioning. They conclude that disability may be strongly reinforced by involvement in the compensation system itself. However, Hadler, Carey, and Garrett (1995) found less of a discrepancy of prolonged disability between workers compensation and non-workers compensation patients although, they found other important differences. Th ey interviewed via te lephone 505 workers compensation patients with acute back pain at 2, 4, 8, 12 and 24 weeks post initial treatment and compared their findings to the 861 non-workers compensation patients with similar symptoms in a similar time frame in North Carolina. They found that the workers compensation group was more likely to categorize their job as physic ally demanding and had been out of work longer in the month before the baseline interview. They also found that while after the baseline interview both groups recovered similarly regardi ng physical functioning or ability to return to work, the non-workers compensation group reported a sense of wellness similar to their preinjury state long before the workers compensation group. In a Meta analysis of 129 studies, Harr is, Mulford, Solomon, van Gelder and Young (2005) found that regardless of t ype of medical intervention, type of compensation, country of 38

PAGE 39

origin, date of publication or methodological aspects, there was a strong association between compensation status and poor outcome after surg ery. Although the studies were not unanimous, 123 of the studies showed a posit ive association between workers compensation status and poor outcome. Five studies showed a negative association but none of the studies reached statistical significance. The authors speculated that the e ffect of workers compensation on outcome may be related to the injury and th e compensation process as well as secondary and tertiary gain. Kwan, Ferrari, and Friel (2001) compare primary, secondary and tertiary gain for people with illnesses or disabilities and their caregivers. They argue that the influence of tertiary gain is very influential and not resear ched enough as compared to secondary gain. They discuss primary gain, a concept very similar to the processes behind conversion disorder, as a minor influence. Secondary gain, which is accomplished by assuming the sick role, gives the person with a disability special rights and privileges, such as being relieved of work, social obligations or other civic duties, in the so ciety. These rewards are always present in ones environment. Both primary and secondary gains are rewards fo r the individual with th e disability however, tertiary gains are rewards for a third party, usually the caregiver. The personal caregiver (ie: spouse or family member) receives special status in the community as caring for the ill, an elevation in the personal relationship with th e sick individual, who is now a dependant, and sometimes financial benefits. There are also professional caregivers and each can receive tertiary gains as well. A medical provider, personal injury lawyer, religious worker, counselor or friend may also receive increased social status for caring for the ill, fulfill a desire to punish big corporations for perceived wrongdoings or receiv e financial rewards. The authors contrast secondary and tertiary gains with secondary and tertiary losses. While some personal caregivers seek the gains without sacrifici ng the losses, for the most part, personal caregivers receive losses 39

PAGE 40

disproportionately. Professional caregivers usua lly receive tertiary gains with no or minor losses. A personal caregiver se eking tertiary gain may combin e with a disabled individual seeking secondary gain and form a symbiotic re lationship that reinforces and enables each others behavior. This creates a significant set of rewards and punishments that inhibit the patients motivation to recover from the illness. The injured or sick individual may also experience guilt if they recover and thus steal the car egivers tertiary gain, especially if the gain is an unconscious personal psychological fulfillment to care for someone ill. Another variable is job satisfaction. Rugulies and Krause (2005) studied 1221 San Francisco public transit opera tors for over seven years and found that the lower the job satisfaction, the higher the incide nce of neck pain. They also found a connection to low back pain but the impact was smaller. Job satisfacti on variables were job strain (a mismatch of high psychological demands and low decision latitude) a nd iso-strain (job stra in plus exposure to low social support at work). Shaw, Linton, and Ptransky (2001) explored prevention strategies th at would reduce the likelihood that acute low back pa in will develop into a chroni c and disabling condition. They attempted to develop a rubric that would identify the specific risk factors of an injured worker that would lead to prolonged disability and matc h the worker with a prov en strategy to address and hopefully neutralize those factors. They revi ewed nine studies of risk factors and nine articles of interventions. Risk factors incl uded fear avoidance, pain catastrophizing, poor expectations for resuming activ ity, poor employer response, no modified duty, mood symptoms, work stress and fear and worries. There we re three intervention categories: personal interventions, technical and ergonomic and organi zational and administrativ e. They found that the majority of the empirically supported interventions focused on psychological and 40

PAGE 41

psychosocial areas, such as cognitive behavioral therapies, scheduled activity exposure, provider reassurance, early employer/wor ker discussions and relaxation training. This would suggest a major role of psychological factors in lost time, prolonged disability and th e disability mindset. Lehane and Stubbs (2001) studied slip and trip accidents and found supervisors and the injured worker attributed blame of the accident differently. Supervisors were more likely to blame internal factors of the injured worker (i.e.: laziness, carelessness). The authors suggest this mindset by managers made investigating accidents, identify ing workplace factors and taking corrective actions more difficult. The attitudinal dissonance also led to employee dissatisfaction. Loisel, et al. (2005) also pointed out that even when supervisors were supportive, most do not have the required skills for pr oactive and supportive communication. They pointed out that this communication results in re duced disability duration. Although once assumed socioeconomic status was a predictor of workplace lost time injuries, Gillen, et al. (2007) found that educa tion and income was less of a predictor than the occupations physical demand level and the work related psychosocial factors. They studied hospital workers and arranged occupations in to six categories; administrator and professional, nursing, other clinical (mental health, nursing rela ted and rehabilitation), clerical, technical, and support. They found that the other clinical, technical, and clerical positions were at a significantly higher risk for pr olonged disability. Psychosocia l factors were measured by a number of measures, but the effort-reward imbalance model (ERI) was the only that was significantly associated with lost time injury. Th e greater the divergence of high effort (ie: time pressure) and low rewards (compensation, respect, advancement prospects and job security) the longer the employee spent off work. 41

PAGE 42

Sullivan, Feuerstein, Gatchel, Linton, and Pransky (2005) reviewed the literature and identified two types of risk factors for prolonge d disability following a work injury. Type one risk factors were individual factors such as in itial levels of reported pain, perceived functional disability, pain related fears, beliefs about the severity of their health condition, pain catastrophizing, poor problem solv ing abilities, low expectancies about the pr obability of returning to work, lack of confidence in the ability to perform work related activities and depressive symptoms. Type two factors were environmental or ot herwise outside of the worker. Job stress, coworker support, lack of social support at work, work dissatisfaction, employer attitudes towards work disabilit y, lack of coworker support for m odified duty, lack of modified work and lack of autonomy in the workplace were all found, in different studi es, to be significant type two predictors of prolonged disability. The authors also reviewed research of interventions designed to address and improve the individu al psychological risk factors for prolonged disability and specifically reco mmend cognitive behavi oral approaches are implemented. They also reviewed interventions with empirical support targeting type two envi ronmental risk factors. Pincus, Burton, Vogel, and Field (2002) reviewed 25 studies concerning predicting prolonged disability and conclude d that six studies met import ant validity criteria. The consensus was that distress, depressive mood and to a lesser extent somati zation were predictors of prolonged disability. Their study, unlike Sullivan et al. (2005), did not de tect as a strong role for catastrophizing. Loisel, et al. (2005) also perf ormed a literature review on a similar topic. They found that because patients adhere to the biomedical model diffused in the media and have expectations that the doctor find a physical abnormality, doctors are more likely to agree to request repeated testing, inappropriately restrict activity and prescribe more pa ssive medical interventions. 42

PAGE 43

Doctors that do not follow best practice guidelines ar e more likely to keep their patient in a state of disability and less likely to c onsider any biopsychosocial options. Because secondary gain and symptom exaggera tion is an important issue for treatment patients on workers compensati on, Fishbain, Cutler, Rosomoff, and Rosomoff (1999) reviewed the literature on chroni c pain symptom exaggeration and argu ed that most research that found cases of symptom exaggeration, malingering or su bmaximal effort was flawed. The authors argued that most measurements of exaggeration, including clini cal exams, isometric testing, questionnaires (ie: MMPI), facial expression te sting, hand grip strength testing or sensory testing, were unreliable. They di d find that isokinetic st rength testing appeared to have potential for discriminating maximal and submaximal effort However, the authors invested heavily in criticism of or arguing that flaws were present in any article they reviewed that concluded some chronic pain patients exaggerated their symptoms. For many of the articles that they did not criticize as being poorly designed or conclude d, they accused the authors of not considering conversion disorders or, in one case, just rationalized those w ho lie or dissimulate may not necessarily malinger (Discussion : Does dissimulation occur in th e chronic pain setting, 2). Interestingly, the authors discussed the Si mmonds, Barlow, and Kreth study (as cited in Fishbain, Cutler, Rosomoff, and Rosomoff, 1999) that found that 35% of physical therapists thought that 75% of their pain patients involved in litigation were insincere regarding the severity of their symptoms. The authors also discussed a Miller study (as cited in Fishbain, Cutler, Rosomoff, and Rosomoff, 1999) that f ound only two of fifty patients, whom doctors initially suspected of having accident neurosis remained disabled after they received a settlement from the insurance company. 43

PAGE 44

Interventions to Prevent Prolonged Disability Although some state governments answer to rising healthcare cost s is decreasing the payment to physicians (Tuckey 2005), Smith (2006) reviews a study of the Eastern Washington Center of Occupational Health and Education th at showed significant success in reducing claims costs by using a four step method that actually increased the re imbursement of the physician. The most significant step was to ensure that if the employees injury was severe enough to prevent them from returning to full duty, the COHE physicians contact the employer regarding the limitations and determine if modified duty is available. This conversation should occur with the patient in the room so there is no confusion about what is said. The physicians also provided a written activity description form. In th e one year study of 7126 injured workers, the researchers found the process decreased workers compensation costs $3.1 million. But because of time and confid entiality concerns, physicians may be hesitant to discuss return to work options with employers (Meril l, Pransky, Hathaway, & Scott, 1990). One option for the hesitant physician may be for them to become more active in learning about the work demands from the patient alone. However, Dasinger, Krause, Thompson, Brand, and Rudolph (2001) found that even if the doc tors proactively discussed retu rn to work options with the injured worker, but not communicate with employers, the patients were no less likely to return to work sooner. Partee (2005) pointed out the workers co mpensation paradox. Although work related injuries have decreased 45% in th e last 15 years, total costs have increased. He suggests a closer working relationship between doctors and the employers. Atcheson et al. (2001) found that when the general practitioners were paid more (between 35% and 69%), total claims costs were 63% lower. Medical costs were decreased 45%, indemnity costs were 85% less and claims were cl osed nearly six months faster. However, the 44

