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Management of musculoskeletal pain in a compensable environment: Implementation of helpful and unhelpful Models of Care in supporting recovery and return to work
Abstract
Models of Care (MoCs) for injured workers in the compensation environment recommend adoption of biopsychosocial management approaches. Still, widespread dominance of biomedical constructs at the system, organisational and individual levels of the compensation system prevails, contributing to suboptimal management practices and outcomes for injured workers. Efforts to implement contemporary MoCs in the compensation environment show some promise in improving outcomes. Areas of promise at the organisational level, particularly in the workplace, and at the system level are discussed. Implementation of a contemporary understanding of pain biology as part of the biopsychosocial approach in the management of the person with pain and associated disability has been effective in the non-compensable environment. The implications of this for the compensable environment are explored. Resultant helpful and unhelpful perspectives and behaviours are presented as a blueprint for areas of potential change in development and implementation of MoCs in a compensable environment.
... As in the general population, shoulder pain/ injuries are common in workers' compensation claims [4, workers, employers and health care providers to improve clinical outcomes within the Australian workers' compensation arena. It aligns well to general recommendations for implementation of models of care in the compensation environment [14]. ...
... These people may have done well due to receiving other guideline-recommended components of care [22] such as reassurance, simple analgesics and advice to remain active. Further review of very early management practices would be beneficial, with a potential goal of avoiding iatrogenesis and over medicalisation [14,27] balanced with the potential benefits of early screening of risk for delayed recovery [29]. We could not determine the utilisation of risk screening from this study, but have previously found it to be low in general physiotherapy practice [30]. ...
... Given the added complexity workers' compensation adds to managing pain and the number of people involved beyond the individual and their health care providers [27,48], it is logical that increasing familiarity of clinical practice guidelines beyond just health care providers can be a positive strategy [49] (e.g. the workers themselves, insurers and employers). Consideration of the organisational and systems level factors that impact delivery of guideline-based care is recommended [14]. Taking workers on this journey in an informed manner would appear to be beneficial [50]. ...
PurposeInvestigate components of care for rotator cuff related shoulder pain in workers’ compensation in relation to claim outcomes (claim duration, total medical spend, total claim cost, return to work outcome).Methods
Engagement with (had care, time to care) four components of care (prescribed exercise, imaging, injections, surgery) were obtained from auditing 189 closed workers’ compensation files. Associations were analysed between components of care and claim outcomes.Results80% received prescribed exercise, 81% imaging, 42% injection and 35% surgery. Median time to imaging (11 days) was shorter than the prescribed exercise (27 days), with injection at 38 days and surgery 118.5 days. With univariable regression analysis higher age, the involvement of legal representation and the presence of rotator cuff pathology from diagnostic imaging (partial thickness tear or full thickness tear) were all associated with increased claim duration, total medical spend, total claim cost and less successful return to work outcomes. After adjusting for these three associations, having an injection or surgery were both positively associated with longer claim duration and greater medical spend, and surgery with greater total claim costs. In general, longer time to receiving components of care was associated with increased claim duration and reduced odds of returning to full duties at work.Conclusion
Early management was not consistent with clinical guidelines for managing workers’ compensation rotator cuff related shoulder pain. This may negatively affect claims outcomes.
... Currently, a biopsychosocial approach is advocated, with education/advice, simple analgesics, early exercise, and where necessary, psychological management being the components of first-line management consistently recommended across these guidelines. These guidelines are consistent with broader recommendations for the management of injured workers with a compensation claim [11] and general musculoskeletal clinical practice guidelines [12]. Once red flags and/or fractures have been ruled out, directing management towards identifying and treating pathoanatomical sources of pain may be unhelpful for many injured workers. ...
... An active workers' compensation claim is associated with increased risk of poorer outcome following surgery across a number of musculoskeletal conditions [13][14][15]. Therefore, when managing hip pain within the workers' compensation environment, adopting contemporary models of care that incorporate a biopsychosocial approach to management, including early commencement of exercises, may have the most benefit in supporting recovery and improving return to work outcomes [11,16,17]. ...
... While it might be tempting to assume that starting exercise sooner will reduce the length of a claim, no such conclusion can be drawn from the data here. Because return to work is a complex, multifactorial premises [11] and exercise is only one element of multimodal management (exercise does not occur in isolation), a reasonable path may be to test the effect of implementation of guideline based management [3,9,10,12] as a whole. ...
