Introduction This report contains the findings and recommendations from a project comprising two large clinical studies that investigated the early identification and management of psychosocial risk factors known to affect recovery and return to work of workers with musculoskeletal work injury. This report is an update of the discussion paper Work-related back pain study: measuring biopsychosocial risk factors. Aims The primary aim of the project was to identify and assess the long term impact of key risk factors for delayed recovery, and return to work and function. The risk factors chosen included those that were identified in the available literature as potentially amenable to evidence informed rehabilitation and health interventions. A secondary aim was to assess the accuracy of risk assessment undertaken in the acute injury phase.by health practitioners and their compliance with treatment guideline recommendations The anticipated project outcomes included: develop and validate local norms for selected psychometric tools and provide these for use by clinicians to help improve accuracy of their risk identification, treatment planning and outcomes. develop guidance for clinicians and key stakeholders (employers, rehabilitation staff and insurers) on strategies to improve return to work. publish information in peer review clinical literature to increase credibility of the advice and improve uptake of recommended management strategies by health, employer, insurer and rehabilitation stakeholders. Project outline The project comprised two large prospective studies involving more than three thousand workers with pain related work injuries to the back, shoulder, neck or knee. Of those three thousand workers, fourteen hundred actively participated by completing a series of questionnaires with the remainder used as a control group; both participants and control groups were tracked for return to work and health outcomes. The study focussed on people with low back injuries, while the second study looked at workers with injuries to low back, upper back, shoulder, neck or knee injuries. People with serious injuries, existing injury claims and severe and specific pathologies were excluded. The studies assessed specific psychosocial, workplace and treatment related risk factors for each participant within each study from time of injury at regular intervals up to three years. The screening of participants comprised clinical assessment tools, claims and qualitative data and information on long term work, recovery and health outcomes. Medical and physiotherapy assessment data was also analysed for risks to recovery. All participants in the study were ‘blinded’ (not informed) about any information from the assessment or database data obtained.
The studies found that ‘one size fits all’ clinical management by health practitioners throughout the injury persisted despite evidence of the worker’s changing risk profile. This approach was associated with poor outcomes and included passive treatment (medications, scans, rest and reduced activity) contrary to recommendations. Interventions by clinical practitioners did not address broader issues such as non-supportive workplace, lack of suitable duties, workplace or rehabilitation relationship conflict. As a consequence even with relatively low level of individual risk factors (e.g. catastrophizing, depression, anxiety) were more likely to have poor outcomes. Ill directed interventions The study findings indicated that inappropriately applied intervention can significantly worsen return to work outcomes for those already at risk and also increases the likelihood of poor outcomes in those initially assessed at low personal risk. In those initially scoring as mild risk, poor outcomes were associated with poor and non-supportive workplace, claims or health management. Proactive support and training of injured workers in self-management skills were associated with improved outcomes even for those initially assessed as at risk. Implication: Apply appropriate and management strategies for optimal recovery. The qualitative component of the study (interviews with injured workers) identified the impact of positive support and providing of suitable duties (from worker perspective). Training and encouragement in by health practitioners and return to work consultants were key to recovery in those assessed as at high risk. Implication: It is critically important to involve the injured worker in self-management and as a full participant in managing their own rehabilitation, return to work and recovery process. Specific findings The results from the data derived from quantitative and qualitative assessment of individuals and accompanied by database outcomes are provided here. high pain intensity and quality high perceived disability which was impacting on most home, work, recreational and social activities excessive pain focus and fear of aggravating pain through normal daily activity beliefs about having a negative future prognosis and belief that work activities were unsafe poor pain related self-efficacy, poor belief in own self-management of pain prominent psychological distress including anxiety and depressive symptoms, poor coping perception of non-supportive workplace, suitable duties not available early in injury targeted