PAGE 45

treatment group GPs received consultation from an orthopaedic surgeon and a rheumatologist. Although the researchers pointed ou t this difference, more weight was given to the financial reward of the GPs the impact the consultants. Educating the injured person in th e absence of other interventions has been studied as well. Hazard, Reid, Haugh, and McFarlane (2000) studied 489 injured workers with low back pain in Vermont. They mailed psychosocial educational pamphlets to 244 of the sample and studied amount of lost time, time until first return to work, pain severity and health care utilization at three and six months post injury. Although the su bjects who received the pamphlets regarded the information as useful, there was unfortunately no statistically significant difference on any of the dependent variables. This finding was also cons istent with Shaw, Linton and Ptransky (2001). They found that physiological knowledge of back injury and understanding of pain mechanisms had no affect on the duration of time off work. In both cases, the treating doctor played no role in the discussion. Franche, Baril, Shaw, Nicholas, and Loisel ( 2005) reviewed 4124 peer reviewed studies of return to work interventions and found str ong evidence that work accommodation offers and early contact between the employe r and treating physician reduced th e duration of disability in workers compensation patients. They found modera te evidence that ergonomic work site visits and the presence of a return to work coordinator also reduced lost time. There was weaker evidence that quality of life was affected. Loisel et al. (2005) reviewed the literature and found evidence for best practice guidelines for all parties. Doctors who provide reassurance to patients to alle viate their fears of reinjury or catastrophe have patients that sp end less time on disability. Alt hough they point out that doctors need more training in this area, in 1986 Deyo a nd Diehl (as cited in Loisel et al., 2005) reported 45

PAGE 46

that patients satisfaction was mo re closely related to their perception that they received an adequate explanation from thei r doctor of their pain. Frank et al. (1998) also revi ewed studies and found similar findings. The researches studied research on disability prevention in the literature for the preceding 4 years and found that offering modified duty to the worker within the fi rst four weeks of a back injury reduced lost time by 50%. From 4 to 12 weeks of intensive case management, an exercise program and ergonomic work adjustments reduced lost time between 35 and 50%. Sympathetic communication and a non-adversarial handling of the claims were also noted to have a positive effect. However, having the employer offer modified work is not always possible. van Duijn, Miedema, Elders, and Burdorf (2004) surveyed 44 company human resource managers and 13 of their occupational health physicia ns and found significant barriers to offering modified duty. The physicians responded that the employees nega tive attitude towards m odified work (54%), insufficient knowledge of the modified duty (77 %) or their own concerns the worker would become reinjured (46%) were barriers towards retu rning to injured worker to modified or light duty. The human resource managers had similar be liefs. The workers negative attitude towards modified work (52%) or their own inflexibility to change the work er tasks (45%), lack of support of coworkers (40%), concerns of reinjury (21%) and inconvenience of modifying the duties (27%) were all considered as barriers to perf orming modified duty. However, van Dujin did not discuss how often the human resource manage r and their occupationa l health physicians communicate. Rossler and Summer (1997) surveyed employer attitudes regarding offering accommodations to workers with injures. Each questionnaire had eleven separate 46

PAGE 47

accommodations and the employer would check the items they thought were reasonable. The majority of employers agreed physical modification to the facility, assistive equipment, flextime, job sharing, temporary reassignments during sick leave and special parking were reasonable accommodations. However, work at home, after noon rest, transportation to work and personal attendants were viewed as unreasonable. Alt hough 62% of employers would be willing to pay between $500 and $5000 dollars for accommodations, they cited cost as the major reason for their selections. However, the researchers ha d only a 21% response rate after mailing out 400 questionnaires. This response may rate may call in to question their fi ndings, especially since 91% of the employers reported that they had worked with a person with a disability, 78% of the businesses reported that they had hired someone w ith a disability in the past three years and 69% of the employers had addressed an employees re quest for a review of his or her needs for a reasonable accommodation. Krause, Dasinger, and Neuhauser (1998) revi ewed the history and effectiveness of modified work for injured workers and found th at despite some employers uneasiness with offering temporary light duty, it is cost effective for the employer. The noted that modified return to work programs help temporarily and permanently disabled workers return to work sooner. Injured workers who are offered modified duties return to work nearly twice as often as those who are not. Modified return to work programs also cut the number of lost work days in half. Loisel et al. (2001) studied the success of pa rticipatory ergonomics in implementing return to work in modified duty programs for employers with injured workers on disability in Quebec. Thirty seven workers with uncomplicated back pain on disability more than four weeks met with an ergonomist and the employer to develop an agreed upon job analysis of the usual position. 47

PAGE 48

The ergonomist then recommended modifications to the duties to eliminate any activities that were perceived to pose risk to wo rsen the injured workers back pa in. Employers rejected 40% of the recommended changes due more to interrupting company work methods than cost. Unfortunately the authors did not comment on the return to work rate. Schultz, Crook, Berkowitz, Milner, and Meloch e (2005) attempted to predict long term disability of injured workers during the first four to six weeks after a lo w back injury. They mailed numerous surveys to injure d workers and noted that the Expectations of Recovery Scale, SF-36 Vitality, SF-36 Mental Health and Waddell Symptoms scales had good predictive value for which workers would return to work. The surveys were of less value for prediction of prolonged disability. The researchers reported that all of thei r predictors were cognitivebehavioral. Variables related to mental he alth and Waddell symptoms replaced pain-behavior and physical examination variablesThe contributi on of mental health va riables is consistent with studies demonstrating that psychological distress is predic tive of disability (p. 373-374). Sullivan et al. (2005) attempted to reduce psychological risk factors by offering a 10 week workshop for injured workers who were out of wo rk for an average of seven months. The 215 workers that agreed to participat e in the British Columbia based pr ogram were selected if 1) they were off work for more than four weeks, 2) pa in symptoms were determined to be a primary limiting factor to return to work (ie: persistent pain with no objective physical findings) and 3) there was evidence of one or more risk factors. The workshop a ddressed mental health factors such as catastrophizing, fear of movement/reinjury, depression and perceived disability and found that 63.7% of participants returned to work within four weeks of completing the program. They also found that a reduction in pain catastrophizing was a significant predictor of who returned to work. Elevated pr e-treatment scores on fear of m ovement and reinjury and pain 48

PAGE 49

severity scales were associated with a lower probability of return to work. The authors conclude that pain reduction will not necessarily achieve quicker return to work and rehabilitation interventions should include psychol ogical risk factors. However, one criticism may be that all participants were simultaneously provided phys ical therapy and ther e was no control group. However, this weakness was addressed by anot her study that same year. Linton, Boersma, Jansson, Svrd, and Botvalde (2005 ) also studied the effects of including a cognitive-behavioral intervention in the medical treatment of Swedes with low back pain that missed work. A total of 185 patients were followed for over a year. Altho ugh the treatment lasted only three months, the researchers found significant differences in health -care utilization and work absenteeism. The weekly two hour cognitive behavioral group sessi ons lasted six weeks. The control group had more than a five times greater chance for devel oping long term disability. Interestingly, there was no difference between the cognitive-behavior al group and cognitive-behavioral and physical therapy group with regards to deve loping long term disability leave. Linton and Andersson (2000) performed a ra ndomized study that included a treatment group that received six sessions of cognitive-behavioral treatments and two control groups that received information packages only. The Swed ish study included 231 volunteers with spine pain and the researches found that the treatment group was nine times less likely to have their spinal pain develop in to prolonged disability. The treatment group utilized less physician as well as physical therapy visits post pretest while the control groups used more of both. The difference was found to be statistically significant. While all three groups improved on the variables of pain, fear avoidance and cogni tions, the treatment group showed a significant decrease in perceived risk. 49

PAGE 50

Von Korff et. al (1998) provi ded a four session educational program, led by paraprofessionals in back pain, for patients with lo w back pain. Their study also included a control group and they found that participants in the treatment group reported significantly less worry about back pain and expressed more confidence in self care. The difference was sustained at 12 months. However, Loisel et al. (2005) reporte d that insurers may be reluctant to cover to support psychologically based interventions as it may imply an extension of liability for any new diagnoses. Also, because patients traditionally ad here to the biomedical model diffused in the media, understanding and having faith in the biopsychosocial model is difficult. Joiner and Sawyer (1992) discussed specific cognitive counseling strategies for working with individuals coping with an injury. Th ey focused on changing dysfunctional beliefs by identifying thoughts that lead to absolutistic thinking, awfulizing, and overgeneralizing. Another strategy was to emphasize developing behaviors related to more functio nal thoughts. Clients learn their interpersonal behavior s are either passive, assertive, or aggressive. The authors speculated that the strategies, aimed at help ing people with injures adjust to permanent limitations, are more successful in the later stages of coping. OBrien (1997) discussed the development of work adjustment services in the public and private sector and presented a case study of one i ndividuals transition from injury to return to work. He discussed that work adjustment coul d be used to help the injured worker avoid development of a disability-dependant role and possibly prevent re-injury. The individual in his case study was participating in a comprehensive f unctional restoration, work hardening and pain management center. OBrien noted the injured worker feared a permanent negative stigma because he had been on workers compensation and used complaining about himself and his supervisors for his own protection. The worker r eceived not only the physical reconditioning but 50

PAGE 51

51 counseling to deal with his insecurities, fear s, and anxiety. Vocati onal Rehabilitation staff performed job analyses on different positions and th e injured worker eventually returned to work as a box taper. Buchbinder, Jolley, and Wyatt (2001) used a multimedia campaign to encourage Australians with back pain to st ay active and exercise, not to re st for prolonged periods and to remain at work. The goal was to reduce fear-avoidance beliefs. They used a three month campaign of television commercial s, featuring medical experts, Australian sports stars and television personalities as well as radio and pr int advertisements, outdoor billboards, posters, seminars, workplace visits and publicity articles The treatment group was the state of Victoria and the control was the state of New South Wale s. Surveys were completed by 4730 individuals and 2556 general practitioners and they found sta tistically significant improvements regarding back pain beliefs and decreases in fear-avoida nce beliefs about physical activity among back pain sufferers in the treatment group. They also found in the treatment group the general practitioners beliefs about back pain management was significa ntly higher than the control group. Mitchell, Alliger, and Morfopoulos (1997) showed that reasonable accommodations do not have to be expensive for the employer. Items such a phone amplifiers or different computer software and task adjustments such as allowi ng switching marginal task s with other workers, short breaks or flexible work hours can allow the wo rker to perform the essential functions of the job at a minimal cost.