Background:
Guidelines recommend early referral for exercise for hip pain. It is unclear if this occurs in the Australian workers' compensation environment.
Objective:
To investigate referral for exercise in workers with a compensable hip claim.
Methods:
Retrospective audit of closed compensation files for workers with hip pain was performed. Exercise commencement was indicated by billing codes for physiotherapy or exercise specific consultations. Time to exercise commencement was calculated. Associations were analysed between time to exercise commencement with claim duration and diagnostic category.
Results:
Exercise management occurred for 33/44 cases. Median time to commence exercise for those cases that had exercise was 14 days post-injury, with 33% commencing beyond 4 weeks. Longer time to commence exercise was associated with a longer claim duration (Spearman's rho = 0.70). Workers with a diagnosis of hip joint pain had a longer time to exercise commencement (median 49.5 days) compared to those with a diagnosis of lateral hip pain (median 14 days) or non-specific hip pain (median 4.5 days).
Conclusion:
Findings indicate practice behaviours in the workers' compensation environment for the management of hip pain with exercise. Further investigation is warranted to see if improved adherence to guideline recommendations improves outcomes for people with compensable hip pain.
... However, 'knowing' is one thing, while 'doing' is another, and clinicians can find it difficult to translate this into effective clinical implementation of biopsychosocial management (Alexanders et al., 2015;Synnott et al., 2015). This paper continues the theme of our work designed to assist clinicians to implement effective contemporary person-centred approaches to musculoskeletal disorders (Beales et al., 2016a;Mitchell et al., 2017;O'Sullivan et al., 2018;Speerin et al., 2014). The paper serves as a companion and progression of our previous work in this area specific to PGP O'Sullivan, 2011, 2015;O'Sullivan and Beales, 2007a,b). ...
... We have attempted to conceptualise graphically the relevant neurobiology and complex system interactions that reflect contemporary pain science as it relates to PGP (Fig. 2). For a more comprehensive appraisal of this neurobiology, readers are referred to key review articles (for example (Beales et al., 2016a;Brodal, 2017;Chimenti et al., 2018; International Association for the Study of Pain, 2011; Kuner and Flor, 2017;Nijs et al., 2015)). ...
... However, nociception and pain are not synonymous. Nociceptors can be activated in the absence of pain, and pain can be experienced in the absence of nociceptor activation (Beales et al., 2016a;Nijs et al., 2015). This distinction helps to explain the individual variability in clinical presentations of PGP (and any pain disorder), with many factors interacting and influencing a pain experience, regardless of potentially similar activation or sensitisation of the "It started right at the end of my first pregnancy (12 years ago), that was 38 weeks and I was just tucking a bed sheet, it was just something that was really small." ...
Introduction
Clinicians need support to effectively implement a biopsychosocial approach to people with pelvic girdle pain disorders.
Purpose
A practical clinical framework aligned with a contemporary biopsychosocial approach is provided to help guide clinician's management of pelvic girdle pain. This approach is consistent with current pain science which helps to explain potential mechanistic links with co/multi-morbid conditions related to pelvic girdle pain. Further, this approach also aligns with the Common-Sense Model of Illness and provides insight into how an individual's illness perceptions can influence their emotional and behavioural response to their pain disorder. Communication is critical to supporting recovery and facilitating behavior change within the biopsychosocial context and in this context, the patient interview is central to exploring the multidimensional nature of a persons' presentation. Focusing the biopsychosocial framework on targeted cognitive-functional therapy as a key component of care can help an individual with pelvic girdle pain make sense of their pain, build confidence and self-efficacy and facilitate positive behaviour and lifestyle change. There is growing evidence of the efficacy for this broader integrative approach, although large scale effectiveness trials are still needed. An in-depth case study provides guidance for clinicians, showing ‘how to’ implement these concepts into their own practice within a coherent practical framework.
Implications
This framework can give clinicians more confidence in understanding and managing pelvic girdle pain. The framework provides practical strategies to assist clinicians with implementation; assisting the transition from knowing to doing in an evidence-informed manner that resonates with real world practice.