Attachment 1. Risk assessment tools Table 1. Individual assessment tools Screening type Risk domain of individual Instrument Brief screeners A range Orëbro, Back Disability Risk Questionnaire Single questions Pain quality Single scale question Durable RTW Single scale question Area of pain Pain drawing Comprehensive instruments Function Pain Disability Index Oswestry Disability Index Fear-avoidance beliefs and pain catastrophising Pain Catastrophising Scale Tampa Scale of Kinesiophobia Fear Avoidance Beliefs Questionnaire Confidence about coping with pain Pain Self-Efficacy Questionnaire Self-perceived disability WHO Disability Assessment – self administered Emotional distress Depression Anxiety and Stress Scale (DASS) Table 2. Individual perceptions of: their workplace; treatment; health practitioners Domain screened Area of risk Information sought Workplace Nature of job Demands of role Supervisor support Making duties available Employment options Availability of suitable duties Expectation of RTW At 4 weeks and 6 months on a scale 0 to 10 Job satisfaction Co-worker support Health practitioners, case managers & RTW consultants of support Strategies used Approach to injury management, referral Treatment models Passive or active Status of recovery What helped and what didn’t help for the outcome
Attachment 2. Suggested actions for general practitioners Early intervention Within 3 weeks post-injury 4-12 weeks post injury Detailed review and modify treatment Chronic phase Rethink, reassess Consider multidisciplinary approach Risk assessments Use brief screeners like Orebro, K10 and pain intensity to gain insight into the worker’s: Function Global prediction of RTW Fear/avoidance behaviour Fears of re-injury Reassess and consider the specific risks test with: Pain Catastrophising Scale Pain Self Efficacy Q’re (coping with pain) K10 for distress To identify and treat persistent pain issues, re-administer DASS/K10, pain self-efficacy Refer to pain psychologist and or multidisciplinary team for detailed risk assessment Clinical response Refer to physiotherapist for active treatment and monitor progress Listen, reassure, foster self-management, extend activity levels to be ‘active despite pain’ Educate pain e.g. it does equate to severity of injury Review physiotherapy treatment Refer to mobile case manager, RTW consultant or coordinator for workplace issues For clinical signs of low mood, high anxiety, depression consider referral to pain psychologist Reassess patient’s understanding of their conditions Work Capacity Certificate to reflect functional abilities Review role of physiotherapy treatment Assess and impact of deactivation Review and treat if sleep difficulties Refer to multi-disciplinary team of experienced clinicians Coordinate with all parties Additional clinical management Expand treatment options beyond pain medication and reducing the worker’s hours of work to address broader pain beliefs and anxiety issues Refer to: (a) return to work coordinator to manage workplace problems e.g. suitable duties, relationships; or (b) mobile case manager to arrange mediation/relationship management Now consider Cognitive behaviour techniques (CBT) for persistent pain addressing: Fear avoidance/behaviour at work High pain focus and distress Re-activation strategy Pain management techniques using: Pain education Physical exercise regime Coaching/motivational techniques Now consider Cognitive behaviour techniques to counter: Distress, depression, anxiety Self-perceived disability Pain management techniques Review impact of CBT to identify specific ongoing difficulties and modify management including pain education approach
Attachment 3. Suggested actions for physiotherapists Early intervention Within 3 weeks post-injury 4-12 post injury Detailed review and modify treatment Chronic phase – rethink and reassess Consider multidisciplinary approach Risk assessments Use brief screeners2 like Orebro in addition to a clinical assessment to gain insight into the worker’s: Function Global prediction of RTW Fear/avoidance behaviour, prominent distress and fears of re-injury Re-administer Orebro and review clinical assessment and consider the specific risks and test with: Pain Catastrophising Scale Pain Self Efficacy Q’re (coping with pain) K10 for distress Identify and treat persistent pain issues Re-administer Orebro and consider pain self-efficacy questionnaire Discuss with GP possible referral to pain psychologist/multidisciplinary team for detailed risk assessment Clinical response Undertake active treatment and monitor progress Listen, reassure, foster self-management, extend activity levels to be ‘active despite pain’ Educate pain e.g. pain/harm Early contact with GP re any concerns, recommendations Reassess progress against goals and patient’s understanding of their condition Review treatment and consider referral to a specialist musculoskeletal physiotherapist Liaise with GP re: Function, suitable duties; using mobile case manager, RTW consultant or coordinator if workplace issues raised by patient Suggest referral to pain psychologist if behaviour or screening indicates risk factors for pain behaviour Review clinical treatment and assess outcomes against goals set Assess and manage impact of deactivation Ask about sleep difficulties and discuss with GP if clearly present Communicate/coordinate with each party and other clinicians involved Additional clinical management Contact GP regarding any concerns raised in the assessment: Prominent distress and or anxiety identified Focus on function and advise on suitable duties Liaise with (a) return to work coordinator and/or (b) mobile case manager if workplace problems identified e.g. suitable duties, relationships Now consider Pain management techniques using: Pain education Physical exercise regime Coaching/motivational techniques Re-activation strategy Now consider Review pain management and education to: Address inaccurate beliefs about the injury and modify management including pain education Focus on re-activation (identify any barriers and manage).