PAGE 52

CHAPTER 3 METHODS In the summer of 2003, a major workers comp ensation insurance company that insures primarily workers in the construction, logging, o il and gas, structural moving and water well drilling industries in 37 states issued a memorandum to the re habilitation counseling companies that routinely provide services to their injure d workers. The providers were instructed to complete a job analysis for any worker that was removed off work by his or her doctor longer than four weeks and present the analysis to th e doctor to comment on the workers anticipated return to work. This was a pol icy shift enacted by the carrier and issued to their respective rehabilitation providers in an attempt to reduce the time injured workers received disability. The theory behind the change was that by having a ph ysician review job analysis, it would ensure he or she consider the injured workers work enviro nment, with objective info rmation, and ability to return to work. Additionally, the information woul d help the carrier better estimate future costs and set reserve funds, monies se t aside from the companys main treasury to spend specifically on the care of the specific injured worker, onc e they knew how much longer the worker would receive indemnity payments. Hypotheses Of the literature reviewed concerning factors that facilitate an injured workers prompt release by a doctor to return to work, none measured the effect of presenting a job description to the treating physician. The primary theory behind th is project was that a job analysis presented to a treating physician would decrease the amount of time an injured work er received indemnity benefits. This was the alterna tive hypothesis. Therefore, the null hypothesis is that the job analysis would have no influence on how long an injured worker received indemnity benefits: 52

PAGE 53

Null Hypothesis One: A job anal ysis presented to the doctor treating an injured worker, who is not working and receiving indemnity bene fits, will have no effect on the amount of time the injured worker receives indemnity benefits. Alternative Hypothesis One: A job analysis presented to th e doctor treating an injured worker, who is not working and receiving i ndemnity benefits, will shorten the amount of time an injured worker receives indemnity benefits. Another hypothesis is that ther e are variables other than the seriousness of the injury that contribute to time on disability. This project will select four other variables and explore their relationship on the dependent variable: attorney involvement, direct pers onal contact with a counselor, age and the body part in jured. Although there are likely other variables related to an injured workers time on disability, only these were included because of the relatively small sample size. Therefore, the s econd alternative hypothesis is that these four variables have a significant relationship on the depe ndent variable. The null hypothe sis is that these variables have no relationship to the time an injure d worker receives disability payments: Null Hypothesis Two: The number of weeks an injured worker receives disability payments is unrelated to his or her ag e, body part injured, involvement with a rehabilitation counselor and/or involvement with an attorney. Alternative Hypothesis Two: The number of weeks an injured worker receives disability payments is influence by his or her age, body part injured, involvement with a rehabilitation counselor and/or involvement with an attorney. Independent Variables The primary predictor variable is whether a job analysis was presented to the treating physician during the course of the injured workers care. This is independent variable one. There will be only two levels, present or not present. Independent variable two, attorney involvement was included as this factor has been found to be a significantly related to longer periods of disability pa yments (Okurowski et al., 2003). Kwan, Ferrari, and Friels (2001) discussion of tertiary gain would also suggest that this third party may prolong the disability period. As an atto rney representing an injured worker receives a 53

PAGE 54

financial reward when his or he r client settles with the carrier, and the greater the settlement value usually the greater the payout for the attorney, it is in the attorneys financial interest that the workers anticipated future medical care be extensive and their earning capacity diminished. For this project, if the injured worker hired an attorney at any time during their time on disability, an attorney was considered present. Otherwise, the injured worker was considered not represented. Age, independent variable three, has also b een found to be a significant factor in time out of work following a work injury (United States De partment of Labor, Bureau of Labor Statistics, 2006b; Okurowski, et al., 2003). That is, older wo rkers required more time to return to work following an injury. For this project, age was categorized to mirror the SSA age ranges. For purposes of evaluating people applying for Social Security Disability, persons age 18 to 49 are categorized as younger individuals and are considered more capable of adapting to new work situations. Workers in the subsequent age categori es are considered less able they are to adapt to different or new work settings. Therefore, for the present study age was arranged into two categories, based on the workers age at the da te of accident. Worker s between age 18 and 49 were categorized as younger workers and work ers age 50 and older were considered older workers. Independent variable four, body area injured, was included based on the United States Department of Labor Bureau of Labor Statis tics (2006b) findings. Although the median time off of work for all lost time injuries in 2005 was seven days, different body areas led to different median times off of work. For example, according to their data, a shoulder injury caused the average worker to spend a median of 17 days away from work, but a foot injury caused the average worker to spend a median of 6 days away from work. For this study, body area was 54

PAGE 55

categorized to reflect the Bureau of Labor Statistics categorization for pa rt of body affected. Although the Bureau has seven different body part areas (head, neck, trunk, upper extremities, lower extremities, body systems and multiple parts) for purposes of this project, primarily because of a relatively small sample size, head, body systems and multiple parts were consolidated in to an other category. The rati onale is based on their 2005 statistics that the trunk, upper extremity and lower extremity areas make up the majority of injuries. These parts are involved in 43%, 29% and 28% of cases respectively. Head, body systems and multiple parts are involved in only 9%, 2% and 12% of cases resp ectively. Therefore, there are four levels to the body part variable: trunk, upper extrem ity, lower extremity and other. Independent variable five, couns elor direct personal contact, was included due partially to Franche et al.s (2005) meta analysis findings co ncerning the positive impact of both a return to work coordinator and direct contact between the employer and the physician on limiting the disability time of an injured worker. Smith (200 6) also concluded that direct contact between the employer and physician significantly reduced disability time. This variable had only two levels: either the counselor was allowed direct personal contact with th e injured worker throughout their entire time on disability or was not. The five independent variables along w ith how they will be categorized are: 1. Was a job analysis presented to doctor? 1) Yes 2) No 2. Did an attorney represent the injured work er at any time during the disability phase? 1) Yes 2) No 55

PAGE 56

3. What was the injured workers age at the date of injury? 1) 1849 2) > 50 4. What body area was injured? 1) Trunk: including back and spine 2) Upper extremity: including hand, shoulder, wrist and finger 3) Lower extremity: including knee, ankle and foot 4) Other 5. Did a rehabilitation counselor have direct pe rsonal contact with the physician and injured worker throughout the disabili ty phase of the injury? 1) Yes 2) No Dependent Variable The dependent variable was the total time, in weeks, the worker received disability payments from the insurance carrier. This is not the same as the time until the patient returned to work. There are two reasons for th is distinction. The first is that not all injured workers return to work when released by the doctor. Some choose to switch employers during their treatment and spend time job-hunting after they are released to return to work. Some have secondary health problems, not related to th eir work injury, that prevent th em from returning. Still others may disagree with their doctors release and not return to work although cleared medically. The second reason is that because indemnity payments cease when the worker is medically cleared to return to work, insurance carriers have a particular inte rest in this data. In addition, as nearly half of all workers compensation costs are for indemnity payments, and all finances originate from employers and are regulated by the resp ective states, these parties monitor and are 56

PAGE 57

interested in these figures as well. Any worker that was eventually accept ed as totally disabled by the carrier was excluded. Participants Three rehabilitation counseling companies that specialize in helping the injured workers of the insurance carrier in question return to wo rk were solicited to provide retrospective information on the independent and dependent vari ables. Each company was offered financial reimbursement to compensate for the time require d to obtain their data. Participants were limited to injured workers who received worker s compensation-covered treatment of a work related injury who were out of work for at le ast one week and were insured by the above-cited company that issued the job analysis memora ndum. Participants injured before the 2003 memorandum who did not have a jo b analysis issued were the control group. Participants injured after the 2003 memorandum that had a job an alysis presented to hi s or her physician, and received disability for at least one week, were the treatment group. Data Collection Questionnaires were issued to the respect ive companies covering the independent and dependent variables. An exampl e of the questionnaire is in th e Appendix. One questionnaire was supposed to be completed for each injured worker. However, two companies submitted their data electronically in a computer spreadsheet. As the confidentiality of the injured workers was of utmost importance, no identifiable information of specific clientele was solicited, provi ded by the companies, used in the project or reported. Only a number or initia l identified each subject. The returned items had no additional information other than the listed variables. 57

PAGE 58

Data Analysis The design employed four statistical analyses For each analysis, the computer program SPSS 16.0 calculated the data entered. Chap ter four presents the specific findings. First, there was a chi-square analysis of the treatment and control groups to determine if either age, direct personal contact, attorn ey involvement and/or body part injured was significantly different between the two. The rationale was that the results could be tainted if the groups were not homogeneous along variables suspected to influence disability time. Second, a t -test was performed ( = 0.05) comparing the job anal ysis group to the non-job analysis group. This test would answer if th e presence of a job anal ysis had a significant influence on the dependent variable. This te st addressed the primary research question. Third, a backwards elimination multiple regre ssion analysis of the four other predictor variables was employed. The regression measur ed how much each remaining variable could predict the variability of the de pendent variable. All variables were nominal but only the age, attorney involvement and direct contact predic tor variables were dichotomous. Because the body part variable had four levels (trunk, upper extremity, lower extremity and other), four separate dummy variables had to be constructe d to utilize multiple regression. Each dummy variable represented a non-body pa rt and was paired with its co rresponding body part to make a dichotomous variable. For example, trunk injure s were compared to a ll non-trunk injuries (upper extremity, lower extremity and other), upper ex tremity injures were compared to non-upper extremity injuries (trunk, lower extremity and ot her) and so on. The mu lticollinearity between the predictor variables was investigated to ensure multiple variables were not measuring the same concept. The likelihood of multicollinearity, especially between the attorney and direct contact predictor variables, called for a backwards multiple regression. 58

PAGE 59

59 The job analysis and non-job analysis groups were then analyzed separately using multiple regressions. Again, the four pred ictor variables were analyzed in each group. The rationale was that the separate regressions w ould better detect interactions be tween the job analysis and the other variables. Any variables found to be si gnificant in one group but not the other would signify a significant interaction between that variable and the job analysis. Finally, multiple t -tests of the five independent vari ables as well as combinations of independent variables was performed. The inte nt of these tests was to investigate if a combination of variables, variables that indi vidually were not signi ficant, could have a significant influence on the dependent variable. Because one of the intentions of this project was to discover concrete factors a nd strategies that may contribute to or avoid prolonged disability, this step would provide tangible steps that could be either app lied in a clinical setting or investigated further.