... MoCs are evidence-based policies or frameworks that recommend how healthcare is best provided to consumers and factor in local operational requirements (Briggs et al., 2014). Beales et al. (2016) recently published detailed analyses of helpful and unhelpful MoCs for PP management in a compensable environment (see below). Some authors of that publication are indeed promoting an education-based "Pain Revolution" (https://www.painrevolution.org), the goal of which is to rethink the way pain is discussed and managed, so as to fully engage with the pain neuroscience paradigm shift. ...
... Some authors of that publication are indeed promoting an education-based "Pain Revolution" (https://www.painrevolution.org), the goal of which is to rethink the way pain is discussed and managed, so as to fully engage with the pain neuroscience paradigm shift. Beales et al. (2016) proposed an integrated MoC to optimize the journey of an injured worker through the compensation environment, focusing on two overarching principles: (i) application of a biopsychosocial approach incorporating contemporary pain neuroscience; and (ii) recognizing that (good) work is good for your health. ...
... Here I sketch key features of what might be deemed a species of the MoC outlined by Beales et al. (2016). Termed "Occupational Pain Medicine" (OPM; or "Occupational Pain Management"-see below), the MoC is firmly founded on the analyses, recommendations, terminology, and practice points outlined in Beales et al. (2016). ...
... The cost of these claims has been escalating over time [2], which is a global phenomenon [3]. Thus, models of care for musculoskeletal compensation claims espouse early identification of claimants at higher risk of longer term work absenteeism, as this practice can inform management to reduce long term absenteeism [4]. ...
... The 10-item Orebro Musculoskeletal Pain Screening Questionnaire (OMPSQ-10) [24] was adopted as the screening questionnaire for implementation into the physiotherapy clinics. There is emerging evidence that screening with the OMPSQ-10 can improve outcomes for people with musculoskeletal disorders [4,9]. Advantages include its brevity and not being body region specific [5], and therefore it is suitable for application in clinical groups such as compensation clients where there would be a mixture of body area injuries. ...
... Implementation of a strategy aimed at addressing potentially modifiable personal (clinician) and external (organisational) factors had a positive effect on the engagement of physiotherapists in using risk profiling questionnaires across multiple clinics. This occurred in a 'real world' environment where there is an ongoing push for evidence informed clinical service delivery [4]. This would seem to be an important first step in capitalizing on the broader benefits that risk profiling might afford in clinical environments. ...
Purpose This study investigated the implementation of a risk profiling process for physiotherapy clients with a compensable musculoskeletal problem. Implementation targeted personal (clinician) and external (organisational) factors to facilitate behavioural change with regard to the use of formal, questionnaire-based risk profiling. Methods A theoretical construct was developed for formal questionnaire-based screening to be implemented across 12 private, metropolitan physiotherapy clinics. To target personal (clinician) factors, a multimodal educational procedure was developed focused on use of the ten-item Orebro Musculoskeletal Pain Screening Questionnaire (OMPSQ-10). To target external (organisational) factors, an administrative process was enacted to ensure routine completion of the OMPSQ-10 by compensable clients. Global practice behaviour with regard to the use of formal risk profiling was complete pre- and post-implementation. Results Pre-implementation physiotherapists understood the potential usefulness of formal risk profiling, but the large majority did not routinely have clients complete these types of questionnaires. Post-implementation there was a significant positive shift in behaviour to more frequent use the OMPSQ-10 for new compensable clients. Conclusions The results provide initial support for the use of a framework to develop an implementation strategy to increase physiotherapist adherence to the use of guideline recommended risk profiling questionnaires in clinical practice.
... Additional challenges occur at the individual level, where people living with chronic musculoskeletal pain often confront stigma. Many face a daily battle to find an explanation for their pain and prove legitimacy, and are subjected to navigating complex health systems and contexts that do not support helpful beliefs or management practices related to their condition (e.g., compensation settings) [17]. The personal impact of ongoing musculoskeletal pain is further amplified by an increase in prevalence of common co-and multimorbidities such as anxiety, depression and sleep disorders with associated negative impacts on their productivity and quality of life [12]. ...
... future science group www.futuremedicine.com timely, effective, evidence-informed and integrated care that captures these comorbidities is challenging, especially given that the complexity of musculoskeletal pain is typically poorly understood across the community, by educators, researchers and trainee and trained health professionals alike [1,17]. ...
