As a claims adjuster, I used to think that if I got the injured worker to show up for their medical appointments and if they followed the doctor’s orders (at least most of the time), they were doing what they were supposed to and that they would recover and return to work. I never thought of physical therapy and what happened there. That activity was below my radar as a claims adjuster.
As a claims examiner, VP of Claims, and later risk manager, I saw some injured workers bounce back with minimal disability—strong, confident, and ready to return to work—while others, with the same injuries, demographics, and treatment plans, seemed stuck in the mud.
This inconsistency made me wonder: How do we really know when someone is engaged in their recovery? Talk is cheap—anyone can nod along in the doctor’s office or say they’re doing their part. But in workers’ compensation, we need something tangible, something observable. That’s when I realized that physical therapy offers us that window.
Physical therapy is not just part of the treatment—it’s the most objective and practical measure of engagement. Are they showing up? Are they doing their exercises at home? Are they gaining strength, flexibility, and confidence? PT becomes the proving ground where engagement—or the lack of it—shows itself. If an injured worker is committed, it shows up in the therapy room, the data, and their progress.
My true epiphany on PT was when I injured my shoulder chasing a thief who had grabbed my camera off of our outdoor dining table in Barcelona. (Yes, I got my camera back, but I also tore the muscle off of my bone in the shoulder when I tackled him.) The Physical Therapy from the shoulder surgery was hard work, and it took several months before I was back to “normal.” Wow! I did not understand the importance of PT, nor did I know how hard it could be.
When I considered different recovery rates, I understood that the difference in recovery boiled down to one key factor: was the patient truly engaged in recovery?
Engagement is not just compliance.
It’s not just attendance.
It’s not just checking boxes.
Engagement is not just a state of mind, it’s a personal investment in one’s recovery. It’s about the injured worker believing in themselves, the treating doctor, and the physical therapist in the treatment process, participating in decisions, asking questions, following through with treatment, and taking ownership of the outcome.
Nothing will improve no matter what the patient does. Another crucial aspect I learned is that engagement doesn’t just come from the injured worker working alone. Genuine engagement is often built on a foundation of support from friends, family, and the broader community (including the claims examiner and the employer). This support is not just a nice addition, it’s a crucial part of the recovery process.
I remember one case where a managed care nurse explained that smoking was interfering with an injured worker’s back fusion healing. Instead of just telling the patient to quit smoking, she got the whole family involved. They all agreed to stop smoking to help support the patient’s recovery. That kind of support doesn’t just impact medical outcomes—it sends a message to the injured worker that they are not alone and that their recovery matters to everyone around them. I knew it worked but did not know that was the ideal engagement.
Patient engagement is emotional, psychological, and behavioral. It involves trust, confidence, and a willingness to put in the effort, even when progress is slow or painful. When patients are engaged, they heal better. Their pain is lower. Their function is higher. And their quality of life—both during and after recovery—is significantly better.
This paper explores authentic engagement and why it’s foundational to everything we do in workers’ compensation. If we want better outcomes—faster recovery, fewer surgeries, reduced disability, and lower costs—we must stop thinking about “compliance” and foster authentic engagement.
Engagement Is Not the Same as Compliance or Satisfaction
One of the key distinctions we need to make in the workers’ compensation system is between compliance and engagement. Compliance is about following instructions because someone told you to. It’s a passive approach that might get someone through a treatment protocol, but it doesn’t necessarily mean they are healing—or even trying to heal. I’ve seen workers who ‘comply’ with everything the doctor says but remain disengaged, frustrated, or checked out. They show up, but they’re not present.
Satisfaction is another metric that can be misleading. An injured worker might say they’re satisfied with their care because the doctor is polite or the clinic is clean. But satisfaction doesn’t necessarily mean they are motivated to do their exercises, challenge themselves, or visualize a return to work. We’ve all seen patients who give glowing reviews of their care team but still drift into permanent disability. This is where engagement differs-it’s internal, it comes from a place of belief, ownership, and hope.
Engagement is different. Engagement is internal. It comes from a place of belief, ownership, and hope. It’s when the injured worker understands the “why” behind the treatment plan and commits to the work—even when it’s uncomfortable or slow progress. It’s when they set goals and track their progress. It’s when they bring questions to their appointments and take recovery seriously. And often, it’s when they have someone—be it a coach, a nurse, or a family member—who walks alongside them.
Engagement is when the injured worker stops seeing themselves as a victim of the system and start seeing themselves as the driver of their recovery. And when that happens, everything changes. But even engagement has its risks when misunderstood. Some workers—especially those naturally competitive or impatient—take engagement too far. They think that if doing 10 repetitions of an exercise is good, then 20 must be better. That mindset can backfire. Overdoing at-home physical therapy can cause setbacks, inflammation, or new injuries. Engagement must be guided by trust in the process, not just drive or ambition. It’s about carefully following the exercises as prescribed.
Barriers to Engagement
There’s a crude joke about the top three lies in the world—but few people know the fourth is: “Yes, I did my physical therapy homework.” It’s said with a straight face to the physical therapist, but the reality can be quite different, like flossing before the dentist’s appointment.
This seemingly small lie reveals a deeper issue—disengagement from recovery and a lack of follow-through with critical at-home exercises. When patients fail to engage in their recovery, outcomes suffer. And often, the first missed PT session is the beginning of a much longer, more expensive, and more painful journey.