PAGE 60

CHAPTER 4 RESULTS Descriptive Statistics Independent Variables In the gathered data, 101 injured workers met the criteria to be included in the study. Fifty-one injured workers met the criteria of the job analysis group and fifty met the criteria for the non-job analysis (control) group. There were nearly twice as many subjects age 18 to 49 (n = 71) compared to the 50 and over (n = 30) group. Of the study subjects, 41 were represented by an attorney while 60 were not. Eighty-six of the injured workers were allowed direct personal contact with a counselor and 15 were not. Lower extremity injuries were the most common (n = 31) followed by trunk injuries (n = 30), upper extremity (n = 29) and other (n = 11). Of the three rehabilitation counseling companies that par ticipated, the contribut ions were 58, 34 and 8 subjects respectively. Of the 101 injured work ers, 93 were counseled by a rehabilitation counselor who was also a mental health counsel or licensed in Florida. However, the job analyses of only one company met the inclusion criteria. In the job analysis group, the mean time a physician reviewed a job analysis was 16.71 weeks after the worker was placed on disability. This variable is not the same as the time in weeks between injury and when the treating physician review ed the job analysis (M = 28.51, mdn = 19.00). The average worker in the study co ntinued working for 12 weeks after his or her injury. Considering the time gap between the median and mean is nearly 10 weeks, there were likely a few injured workers (outliers) who worked a significantly long time before being placed on disability. The job analysis and non-job analysis groups were then compared to determine if any of the independent variables (age, attorney invo lvement, body part injure d and direct contact) 60

PAGE 61

significantly correlated to one another. Because the independent variables were nominal, a chisquare analysis was used. Table 1 shows the overall number of cases (n) of each variable and their percentages distributed overall, in the job analysis group and in the non-job analysis group. A chi-square test noted that the non-job anal ysis group (No JA) wa s significantly younger compared to the job analysis (JA) group, 2 (1, N = 101) = 4.17, p = .04. That is, there is a significantly higher perc ent of younger workers in the non-jo b analysis group. As previous research (Atlas et al., 2006; O kurowski et al, 2003) and the BLS (United States Department of Labor, Bureau of Labor Statistics 2006b) report that younger workers return to work sooner, this may act as a confounding variable. Because the presence of a counselor working directly with the injured worker has been shown to decrease time on disabi lity (Linton, Boersma, Jansson, Svrd, & Botvalde, 2005; Linton and Andersson, 2000; Franch e, et al., 2005; Smith, 2006), an analysis of the direct personal contact variable was performed to dete rmine if the two groups were identical. The results are displayed in Table 1. DC (direct contact) and No DC (no direct contact) are the compared groups. A chi-square test revealed that attorney involvement was significantly different, 2 (1, N = 101) = 11.343, p < .01. Those who di d not have direct contact with a counselor (n = 15) were significantly more likely to be repres ented by an attorney than those who did have direct contact with a reha bilitation counselor (n = 86). Because attorney involvement has been show n to influence time on disability (Okurowski et al., 2003; Katz et al., 2005; Kwan, Ferrari, & Friel, 2001), the a ttorney group was compared to the non-attorney group to determine if there were other variables that co incided with attorney involvement. Table 1 also examines the differences between the group of injured workers represented by an attorney and those not represented. A chi-square test revealed a significant 61

PAGE 62

difference in the dir ect contact factor, 2 (1, N = 101) = 11.343, p < .01. Injured workers with an attorney (n = 41) were significan tly more likely not have direct contact with a counselor than were those not represented by an attorney (n = 60). The Att column (attorney represented) illustrates that 29% of those represented by an attorney had no direct contact with a counselor, compared to only 5% of the No Att (no attorney) workers. Dependent Variables The dependent variable, mean time on disabili ty, for the entire sample (N = 101) was 27.10 weeks (median = 19.00 weeks). Although this figure seems high compared to the national average, for transportation workers, industrial machinery mechanics and construction workers (median = 12, 11 and 10 weeks respectively), the BL S data (2005) includes work injures that had no lost time. This study examines only lost time in juries. As 70% of injures incur no lost time, the BLS median data would be considerab ly lower than the present sample. The mean disability time for the job analysis group (n = 51) was 26.75 weeks (median = 20.00 weeks) while the mean time on disability for the control group was (n = 50) 27.46 weeks (median = 19.00 weeks). The standard devia tion for the job analysis group (25.30) was considerably higher than the control group (21.66). The mean and median scores of the entire sample (N= 101) were then compared to determine the distribution of scores. The mean score (27.10) was nearly eight weeks higher than the median score (19.00). A histogram revealed the dependent variable was positively skewed (to the right), 1.71. That is, there were a few subj ects (outliers) who remained on disability for a substantial period of time, dragging the mean score up. The 33rd and 66th percentiles were 13.66 and 27.00 weeks respectively. To determine if the spread of scores for the job analysis (n = 51) a nd non-job analysis (n = 50) groups were different, the sa me measurements were obtained for both groups separately. In 62

PAGE 63

the job analysis group, the mean score (26.75) was only 6.75 weeks higher than the median (20.00). A histogram revealed the variable of time on disability was also positively skewed, but less than the group as a whole, 1.64. The 33rd and 66th percentiles were 14.32 and 27.32 weeks respectively. For the non-job analysis group, the mean score (27.46) was more than 8 weeks higher than the median (19.00). A repeat histogram revealed the variable of time on disability was also positively skewed, 1.76. The 33rd and 66th percentiles were 11.00 a nd 26.32 weeks, respectively. As the first one-third percentile in the job analysis group was mo re than three weeks higher than in the non-job analysis group, this signifies that a greater number of s ubjects in the non-job analysis group were off disabili ty quickly compared to the nonjob analysis group. One third of the non-job analysis group was off disability after 11.00 weeks. However, at 11.00 weeks only 23% of those in the job analysis group were off disability. It took more than 14.00 weeks for one third of the job analysis group to be off disabilit y. This would become extremely relevant as the median time for a job analysis presented was 16. 7 weeks. At that point, 43% of the non-job analysis group was off disability. Initial t-test Comparing the Job Anal ysis to the Non-Job Analysis Group A t-test comparing those injured workers with a job analysis to those injured workers without a job analysis revealed no signi ficant difference in time on disability. Backward Multiple Regression Analysis A backwards multiple regression analysis was conducted to determine if age, body area, attorney involvement or counselor direct persona l contact had an influence on the length of time on disability. The likelihood of multicollinearity, especially betw een the attorney and direct contact predictor variables, called for a backward s multiple regression. The results are presented in Table 4-2. The proportion of variance (R2) in the criterion variable (time on disability) that 63

PAGE 64

was accounted for by the predictor variables is pr ovided in the foot of the table. Because R2 has a tendency to overestimate the success of the model (Brace, Kemp, & Snelgar, 2000), an adjusted R2 ( R2), which takes in to account the number of other predicto r variables and the number of participants (sample size), is also avai lable in the foot of the table. The regression coefficient (B) was included in the table, as well as the standard error of the regression coefficient (SE B). Beta ( ) was not included in the table, as the study is primarily applied (American Psychological Association, 2001) and th e unit of measurement of each variable is readily interpretable (Wilkinson and the Task Fo rce on Statistical Infere nce, 1999; as cited in Hoyt, Leierer, & Millington, 2006). The multiple regression analysis of the predic tor variables across all subjects (N = 101) resulted in a significant model, R2 = .33, F(6,94) = 7.83, p <.01. The regression revealed that attorney involvement (p < .01, B = 23.92, SE B = 4.32) could help predict time on disability. If an attorney was involved, the in jured worker received disability payments 23.92 weeks longer than if an attorney was not involved. The adjusted R2 (.29) revealed the model accounts for 29% of the variance in time on disa bility, a modestly predictive m odel (Muijs, 2004). None of the collinearity statistics were be low 0.68, suggesting little multico llinearity amongst the variables when predicting the dependent variable. The regression was repeated for the job analysis group and the non-job analysis groups individually. In the job analysis group (n = 51), a significant model also emerged, R2 = .404, F(6,44) = 4.98, p < .01. The variables of attorn ey involvement (p < .01, B = 20.42, SE B = 5.74) and direct contact with the injured worker (p =.041, B = 20.15, SE B = 9.59) were predictive of time on disability. If an attorney was involved, the injured worker received disability payments 20.42 weeks longer than if an attorn ey was not involved. If there was direct contact between the 64

PAGE 65

counselor and injured worker, the average work er spent 20.15 fewer weeks receiving disability than a worker without direct contact. The adjusted R2 (.32) revealed the model accounts for 32% of the variance in time on disa bility, a moderately predictive m odel (Muijs, 2004). None of the collinearity statistics were below .67, sugges ting little multicollinearity amongst the variables when predicting the dependent variable. In the non-job analysis group (n = 51), a significant model again emerged, R2 = .36, F(6,43) = 3.84, p < .01. Attorney involvement wa s again significant (p < .01, B = 23.83, SE B = 7.09). On average, an injured worker represen ted by an attorney remained on disability 23.83 weeks longer than if he or she was not represented by an attorney. The adjusted R2 (.28) revealed the model accounts for 28% of the varian ce in time on disability, a modestly predictive model (Muijs, 2004). None of the collinearity statistics were below .760, suggesting little multicollinearity amongst the variables. Interestingly, in the job analysis group, the average injured worker with an attorney received disab ility payments three fewer weeks than the average injured worker in the non-job analysis group with an attorney. However, a Satterthwaite t-test (assuming unequal variances) performed afterwar ds would reveal this difference was not significant. A trend was also noticed with age in the non-j ob analysis group. In the non-job analysis group, the mean time on disability for younger workers was 22.30 weeks compared to 47.00 weeks for older workers. A Satterthwaite t-test showed that was also a trend that did not meet the criteria of significance. Comparison of Individual Independent Variables on the Dependent Variable The multiple independent variables were then compared individually to the dependent variable. Most sub-groups underw ent individual t-tests. Any s ub-group that had a sample size of less than five for either vari able was excluded. Also, in most cases the other body part was 65

PAGE 66

excluded as it would be difficult to make meaningful conclusions on a miscellaneous category. Table 4-3 lists the individual t-tests. In most cas es the results of the t-test mirrored the multiple regression, but there were a few exceptions. In those cases that diffe rence is discussed. Satterthwaite t-tests (assuming unequal varian ces) revealed that attorney involvement significantly increased time on disability across all ot her variables. Workers with a trunk injury (p < .01), an upper extremity injury (p = .03), a lower extremity inju ry (p < .01), who are younger (p < .01), who are older (p < .01), with direct contact with a counselor (p < .01), without direct contact with a counselor (p < .01), with a job analysis (p < .01) or without a job analysis (p < .01) all remained on disability significantly longer if represen ted by an attorney. No other variable was this powerful. Direct contact with a counselor was significant in the job an alysis group (p = .02) but not in the non-job analysis group. This finding was consistent in the multiple regression, as well. Direct contact was also signi ficant for younger workers (p = 02) but not older workers. Older workers with a job analysis received si gnificantly less disability than older workers without a job analysis (p = .03). There was a trend with younger workers but it was not significant (p = .13). In no other gro up was job analysis significant. Regarding body part, there were some differenc es detected. Including all variables, the mean disability time for an upper extremity injury was significantly less than the mean disability time for all non-upper extremity injuries (p = .01), although significance was not achieved using multiple regression. There were trends with the job analysis and non-job analysis groups regarding an upper extremity injury, but neither was significant. A trend among younger workers with an upper extremity injury was not si gnificant (p = .053). In all three of the latter 66

PAGE 67

67 cases, the trend was that the mean disability time of an upper extr emity injury was less than the mean time for all non-upper extremity injuries.