... Treatment is matched to the risk of chronicity, with resource allocation supporting lower risk management in primary care settings, and multidisciplinary care for those at higher risk. Similarly, many primary care settings have adopted short-form derivatives of the validated Örebro Musculoskeletal Pain Screening Questionnaire, to help estimate risk of chronicity and guide management decisions and resource allocation, including within compensable settings [17]. ...
... Workplace culture and satisfaction, as perceived by the injured worker, can also negatively influence return to work outcomes following workplace injury [24]. Management of musculoskeletal conditions is associated with poorer outcomes in workers' compensation settings [14,15,25]. For injured workers who do experience negative influences during their compensation claim, it is plausible that their wellbeing might continue to be affected beyond the finalization of the claim [7]. ...
... While this review did not identify any studies directly assessing wellbeing, it did identify a range of impacts on physical and psychosocial or behavioural health post-claim. Contemporary practice for the management of injured workers during a compensation claim demands a biopsychosocial approach [25,82], to maximize integration back into work. The progression over recent decades towards workers' compensation systems that promote workplace rehabilitation and wider ranging health supports (including support for mental health) beyond financial compensation is in keeping with the biopsychosocial approach [83]. ...
A workers’ compensation claim may have significant negative impacts on an injured worker’s wellbeing. Wellbeing provides a good global measure of potential effects of a claim on an individual, and is important for contemporary economic modelling. The purpose of this study was to synthesize knowledge about the wellbeing of injured workers after the finalization of a workers’ compensation claim and identify gaps in the current literature.
A systematic scoping review was conducted.
71 full-text articles were screened for inclusion, with 32 articles eligible for this review. None of the included articles evaluated overall wellbeing. Included articles did evaluate a variety of constructs inherent in wellbeing. Injured workers were generally disadvantaged in some manner following claim finalization. The literature recommends a focus on reducing negative impacts on injured workers after finalization of a compensation claim, with a need for regulatory bodies to review policy in this area.
There appears to be potential for ongoing burden for individuals, employers, and society after finalization of a workers’ compensation claim. A gap in knowledge exists regarding the specific evaluation of wellbeing of injured workers following finalization of a workers’ compensation claim.
... In chronic post-injury orthopaedic, neurological and other disorders, the biopsychosocial paradigm [19][20][21] is required for adequate and informative explanation of the claimant's ongoing symptoms and disability. [22] The value of biopsychosocial assessment and management has been emphasised in occupational medicine and medicolegal contexts [23][24][25][26] and in injuries sustained in motor transport-related injury. [27][28][29] Biopsychosocial assessment and management are especially important in contexts where chronic pain is prominent. ...
... This was a retrospective cohort study of consecutive claimants with painful musculoskeletal injuries and non-recovery post-MVA in which we have highlighted the importance of biopsychosocial assessment. The assessed sequelae to or associations of injuries were broadly influenced by biopsychosocial principles [19 , 20] which are emphasised in pain medicine, [21 , 30-33] occupational medicine, [23][24][25][26] and recent Australian studies of outcomes after MVAs. [27][28][29] Such is the complexity of the multidimensional sequelae of injury, as shown by the association results, that the common biomedical focus of medico-legal assessments is clearly inadequate and there is need to consider complexity science [42] and biopsychosocial principles. ...
Background
Claimants with chronically painful injuries sustained in motor vehicle accidents (MVAs) undergo assessment and management influenced by insurance and medico-legal processes defined by a biomedical paradigm which is discordant with best evidence. We aim to demonstrate the impact of biopsychosocial factors on post-MVA sequelae which contribute to non-recovery.
Methods
This was a retrospective cohort study of medico-legal documents and reports on 300 consecutive claimants referred to a pain medicine physician over 7 years (2012-2018) for assessment of painful musculoskeletal injuries post-MVA. One hundred data items were extracted from the medico-legal documents and reports for each claimant and entered into an electronic database. Post-MVA sequelae were analysed using chi-square analysis (OR >2) for significant associations with demographic, pre-MVA and post-MVA variables. Factors with significant associations were entered into a logistic regression model to determine significant statistical predictors of post-MVA sequelae contributing to non-recovery.
