Dr Melita Giummarra said in her presentation for ISCRR that the injury itself may not be bring about a bad outcome, but rather it may be “the way that that person responds to that injury and the beliefs that they hold about that injury.”

A systematic review was conducted, looking at chronic pain after road trauma and the role of seeking or receiving compensation. They screened almost 6000 papers to conduct the research, and included 27 papers after assessment. These papers looked at injuries which were compensable versus non-compensable, or between compensation scheme types. All measured pain as an outcome, along with psychological and other outcomes.

They found that in 70% of the studies reviewed, adverse pain outcomes were found when injuries were compensable. The remaining studies found either no positive benefits to compensation or had no have findings on it. None of the studies reported positive outcomes.

In the study, compensable injury was found to be consistently related to greater incidence, intensity or disability related to pain, as well as a higher incidence of related mental health disorders such as PTSD or depression, and a poorer return to work. They found that the negative pain outcomes were particularly related to the involvement of lawyers or court cases related to compensation. Even within no-fault schemes, the perception that someone else was to blame was associated with poor outcomes. 

Melita did note however that the quality of the studies were quite poor, and that the studies didn’t explore why compensable injuries lead to poorer outcomes.

Perceptions of justice have a large part to play in recovery. When people believe that the world is morally balanced, it can impact recovery. Holding ‘just world beliefs’ can lead to perceptions of fault and attributions of blame in terms of the accident and its results. Procedural justice is also needed to make sure that people feel they are treated with respect and dignity. When people feel that the procedures are unfair, people tend to have poorer results.

Perceptions of injustice can leading to feelings of anger or pain catastrophising, and may have a variety of negative results (including depression, poorer return to work and higher reported pain intensity). 

Their aims in the research were:

1. To understand the associations between psychological distress, perceived injustice and return to pre-injury function (ie. Return to work) after traumatic injury.
2. To investigate the role of the compensation system experience in recovery from traumatic injury, especially pain and pain-related disability; and to identify modifiable aspects of compensation systems and/or healthcare delivery to improve trauma recovery.

They recruited 208 injured patients in a Melbourne hospital. Patients were asked a series of questions that provided researchers with information on:

1. Injury severity score
2. Information about the trauma
3. SF-12 (a questionnaire related to health status)
4. 1CD-10-AM (an international statistical classification of disease and related health problems)
5. The number of days hospitalised
6. The discharge location
7. The patient’s work status

At the 12 to 18 month stage, the researchers also collected information on:

1. Brief pain inventory
2. Pain Self Efficacy Questionnaire
3. Pain Catastrophising Scale
4. Roland Morris Disability Questionnaire
5. Hospital Anxiety and Depression Scale
6. Posttraumatic Stress Disorder Checklist
7. Injustice Experience Questionnaire

In the Injustice Experience Questionnaire, patients were asked questions to identify the degree to which they rated their injury severity and the locus of blame. They answered on a scale questions such as ‘I just want my life back’ and ‘My life will never be the same’.

The researchers found that the injury severity was higher in the compensable group, however the non-compensable group also had high injury severity  (including falls from ladders or horses, and some victims of violence). The non-compensable group were also almost twice as likely to be discharged to rehabilitation.

Perceptions of the injury being severe correlated with lower levels of education and a lower household income. Perceptions of blame were lowest in the group with the highest household income. 

The pain severity and blame scores were the highest in:

1. People who were not working at the 12 month point
2. People who had been injured in a road accident
3. People who were not at fault in their accident
4. People who had consulted a lawyer

When they looked at predictive factors around perceptions of injustice, they found that only consulting a lawyer and work status were independent predictors.

They also found that, after taking into account other factors, perceptions of injustice only significantly predicted clinically elevated PTSD symptoms (not anxiety or depression). 

A further finding was that compensation status was associated with poorer return to work.

The research suggested that early detection of perceptions of injustice is very important. They identified some of the early risk factors as:

1. Attribution of blame
2. Disabling/severe injury
3. Work status following injury
4. Household income at time of injury
5. Prior embitterment and/or psychological disorders
6. Ruminations about the injury/incident
7. Sense of hopelessness
8. Consulting a lawyer (this may also be a delayed risk factor)
9. A further delayed risk factor was a failure to return to work or study

When people felt injustice with regard to their injury, they were more likely to feel there were barriers around claim procedures. This might be complicated paperwork (particularly impacting people with poor health literacy or reading/writing skills), long waiting times for claims outcomes, or fault versus no fault entitlements.

Melita noted the importance of communication style with regard to claimants. This includes the spoken content, the way it is said, and in terms of providing motivation for clients to change their behaviour. It’s important to acknowledge the embitterment which an injured worker may feel, however the focus should be on providing people with the sense that they are being treated fairly.  

System changes may be needed to ensure that injured workers have early access to medical treatment, interventions provided for at-risk patients, injured workers feel as though they have been ‘heard’, and there has been a sense of procedural justice.

Healthcare may become further involved through early identification of high risk patients, providing acceptance and commitment therapy, progressive goal attainment therapy, anger management training, forgiveness-oriented treatments or trans-diagnostic treatments to help improve emotion regulation. These all relate to the patient gaining better self-management skills around their injury.

In summary, the researchers believe that the connection between injury, compensation and perceptions of injustice require much more attention. Removing or reducing the perceptions of injustice in the early stages post-injury, will:

• Prevent chronic embitterment
• Improve psychological wellbeing
• Reduce disability
• Increase return to work
• Facilitate self-management of health, pain and function
• Reduce healthcare costs and compensation claim benefits