PAGE 68

Table 4-1. Chi-Square Comparison of I ndependent Variables for Correlations Overall JA No JA Att No Att DC No DC Variable Analyzed n % n = 51 n = 50 n = 41 n = 60 n = 86 n = 15 Variable 1849 Years Old 72 71 63% 81%* 68% 75% 70% 80% 50 or Older 28 28 37% 19% 32% 25% 30% 20% Attorney Involved 41 41 45% 36% 34% 80%** No Attorney 60 59 55% 64% 66% 20% Trunk 30 30 33% 26% 34% 27% 30% 27% Upper Extremity 29 29 21% 26% 20% 35% 33% 7% Lower Extremity 31 31 27% 34% 32% 30% 37% 53% Other 11 11 8% 14% 15% 8% 10% 13% Direct Contact 86 85 90% 80% 71% 95% No Direct Contact 15 15 10% 20% 29%** 5% *p < .05., **p < .01. 68

PAGE 69

69 Table 4-2. Multiple Regression Analysis a All Subjects N = 101 b Job Analysis n = 51 c No Job Analysis n =50 Regression Models B SE B B SE B B SE B Variable Age 4.75 4.34 1.48 4.47 -16.48 7.93 Trunk -1.12 5.16 -1.49 10.32 -1.76 8.06 Upper Extremity 3.65 5.26 7.14 8.09 Lower Extremity 0.16 6.81 Other -3.34 6.97 -3.90 10.44 2.51 10.01 Attorney -23.92** 4.32 20.42** 5.47 23.83** 7.09 Direct Contact 5.19 6.05 -20.15* 9.59 5.63 8.27 *p < .05., **p < .01., aR2= .333, a R2 = .291, bR2 = .404, b R2= .323, cR2= .360, c R2= .285.

PAGE 70

Table 4-3. Comparing the Sub-Groups on Time on Disability Individually All Subjects JA No JA Sub-Group n M SD n M SD n M SD Variable Job Analysis 51 26.74 21.66 No Job Analysis 50 27.46 25.30 1849 Years Old 71 25.11 22.41 32 28.46 24.31 39 22.35 20.64 50 or Older 28 31.53 25.47 19 23.84 16.47 9 47.78 33.78 Attorney Involved 41 42.78** 26.94 23 40.48** 25.05 18 45.72** 29.64 No Attorney 60 16.38 12.25 28 15.46 8.04 32 17.18 15.10 Trunk 30 30.43 24.87 17 27.24 24.02 13 34.62 26.32 Not Trunk 71 25.69 22.82 34 26.50 20.76 37 24.95 24.82 Upper Extremity 29 20.00 17.51 16 21.19 18.91 13 18.54 16.24 Not UE 72 29.96* 24.96 35 29.29 22.61 37 30.59 27.30 Lower Extremity 31 28.00 23.63 14 29.14 20.38 17 27.06 26.59 Not LE 70 26.70 23.49 37 25.84 22.33 33 27.67 25.04 Other 11 34.18 30.35 7 31.71 33.57 Not Other 90 26.23 22.49 70 43 26.77 34.14 Direct Contact 86 24.62 22.05 46 23.59 19.60 40 25.80 24.78 No Direct Contact 15 41.33* 26.65 5 55.80* 19.33 10 34.10 27.65 *p < .05. **p < .01

PAGE 71

71 Table 4-3. Continued. 18-49 Years Old 50 or Older Attorney Involved Sub-Group n Mean SD n mean SD n mean SD Variable 1849 Years Old 27 40.37 26.30 50 or Older 13 46.46 29.45 Attorney Involved 27 40.37 26.30 14 47.43 28.53 No Attorney 44 15.75** 12.79 16 18.12** 10.82 Trunk 18 28.28 23.21 12 33.67 27.92 14 44.50 30.47 Not Trunk 53 24.04 22.26 18 30.56 24.37 27 41.89 25.49 Upper Extremity 21 18.10 tr 17.10 8 25.00 18.74 8 35.00 21.87 Not UE 50 28.06 23.84 22 34.27 27.42 33 44.67 27.99 Lower Extremity 24 28.12 25.61 7 27.57 16.67 13 43.54 24.16 Not LE 47 23.57 20.72 23 33.09 27.73 28 42.43 28.55 Direct Contact 59 22.42* 21.69 29 40.65 27.58 No Direct Contact 12 38.33 22.06 12 47.91 25.70 Job Analysis 32 28.47 24.31 19 23.84* 16.47 23 40.48 25.05 No Job Analysis 39 22.36 20.64 11 45.55 32.53 18 45.72 29.64 *p < .05., ** p< .01, tr p = .053

PAGE 72

Table 4-3. Continued. No Attorney Involved Direct Contact No Direct Contact Sub-Group n M SD n M SD n M SD Variable 1849 Years Old 44 15.75 12.79 59 22.42 21.69 50 or Older 15 18.60 11.02 25 28.92 22.24 Attorney Involved 29 40.66** 27.59 No Attorney 57 16.46 12.51 Trunk 16 18.13 6.74 26 27.31 21.73 Not Trunk 44 15.75 13.73 60 23.45 22.27 Upper Extremity 21 14.29 11.72 28 20.00 17.83 Not UE 39 17.51 12.34 58 26.84 23.65 Lower Extremity 18 16.78 15.98 23 25.13 24.33 8 36.25 20.67 Not LE 42 16.21 10.49 63 24.43 21.37 7 47.14 32.94 Direct Contact No Direct Contact Job Analysis 28 15.46 8.04 46 23.59 19.60 5 55.80 19.33 No Job Analysis 32 17.18 15.10 40 25.80 24.78 10 34.10 27.65 *p < .05., ** p< .01 72

PAGE 73

73 Table 4-3. Continued. Trunk Injuries Upper Extremity Lower Extremity Sub-Group n M SD n M SD n M SD Variable 1849 Years Old 18 28.28 23.21 21 18.10 17.10 24 28.12 25.61 50 or older 12 33.67 27.92 8 25.00 18.74 7 27.57 16.67 Attorney Involved 14 44.50** 30.47 8 35.00* 21.87 13 43.54** 24.16 No Attorney 16 18.12 18.12 21 14.29 11.79 18 16.78 15.97 Direct Contact 23 25.13 24.33 No Direct Contact 8 36.25 20.67 Job Analysis 17 27.24 24.02 16 21.19 18.91 14 29.14 20.38 No Job Analysis 13 34.62 26.32 13 18.54 16.24 17 27.06 26.59 *p < .05., ** p< .01.

PAGE 74

CHAPTER 5 DISCUSSION Overview of Significant Findings Job Analysis Although this study did not conclude that presenting a job analysis in every case significantly decreased the time on disability, there was a signif icant difference with workers aged 50 and over. Older individu als in the job analysis group were removed from the disability role significantly sooner than were older work ers in the control group. In this study, the mean disability time was 23 weeks for an older worker who had a job analysis pr esented to his or her treating physician, while the mean disability time for the non-job analysis older workers was 45 weeks. There was a trend with younger workers, but the difference was not significant. The presentation of a job analysis, in conjunction with direct personal contact, did have a significant relationship with disability time. That finding is discussed in the next section. The exertional level of most positions st udied, being either medium or heavy, likely contributed to the non-significance of the job analyses. The inju red workers studied in this project were employed in the c onstruction, logging and mineral ex traction occupations only. The availability of deskwork, one-handed work or positions involving lifting only small amounts of weight may be less common in these industrie s than in other industries. Unless modified duties are available, the injured worker will not be capable of returning to work until he or she is fully recovered and capable of full duty. If a physician were cognizant of the importance of considering the patients ability to work at e ach appointment, a job analysis would only confirm the doctors suspicions that the workplace is fr aught with heavy exertional forces. However, there may be other explanations for the nonsignificance and those are explored in the Limitations section. 74

PAGE 75

The significance discrepancy between younger a nd older workers with a job analysis is difficult to explain. Although nationally older workers remain off work longer than younger workers do, age alone in this st udy was not significant. One suggestion may be that older employees in these occupations work in the less physically demanding positions. An older workers experience and seniority may allow him or her the option of operating or driving machinery, in many cases the higher skilled positi ons, and stay away from manual labor. If younger workers rely more on their youth and physic al strength to secure employment, they may end up working heavier exertional positions compared to the older workers. An older workers seniority may also allow more accommodations. In either case, the treating doctor may be surprised to learn accommodations ar e available for the worker or the specific position is less physically exertional than he or she assumed. The job analysis would therefore clarify a misconception the doctor may have had regarding the line of work and the doctor would feel comfortable allowing the worker to resume their duties. Direct Contact Having direct personal contact with a counselor alone did no t significantly reduce disability time when all variables were analyzed together. However, among younger workers, direct personal contact was si gnificant. That is, injured wo rkers under age 50 who had direct personal contact with a counselor spent significantly less time on disability than younger workers who had no direct personal contact with a counsel or. The mean disability times were 22 and 38 weeks respectively. Direct contact with a couns elor in conjunction with a j ob analysis also significantly reduced disability time when compared to those with a job analysis and no direct contact with a counselor. The mean disability time was 22 weeks for an injured worker who had direct contact with a counselor and his or her treating physic ian reviewed a job analysis, while the mean 75