Injured workers face many barriers that interfere with their ability to participate fully in their recovery. These are not just logistical problems but deeply personal, emotional, and systemic challenges that must be understood before we can address them.
Below is a breakdown of the most common barriers:
- Kinesiophobia: A fear of movement or re-injury that leads patients to avoid exercise or therapy, even when it is safe. This fear can slow down or completely halt recovery.
- Catastrophizing: The tendency to fixate on worst-case outcomes increases emotional distress and discourages action.
- Learned Helplessness: The belief that nothing will improve no matter what the patient does, Often rooted in long-term negative experiences with systems or authority figures.
- Low Self-Efficacy: A lack of confidence in one’s ability to heal or follow through with therapy. These patients may need more encouragement and structure.
- Depression and Isolation: The loss of work identity and social contact can lead to depression, which makes it harder to find the energy or hope required to stay engaged.
- Avoidance Coping: Some workers avoid dealing with their injury or treatment, miss appointments, or refuse to discuss their progress.
- Negative Transference: Emotional baggage from past medical or workplace interactions can lead to mistrust of current providers or systems.
- Shame or Embarrassment: Internalizing the injury as a weakness can keep people from asking for help or being honest about their struggles.
- Distrust in the System: Suspicion toward insurers, employers, or healthcare providers can make injured workers feel like the system is against them.
- Fear and Uncertainty: Anxiety about pain, prognosis, or job security can become paralyzing.
- Cultural Beliefs: Cultural norms discouraging pain or relying on others can limit a person’s willingness to engage.
- Inconsistent Communication: Mismatched messages from different parties—doctors, adjusters, employers—can cause confusion and disengagement.
- Low Health Literacy: When patients don’t understand their condition or treatment plan, they can’t follow through effectively.
- No Sense of Agency: If workers feel the recovery process is out of their control, they are less likely to take an active role.
- Technology Barriers and Digital Literacy: The increasing use of apps and virtual tools can exclude the less tech-savvy.
- Language Barriers: Miscommunication due to language differences can cause confusion, misdiagnosis, or disengagement.
Identifying and Encouraging Engagement
In addition to these observations, a recent peer-reviewed study published in the Journal of Advances in Medicine and Medical Research (Hui & Gorham, 2025) demonstrated that digital health solutions—like Plethy’s Recupe platform—greatly enhance engagement and adherence to home exercise programs. The study followed over 1,000 injured workers and found that 72% engaged with their home exercise program at least half the time, with 60% engaging over 75% of the time. This is a remarkable improvement compared to the historically reported 70% non-compliance rate. Notably, pain levels dropped by an average of 3.9 points out of 10, suggesting not just activity but real recovery.
This evidence highlights that engagement can be measured and improved with the right tools and support systems. It’s not just about encouraging workers, it’s about giving them resources that meet them where they are technologically, emotionally, and behaviorally.
Once we understand what the barriers look like, the next step is recognizing when a worker is disengaged and knowing what to do about it. Every stakeholder in the recovery process plays a role. Here’s how we can counter the specific barriers we’ve identified:
- Kinesiophobia: Doctors and PTs can educate the patient on safe movement, demonstrate exercises with reassurance, and provide clear benchmarks for progress. Gradual exposure to movement with positive reinforcement reduces fear.
- Catastrophizing: PTs and claims professionals can use supportive language and motivational interviewing to reframe the narrative. Helping workers set realistic goals and track minor improvements combats the spiral of worst-case thinking.
- Learned Helplessness: Employers and claims examiners can empower workers by involving them in goal setting and treatment decisions. Even small choices—like selecting appointment times—can rebuild a sense of control.
- Low Self-Efficacy: Providers should highlight early wins and reinforce positive behavior. When patients feel their actions matter, they become more engaged.
- Depression and Isolation: Doctors should screen for depression and refer to behavioral health support when needed. Regular, non-clinical contact from a nurse or employer helps reduce isolation.
- Avoidance Coping: PTs can break recovery into manageable steps and celebrate completion. Making engagement less daunting encourages participation.
- Negative Transference: All parties should approach the injured worker empathetically and without judgment. Consistency, transparency, and kindness can break through prior trauma.
- Shame or Embarrassment: Employers and medical providers can affirm that asking for help is a strength, not a weakness. Creating a nonjudgmental environment encourages honesty.
- Distrust in the System: Clear, respectful, and consistent communication from adjusters and medical providers rebuilds trust. Following through on promises builds credibility.
- Fear and Uncertainty: Doctors should explain what to expect in treatment and recovery. A roadmap with milestones offers reassurance.
- Cultural Beliefs: Employers and clinicians should be culturally sensitive and adapt their approaches to align with workers’ values.
- Inconsistent Communication: All stakeholders must coordinate and speak with one voice. When messages align, the worker feels supported, not confused.
- Low Health Literacy: Providers should use plain language, visual aids, and teach-back methods to ensure understanding.
- No Sense of Agency: Give injured workers a say in their recovery plans. When people feel heard and empowered, they engage more deeply.
- Technology Barriers and Digital Literacy: Provide tech support or offer alternatives to app-based programs. Don’t assume digital comfort—assess and support it.
- Language Barriers: Always offer professional interpreters or translated materials. Engagement starts with comprehension.
Engagement isn’t something we wait for. We cultivate it through relationships, trust, and thoughtful actions. When we see a lack of engagement, we must ask ourselves not just, “What’s wrong with this worker?” but also, “What do they need to feel safe, heard, and supported on their path to recovery?”