PAGE 76

disability time for an injured worker who had a job analysis but no direct personal contact with a counselor was 38 weeks. Direct contact did not significantly reduce di sability time in the non-job analysis group. One possible explanation may be that in the job analysis group, there was a guarantee that the counselor discussed return to work strategies with the worker and/or doctor. In the non-job analysis group, that conversation could not be veri fied. This explanation is postulated on one of the hypotheses of this project. Just by discussi ng returning to work with both the treating physician and injured worker, a counselor can re duce the injured workers time on disability. Attorney Involvement The most significant variable was attorney invo lvement. Analyzing all variables together, those represented by an attorney received disa bility significantly l onger than those not represented (43 versus 16 weeks). Removing the influence of the other variables, an attorneys involvement increased mean disability time 23 week s across all vari ables. For those with a job analysis, the difference was 20 weeks. Attorney involvement significantly increased disability time across every individual meaningful sub-group comparison as well. Inju red workers with a trunk injury (45 versus 18 weeks), an upper extremity injury (35 versus 14 weeks), a lower extremity injury (44 versus 17 weeks), those who are younger (40 versus 16 week s), those who are older (47 versus 18 weeks), those with direct personal contact with a c ounselor (41 versus 16 w eeks), those with a job analysis (41 versus 15 weeks) or those without a job anal ysis (46 versus 17 weeks) all remained on disability significantly longer if represented by an attorn ey. Any variables that were not analyzed were only excluded because the sample size was too small. These findings do not elucidate any cause a nd effect relationship. Because the injured workers self-selected to which attorney group they belonged and were not randomly assigned, it 76

PAGE 77

is difficult to ascertain which factor more influen ced the disability time. Those more inclined to seek an attorney may be more interested in remaining on disability or in receiving higher financial rewards. It may also be likely that an attorney, who has a consid erable financial tertiary gain from more complicated injuries or those who require more time off of work, will either coach a client on remaining out of work, spark conflict among the parties, or work to drive up both medical and indemnity costs in order to collect the largest sett lement possible. An attorney, however, may argue that employers and carriers who do not provide proper care and prompt disability benefits ar e the imputes for litigation and conf lict. Withholding proper care, an attorney could claim, employers actually prolong disability. Body Part Injured In this project, those with an upper extremity injury received disability for a significantly shorter duration when compared to those with non -upper extremity injuries. This difference is somewhat counter-intuitive. A construction worker or logger would presumably require good and strong use of both upper extremities to perfor m his or her job. To understand how a worker with poor use of one hand can resume working significantly sooner than a wo rker with an injury to another body part requires more investigatio n. Perhaps because much of the construction, mineral extraction or logging industries is b ecoming more automated, with large machines assisting with most of the work, a worker with one hand may still be capable of working some controls. A lumbar injury, on the other hand, is more prone to prevent prolonged sitting. A knee injury is more prone to prevent climbing in a nd out of equipment or prolonged standing and walking. Age Although in nearly every analys is of each independent variable (e.g. body part injured or those with an attorney) the mean disability time for workers over age 49 was higher than for 77

PAGE 78

workers under age 50, in no circum stance did age alone have a signi ficant relationship with time on disability. However, as mentioned earlier, ag e was a significant factor in combination with other variables. Injured workers over age 49 with a job analysis we re off disability significantly sooner than that same age group without a job anal ysis. Injured workers unde r age 50 with direct personal contact with a counselor were off disa bility significantly s ooner when compared to workers under age 50 without direct personal contact. Limitations Job Analysis Analysis of the data revealed a few possible limitations. First, the mean time at which a job analysis was presented to the doctor was cons iderably longer than anticipated. On average, physicians reviewed a job analysis 16 weeks af ter the worker was removed from work. As a result, anyone who returned to work before th e job analysis was presented to the doctor was excluded from the treatment group. No subjects were excluded fr om the control group, provided they received disability for at least one week. By 16 weeks, 43% of the control group was already off disability. This dilemma would obvi ously skew the numbers of low time disability patients in favor of the control group. Performing a job analysis and meeting with a phy sician to present a j ob analysis is often a time consuming process. The counselor must contact the employer, arrange a meeting at the worksite, perform the analysis, generate a report and then, usually the most time draining factor, meet with the doctor to review the analysis. It is also not uncommon for an injured worker to be referred to a rehabilitation couns elor only after his or her disab ility payments have begun. By the time the counselor receives the pertinent r ecords from the carrier, weeks of disability payments may have elapsed. 78

PAGE 79

Another explanation, which may be related to the primary limitation, was that the control group was significantly younger than the treatment group. Both prior research and this study found that older workers required more time to resume work following an injury than younger workers. If younger injured worker s were taken off the disability role quickly in this study, then that may explain why there were so few younger workers in the treatment group. That is, many of the younger workers had returned to work before the job analysis coul d be presented to the doctor. It may also explain why the job anal ysis was not found to be significant with younger workers, as there were significan tly fewer in the treatment group. Comparison of Individual Independent Variables Unfortunately in some of the sub-group comparisons, the sample size was small. For example, in the sub-group analysis comparing workers over age 49 with direct personal contact with a counselor to those over 49 without, only three subjects met the cr iteria for the second group. With only three subjects, out of 101, that were over age 49 w ith no direct contact with a counselor, it is difficult to compare thei r time on disability to other variables. Suggestions for Further Research Although likely difficult to arrange, an excellent study would be to present a job analysis to the treating doctor very quickly after disability begins. Pr ior research suggest s that the longer an injured worker is on disability, the less likely he or she is to return to work. Even with the limitations of this study, a job analysis significant reduced disability time on some variables. Another suggestion, also difficult, would be to randomly assign injured workers to the job analysis and control group. This would problematic especi ally in the control group. Understandably, many insurance carriers would like ly not permit an intervention, especially an inexpensive intervention that may return an injured worker to wo rk significantly sooner, to be withheld deliberately from thei r patients case. Also, the inju red worker or physician may seek 79

PAGE 80

vocational information informally and, as a result, obtain a quasi-job analysis although he or she was assigned to the control group. Such a study w ould have to be agreed upon with a carrier(s) in advance of the study and to last for a prolonged time. A large number of vocational rehabilitation counselors would have to be involv ed, to ensure prompt job analysis, and a large numbers of physicians would need to agree, in advance, to address job analyses with short notice. Of course, this last caveat would taint the project because the poo l of physicians who agree to participate in a study involving return ing to work would already be cognizant of addressing returning to work with injured workers. Another suggestion would be to analyze di rect personal contact controlling better for attorney involvement. Most subjects who did no t have direct personal contact with a counselor were represented by an attorney. Considering the relationship attorney involvement had with time on disability, a study with relatively equal numbers of attorney represented injured workers in the direct personal contact group and non-direct personal co ntact may better elucidate a counselors influence. A repeat study with a larger sample size woul d contribute to the quali ty of the data. In this study, many other possible cont ributory variables could not be included, as the available sample size was limited. Variables like the se riousness of the inju ry (although difficult to quantify), whether modified duty was available, the specific injured part (e.g. elbow), the physicians specialty, the job satis faction level of the worker a nd the exact occupation of the injured worker may all have accounted for a large pr oportion of the variability of disability time. The carrier in this particular pr oject that required implementation of a job analysis on disability cases made few referrals to rehabilitation couns eling companies in the region. The company was 80

PAGE 81

a nationwide carrier and its response to requests for further data was th at obtaining information on the variables in their own records would be extremely time consuming. Implications for Practice and Policy The philosophy behind this project was to dete rmine what variables prolong an ordinarily temporary disability and what inte rventions can be used to hasten cessation of disability. The intent is not to prevent someone with a totally disabling injury from receiving benefits, but to prevent a partial disability from evolving into a permanent and total disa bility. If non-medical factors influence what injuries le ad to prolonged periods of disabil ity, contribute to mental health problems and convince someone with a partial di sability that he or she is completely unemployable, then interventions to address those non-medical factors should be explored. Legislators, insurance companies and rehabili tation counselors should further explore what factors contribute to and what factors can prevent prolonged disa bility. In this study, a job analysis was a tool that provide d the rehabilitation counselor a di fferent perspective to mediate disability. His or her direct counseling effort was another tool Research suggests numerous variables can influence disability time. This study did not have a suffi cient sample size to include every variable or sufficien t resource to include more subjects. If future research could identify the variables that prolong temporary disability and the tool s to neutralize th ose variables, a protocol could be developed for all providers, employers and carriers to follow. Practice guidelines would instruct the par ties to introduce particular interv entions to match the particular variables in an injured workers case (e.g. type and seriousness of injury, age of the worker, occupation of the worker). More injured wo rkers could avoid the pe nalties of prolonged disability and unemployment. So ciety would benefit from a great er and healthier work force, fewer people collecting government supported di sability and a larger tax paying population. 81

PAGE 82

82 APPENDIX QUESTIONNAIRE Injured Worker Number 1. Age at time of injury 1) 1849 2) > 50 2. Body area injured 1) Trunk: spine, back, hip, cervical 2) Upper extremity: shoulder, hand, elbow, finger, arm 3) Lower extremity: knee, foot, ankle, leg 4) Other 3. Place a check if rehabilitation counselor was allowed constant direct personal contact with the physician and injured worker 4. Place a check if a job analysis was presented to doctor 5. Place a check is an attorney represented th e injured worker at any time during the disability phase 6. Total time received indemnity payments from carrier (please specify if weeks or months)

PAGE 83

LIST OF REFERENCES Althoff, J., & Andruss, M. ( 1996). Study finds attitude does a ffect return to work (Gallup Organization study). National Underwriter Property and Casualty Risk and Benefits Management, 100(8), 8, 26. American Psychological Association. (2001). APA editorial style. In Publication manual of the American psychological association (5th ed., pp. 77-214). Washington, DC: American Psychological Association. Asvall, J. E. (1987). Foreword. Social Science Medicine, 25(2), 99. Atcheson, S. G., Brunner, R. L., Greenwald, E. J., Rivera, V. G., Cox, J. C., & Bigos, S.J. (2001). Paying doctors more: Use of musculos keletal specialists and increased physician pay to decrease workers' compensation costs. Journal of Occupational and Environmental Medicine, 43 (8), 672-679. Atlas, S. J., Chang, Y., Keller, R. B., Singer, D. E., Wu, Y. A., & Deyo, R. A. (2006). The Impact of disability compensation on longterm treatment outcomes of patients with sciatica due to a lumb ar disc herniation. Spine, 31 (26), 3061. Barsky, A. J., & Borris, J. F. (1999) Functional somatic syndromes. American Society of Internal Medicine, 130 (11), 910-921. Benbadis, S., R., Herrera, M., & Orazi, U. (2002). Does the neurologist cont ribute to the care of patients with chronic back pain? European Neurology, 48, 61. Bishop, P. B., & Wing, P. C. (2003). Compliance w ith clinical practice guidelines in family physicians managing workers compensation boar d patients with acute lower back pain. The Spine Journal 3 (6), 442. Buchbinder, R., Jolley, D., & Wyatt, M. (2001). Effects of a media campaign on back pain beliefs and its potential influence on management of low back pain in general practice. Spine, 26(23), 2535. Carmona, L., Faucett, J., Blanc, P. D., & Yelin, E. (1998). Predictors of rate of return to work after surgery for carpa l tunnel syndrome. Arthritis Care and Research 11 (4), 298-305. Commission on Rehabilitation Couns elor Certification. (n.d.). About CRCC. Retrieved September 1, 2007, from http://www.crccertification.com/index.html Crawford, P. (2004, May 18). Return to wor k. Powerpoint presen ted at the 2004 risk management user group. Austin: Texas St ate Office of Risk Management Workers Compensation Division. D'Arcy, C ., & Siddique, C. M (1985). Unemployment and health: An analysis of "Canada Health Survey" data [Abstract]. International Journal of Health Services : Planning, Administration, Evaluation, 15 (4), 609-635. 83

PAGE 84

Dasinger, L. K., Krause, N., Thompson, P. J. Brand, R. J., & Rudolph, L. (2001). Doctor proactive communication, return -to-work recommendation, and duration of disability after a workers compensation low back injury. Journal of Occupational and Environmental Medicine, 43 (6), 515-525. Dawis, R., & Lofquist, L. (1984) A psychological theory of wo rk adjustment. Minneapolis: University of Minnesota Press. Derebery, V. J., Giang, G. M., Saracino, G., & F ogarty, W. T. (2002). Evaluation of the impact of a low back pain educational intervention on physicians practice patterns and patients outcomes Journal of Occupational and Environmental Medicine, 44 (10), 977. Di Iorio, D., Henley, E., & Doughty, A. (2000). A survey of primary care physician practice patterns and adherence to acute low back problem guidelines. Archives of Family Medicine, 9 (10), 1015. Disabilitysecrets.com. (n.d.). Retrieved October 20, 2007, from http://www.disabilitysecrets.co m/disability-denial.html Elders, L. A., van der Beek, A .J., & Burdorf, A. (2000). Return to work after sickness absence due to back disordersA systematic review on interv ention strategies. International Archives of Occupational Environmental Health, 73 (5), 339. Fishbain, D. A., Cutler, R., Rosomoff, H. L., & Rosomoff, R.S. (1999). Chronic pain disability exaggeration/malingering and submaximal effort research. Clinical Journal of Pain, 15(4), 244-274. Florida Department of Financial Services Divisi on of Insurance Fraud a nd Division of Workers Compensation (2007). Joint report to the President of the Florida Senate and the Speaker of the Florida House of Representatives Tallahassee, FL. Florida Division of Workers Compensation. (2 006). Florida workers compensation uniform medical treatment/status reporting form DFS-F5-DWC 25 (revised 2/14/2006). Florida Workers Compensation Law. (2000). In Florida Workers Compensation Reference Manual (pp. 1-172). Tallahassee: Florid a Workers Compensation Institute. Franche, R. L., Baril, R., Shaw, W. S., Nic holas, M., & Loisel, P. (2005). Workplace-based return-to-work interventions: Optimizing the ro le of stakeholders in implementation and research. Journal of Occupational Rehabilitation, 15 (4), 525. Frank, J ., Sinclair, S ., Hogg-Johnson, S ., Shannon, H ., Bombardier, C ., Beaton, D ., & Cole, D (1998). Preventing disability from work-rela ted low-back pain. Ne w evidence gives new hope--if we can just get a ll the players onside. Canadian Medical Association Journal, 158(12), 1625-1631. Frese, M (1987). Alleviating depression in the unem ployed: Adequate financial support, hope and early retirement [Abstract]. Social Science and Medicine, 25 (2), 213-215. 84

PAGE 85

Frese, M ., & Mohr, G (1987). Prolonged unemployment and depression in older workers: a longitudinal study of interven ing variables [Abstract]. Social Science and Medicine, 25(2), 173-178. Gillen, M., Yen, I. H., Trupin, L., Swig, L., Ru gulies, R., Mullen, K., et al. (2007). The association of socioeconomic status and psychosocial and physical workplace factors with musculoskeletal injury in hospital workers. American Journal of Industrial Medicine, 50 245. Greenberg, P. E ., Kessler, R. C ., Birnbaum, H. G ., Leong, S. A ., Lowe, S. W ., Berglund, P.A ., et al. (2003). The economic burde n of depression in the United States: How did it change between 1990 and 2000? Journal of Clin ical Psychiatry, 64 (12), 1465-1475. Retrieved July 21, 2007, from PubMed database. Greer, B. C., Roberts, R., & Jenkins, W.M. ( 1990). Substance abuse among clients with other primary disabilities. Rehabilitation Education, 4 (1), 33-40. Hadler, N. M., Carey, T., S., & Garrett, J. (1995) The influence of indemnification by workers compensation insurance on recovery from acu te backache. North Carolina Back Pain Project [Abstract]. Spine, 20 (24), 2710. Harris, I., Mulford, J., Solomon, M., van Gelder, J. M., & Young, J. (2005). Association between compensation status and outcome af ter surgery: A meta-analysis. Journal of the American Medical Association, 293 (13) 1644. Hashemi, L., Webster, B.S., & Clancy, E. A. ( 1998). Trends in disability duration and cost of workers compensation low back pain claims (1988). Journal of Occupational Environmental Medicine, 40 (12), 1110. Hashemi, L., Webster, B. S., Clancy, E. A., & Voli nn, E. (1997). Length of disability and cost of workers compensation low back pain claims. Journal of Occupational and Environmental Medicine, 39 (10), 937-945. Hazard, R. G., Reid, S., Haugh, L. D., & McFarl ane, G. (2000). A controlled trial of an educational pamphlet to prevent disabili ty after occupational low back injury. Spine, 25(11), 1419-1423. Hoyt, W. T., Leierer, S., & Mil lington, M. J. (2006). Analysis and interpretation of findings: Using multiple regression techniques. Rehabilitation Counseling Bulletin, 49 (4), 223233. Hussey, S., Hoddinott, P., Wilson, P., Dowell, J., & Barbour, R. (2003). Sickness certification system in the United Kingdom: Qualitative st udy of views of gene ral practitioners in Scotland. British Medical Journal, 328 88-93. Insurance Information Institute. (n.d.). Workers Compensation: Background. Retrieved October 13, 2007, from www.iii.org/media/hottopics/insurance/workerscomp. 85

PAGE 86

Joelson, L., & Wahlquist, L. (1987). The psychological meaning of job insecurity and job loss: Results of a longitudinal study. Social Science Medicine, 25(2), 179-182. Joiner, J. G., & Sawyer, H. W. (1992). Couns eling strategies for adjustment services. Vocational Evaluation and Work Adjustment Bulletin, 25 (3), 97-99. Katz, J., N., Amick, B. C., Keller, R., Fossel, A. H., Ossman, J., Soucie, V., & Losina, E. (2005). Determinants of work absence following surgery for carpal tunnel syndrome. American Journal of Industrial Medicine, 47, 120-130. Kessler, R. C., Greenberg, P. E ., Mickelson, K. D., Meneades, L. M., & Wang, P. S. (2001). The effects of chronic medical conditions on work loss and work cutback. Journal of Occupational and Environmental Medicine, 43 (3), 218-225. Retrieved July 21, 2007, from Health Wellness Resource Center database. Krause, N., Dasinger, L. K., & Neuhauser, F. (1 998). Modified work and return to work: A review of literature. Journal of Occupati onal Rehabilitation, 8 (2), 113. Kwan, O., Ferrari, R., & Friel, J. (2001). Tertiary gain and disability syndromes. Medical Hypotheses, 57 (4), 459-464. Lehane, P., & Stubbs, D. (2001). The perceptions of managers and accident subjects in the service industries towards s lip and trip accidents. Applied Ergonomics, 32 (2), 119-126. Lerner, D., Adler, D. A., Chang, H., Berndt, E. R., Irish, J. T., Lapitsky, L., et al. (2004). The clinical and occupational co rrelates of work productivity loss among employed patients with depression. Journal of Occupational Environmental Medicine, 46 (6 supplement), S46-S55. Linton, S. J., & Andersson, T. (2000). Can chroni c disability be preven ted? A randomized trial of a cognitive-behavioral intervention and two forms of information for patients with spinal pain. Spine, 25(21), 2825. Linton, S.J., Boersma, K., Jansson, M., Svrd, L., & Botvalde, M. (2005). The effects of cognitive-behavioral and physical therapy prev entive interventions on pain related sick leave: A randomized controlled trial. Clinical Journal of Pain, 21 (2), 109-119. Linton, S.J., Vlaeyen, J., & Ostelo, R. (2002). The back pain beliefs of health care providers: Are we fear-avoidant? Journal of Occupational Rehabilitation, 12 (4) 223. Livneh, H. (1987). Person-environment congruence: A rehabilitation perspective. International Journal of Rehabilitation Research, 10 (1), 3-19. Loisel, P., Buchbinder, R., Hazard, R., Keller, R., Scheel, I., van Tulder, M., et al. (2005). Prevention of work disability due to musc uloskeletal disorders: The challenge of implementing evidence. Journal of Occupational Rehabilitation, 15 (4), 507. 86

PAGE 87

Loisel, P., Gosselin, L., Durand, P., Lemaire, J., Poitras, S., & Abenhaim, L. (2001). Implementation of a participatory ergonomics program in the rehabilitation of workers suffering from subacute back pain. Applied Ergonomics, 32(1), 53. Lustig, D. C., & Vanden Boom, D. C. (1997). Th e relationship between em ployment status and quality of life for individuals with seve re and persistent mental illness. Journal of Applied Rehabilitation Counseling, 28 (4), 4-8. Mahmud, M. A., Webster, B. S., Courtney, T. K., Matz, S., Tacci, J. A., & Christiani, D. C. (2000). Clinical management and the duration of disability for work-related low back pain. Journal of Occupational En vironmental Medicine, 42 (12), 1178. McGurik, B., King, W., Govind, J., Lowry, J., & B ogduk, N. (2001). Safety, efficacy and cost effectiveness of evidence-based guidelines fo r the management of acute low back pain in primary care. Spine, 26(23), 2615. McGill, C. M. (1968). Industrial back problems: A control program. Journal of Occupational Medicine, 10(4), 174-178 Merill, R.N., Pransky, G., Hathaway, J., & Scott, D. (1990). Illness and the workplace. A study of physicians and employers. Journal of Family Practice, 31 (1), 55-9. Mitchell, K. E., Alliger, G. M., & Morfopoulos R. (1997). Toward an ADA-appropriate job analysis. Human Resource Management Review, 7 (1), 5-26. Montgomery, S. M ., Cook, D. G ., Bartley, M. J ., & Wadsworth, M. E (1999). Unemployment pre-dates symptoms of depression and anxiet y resulting in medical consultation in young men [Abstract]. International Journal of Epidemiology, 28 (1), 95-100. Muijs, D. (2004). Multivariate analysis: Usi ng multiple linear regression to look at the relationship between several predictors and one dependent variable. In Doing Quantitative Research in Education with SPSS (pp. 159-184). London: Sage Publications. Nathan, P. A., Meadows, K., D., & Keniston, R. C. (1993). Rehabilitation of carpal tunnel surgery patients using a short surgical incision and an early program of physical therapy. Journal of Hand Surgery, 18A(6), 1044-1050. OBrien, M. D. (1997). Work adjustment in the private sector: A case study. Vocational Evaluation and Work Adjustment Bulletin, 27 (3), 99-101. Okurowski, L., Pransky, G., Webster, B., Shaw, W. S., & Verma, S. (2003). Prediction of prolonged work disability in occupationa l low-back pain based on nurse case management data. Journal of Occupational Medicine, 45 (7), 763770. Partee, W. (2005). Doctors and employers must cooperate to solve workers' comp paradox. Los Angeles Business Journal, 27 (34), 51-55. 87

PAGE 88

Payne, R ., Warr, P ., & Hartley, J (1984). Social class and psychological ill-health during unemployment [Abstract]. Sociology of Health and Illness, 6 (2), 152-174. Pincus, T., Burton, A. K., Vogel, S., & Fiel d, A. P. (2002). A systematic review of psychological factors as predictors of chronicity/disability in prosp ective cohorts of low back pain. Spine, 27(5):E109. Rainville, J., Sobel, J. B., Hartigan, C., & Wright, A. (1997). The effect of compensation involvement on the reporting of pain and disa bility by patients referred for rehabilitation of chronic low back pain. Spine, 22(17), 2016. Rehabilitation Research and Traini ng Center on Disability Demogr aphics and Statistics. (2005). Disability status report Cornel University. Re trieved October 16, 2007, from http://www.ilr.cornell.edu /edi/disabilitystatistics Rodriguez, E Lasch, K & Mead J. P (1997). The potential role of unemployment benefits in shaping the mental health impact of unemploymen t [Abstract]. International Journal of Health Services : Planning, Administration, Evaluation, 27 (4), 601-623. Rossler, R. T., & Summer G. (1997). Employe r opinions about accommodating employees with chronic illnesses. Journal of Applied Rehabilitation Counseling, 28 (3), 29-34. Rubin, S. E., & Roessler, R. T. (1995). Current rehabilitation history 1970 -1992. In D. Berman (Ed.), Foundations of the vocati onal rehabilitation process (4th ed., pp. 41-82). San Antonio, TX: Pro-ed. Rugulies, R., & Krause, N. (2005). Job strain, iso-strain, and the incidence of low back and neck injuries. A 7.5-year prospective study of San Francisco transit operators. Social Science and Medicine, 61 (1), 27-36. Sanchez, J. I. (2000) Adapting job analysis to a fast paced and electronic business world. International Journal of Selection and Assessment 8 (4), 207. Saran, M., & Patterson, J. (2007). The misuse of social security disability income on drug and alcohol abuse. Southern Medical Journal, 100 (2), 222-223. Schultz, I. Z, Crook, J., Berkowitz, J., M ilner, R., & Meloche, G. R. (2005). Predicting return to work after low back injury using the psychosocial risk for occ upational disability instrument: A validation study Journal of Occupational Rehabilitation, 15 (3), 365-376. Shaw, W. S., Linton, S. J., & Pransky, G. (2006) Reducing sickness absence from work due to low back pain: How well do intervention strategies match modifiable risk factors? Journal of Occupational Rehabilitation, 16 (4), 591-605. Smith, S. (2006). Assessing fitness for duty: A st ate-sponsored occupational health program is teaching Washington doctors and employers how to get injured workers back on the job. Occupational Hazards, 68 (8), 39-41. 88

PAGE 89

Steinntz, E. (2006, May 12). Americans with di sabilities: 2002. Washington, DC: U.S. Census Bureau, Housing and Household Economic Statistics Division Current Population Reports, P70-107. Stewart, W. F., Ricci, J. A., Chee, E., Hahn, S. R., & Morganstein, D. (2003). Cost of lost productive work among US workers with depression. JAMA, 289, 3135-3144. Sullivan, M. J., Feuerstein, M., Gatchel, R., Li nton, S. J., & Pransky, G. (2005). Integrating psychosocial and behavioral interventions to achieve optimal rehabilitation outcomes. Journal of Occupational Rehabilitation, 15 (3), 475-489. Sullivan, M. J., Ward, L. C., Tripp, D., French, D. J., Adams, H., & Stanish, W. D. (2005). Secondary prevention of work disability: Co mmunity-based psychosocial intervention for musculoskeletal disorders. Journal of Occupational Rehabilitation, 15 (3), 377-392. Tuckey, S. (2005). Texas moves to cut soaring WC costs: Establishing medical care networks seen as remedy for dying system. National Underwriter Prop erty & Casualty-Risk & Benefits Management, 109(17), 36-39. Turner, R. J., Donald A. L., & Taylor, T. (2006). Physical disability and mental health: An epidemiology of psychiatric and substance disorders. Rehabilitation Psychology, 51 (3), 214. United States Department of Labor (1991). Dictionary of Occupational Titles. Washington, DC: Author. United States Department of Labor Bureau of Labor Statistics. (n.d.). Injuries, illnesses and fatalities. Retrieved September 30, 2007, from http://www.bls.gov/iif/home.htm United States Department of Labor Bureau of Labor Statistics. (2006a). Occupational injuries and illnesses: Counts, rates, and characteristics, 2004, bulletin 2584 Retrieved September 30, 2007, from http:// www.bls.gov/iif/oshbulletin2004.htm United States Department of Labor Bu reau of Labor Statistics. (2006b). Nonfatal occupational injuries and illnesses requiring days away from work (USDL Publication No. 07-1741). Washington, DC: U.S. Government Printi ng Office. Retrieved November 14, 2007, from http://www.bls.gov/iif/oshw c/osh/case/osnr0029.pdf. United States Department of Labor Employment and Traini ng Administration. (1991). The Revised Handbook for Analyzing Jobs Indianapolis, IN: JIST Works. United States Social Secur ity Administration. (n.d.). Press Office Fact Sheet. Retrieved October 16, 2007, from http://www.ssa.gov/pressoffice/basicfact.htm United States Social Secur ity Administration (2003). 2003 Red book (SSA Pub. No. 64-030, ICN 436900) U.S. Government Printing Office. 89

PAGE 90

United States Social Secur ity Administration. (2005). Disability Evaluation Under Social Security, Listing of Impairments-Part A (SSA Pub. No. 64-039). Baltimore, MD: US Government Printing office. United States Social Security Ad ministration. (2006, February). State statistics for December 2004: Florida (SSA Publication No. 13-11709) Washington, DC: Arthur. United States Social Security Administration Offi ce of Hearings and Appeals. (1990, February). Vocational Expert Handbook (DHHS Publication). Washington, DC: U.S. Government Printing Office. University of Florida Colle ge of Medicine. (n.d.). Future students, MD/PhD Program Retrieved October 20, 2007, from http://www.med.ufl.edu/md-phd/curriculum.htm van Duijn, M., Miedema, H., Elders, L., & Burdor f, A. (2004). Barriers for early return-to-work of workers with musculoskeletal disorders according to occupati onal health physicians and human resources managers. Journal of Occupati onal Rehabilitation, 14 (1), 31. Von Korff, M., Crane, P., Lane, M., Migliore tti, D., Simon, G., Saunders, K., et al. (2005). Chronic spinal pain and physical-mental como rbidity in the United States: Results from the national comorbidity survey replication. Pain, 113 (3), 331-339. Von Korff, M., Moore, J. E., Lorig, K., Cherki n, D.C., Saunders, K., Gonzalez, V.M., et al. (1998). A randomized trial of a lay personled self-management group intervention for back pain patients in primary care. Spine, 23(23), 2608. Vinokur, A. D ., Price, R. H ., & Caplan, R. D (1996). Hard times and hurtful partners: how financial strain affects depression and rela tionship satisfaction of unemployed persons and their spouses [Abstract]. Journal of Personality and Social Psychology, 71 (1), 166179. Weed, R. O., & Field, T. F. (1994). Job analyses. In Rehabilitation Consultants Handbook (pp. 125-144). Athens, GA: Elliott and Fitzpatrick, Inc. Wilk, J., West, J. C., Rae, D. S., & Regier, D.A. (2006). Relationship of comorbid substance and alcohol use disorders to disability among patients in routine psyc hiatric practice. The American Journal on Addictions, 15, 80. World Health Organization. (n.d.). Health topics: disabilities. Retrieved October 20, 2007, from http://www.who.int/topics /disabilities/en/ Young, A. E., Wasiak, R., Roessler, R. T., McPher son, K. M., Anema, J. R., & van Poppel, M. N. (2005). Return-to-work outcomes following work disability: Stakeholder motivations, interests and concerns. Journal of Occupati onal Rehabilitation, 15 (4), 543-556. 90

PAGE 91

91 BIOGRAPHICAL SKETCH David Jackson received his B achelor of Science degree in psychology from the University of Florida in 1996. David also received his Master of Health Science degree in rehabilitation counseling from the University of Florida in 199 9. He was admitted in to the University of Florida Department of Counselor Education in 2000 majoring in mental health counseling and should receive his Doctor of Philosophy degree in 2008. David became licensed as a Mental Health Counselor in Florida in 2001 and received his National C ounselor Certification in 2000. He has been a Certified Rehabili tation Counselor since 2000 as we ll as a Qualified Rehabilitation Provider in Florida since 2000. He has returned to the Universi ty of Florida as an adjunct professor in the Rehabilitation Science departme nt. David has maintained memberships in the American Counseling Association, the American Mental Health Counseling Association, the Florida Mental Health Counseling Association a nd both the national and Florida chapters of the International Association of Rehabilitation Providers. He works within the private sector as a rehabilitation counselor providi ng medical case management and vo cational services for injured workers. He is also recognized as a vocational e xpert by Social Security and frequently testifies in Social Security Disability and Social Securi ty Disability Insurance hearings. David also quarterly provides a three day seminar on vocational aspects to Social Security adjudicators. He lives in Gainesville, Florida, with his wife Jennifer and two children Quinn and Amelia.