Results
The claimants were aged 17 to 80 years (mean age 42 years), and approximately half (53%, n=159) were female. The time from MVA to interview averaged 2.5 years. Widespread pain was present in 18% (n=54), and widespread somatosensory signs implying central sensitisation (OR=9.85, p<.001) was the most significant multivariate association. Long-term opiate use post-MVA (32%) was predicted by pre-MVA sleep disturbance (OR=5.08, p=.001), post-MVA major depressive disorder (MDD) (OR=3.02, p=.003) and long-term unemployment (OR=2.22. p=.007). Approximately half (47%, n=142) required post-MVA support from a psychologist or psychiatrist. Post-traumatic stress disorder (PTSD) was diagnosed by a psychiatrist or psychologist in 20% (n=59), yet early identification of risk of PTSD was rare. Pre-MVA, 89.4% (n=268) were studying or employed. Permanent unemployability post-MVA occurred in 35% (n=104) and was predicted by MDD (OR=3.59, p=.001) and antidepressant use (OR=2.17, p=.005). Major social change post-MVA (70%) was predicted by older age (OR=.966, p=.003), depressive symptoms (OR=3.71, p<.001) and opiate use (OR=2.00, p=.039).
Conclusions
Biomedical factors, including older age, impaired sleep and indicators of widespread central sensitisation, and psychological factors, including stress, anxiety and depression, were the most prominent multivariate associations as statistical predictors of major adverse sequelae contributing to non-recovery for claimants with chronic pain post-MVA.
... However, as work-related injuries are a significant issue [2], the management of these injuries has led to a rise and gradual acceptance in physiotherapy services becoming available at the workplace [3][4][5][6]. This arrangement enables the practitioner to become familiar with the onsite context with the potential to influence return-to-work (RTW) outcomes [7]. By necessity, the physiotherapist needs to work collaboratively with employers and employees to manage a range of work injuries, including musculoskeletal injuries, which is their area of expertise [5,[8][9][10]. ...
... The removal of onsite healthcare providers from compensable workplace injury is in line with evidence for de-medicalisation of disability decision making [38]. Sustainable models of healthcare for compensable injury [7] and recommended clinical frameworks [20,39] recommend strategies encourage activity and remain at work when possible and that outcomes should be monitored through a variety of measures. In this study, it is evident that removal of a health service had no negative consequences. ...
Purpose As part of an integrated system to manage work injuries, some organisations utilise the skills of an onsite physiotherapist. Onsite physiotherapy can provide benefits for the workers and organisation when delivered as part of an early intervention injury prevention program (IPP) at a poultry meat processing plant. However, once established, the sustainability of this service on work injury and compensation outcomes without ongoing physiotherapy contribution is unknown. Methods Through analysis of two large secondary datasets of workplace injuries and compensation claims, outcome measures of injury rates, cost per workers’ compensation claim and duration of work absence were compared over a 36-month period where onsite physiotherapy contributed to the IPP and was later removed. Results 3951 injuries and their 781 resultant compensation claims were analysed within a 36-month analysis period. A small but non-significant rise in injury rates and duration of work absence was associated with the removal of onsite physiotherapy. There was also a shift towards more compensations claims with work absence after physiotherapy was removed. However, there was a significant reduction in adjusted mean costs per claim of $847 for all injury types (p < 0.001) and $930 for musculoskeletal disorders (p < 0.001) after the removal of onsite physiotherapy. Conclusions Once an IPP was embedded within an organisation, onsite physiotherapy services were able to be discharged without significantly and negatively impacting demonstrated benefits and injury outcomes. There was also cost savings to the insurer through reduced mean claim costs and to the employer by not funding the onsite physiotherapy service.
... The participants' rehabilitation and RTW were not necessarily voluntary. Like many insurers, SWCB emphasizes function over symptoms and encourages healthcare providers to make recommendations based on ability, contrary to workers who may expect to be pain-free before returning to work (19). To continue receiving benefits, participants would have been required to participate in a rehabilitation program operated by an independent rehabilitation provider. ...
Background
Research demonstrates sustained return to work (RTW) by individuals on medical leave is influenced by personal and job resources and job demands. Relatively few studies have been conducted in the workers’ compensation context that is known to have longer absence durations for RTW.
Aims
This study sought to illuminate workers’ experience as they returned to work following a work injury that was either psychological in nature or involved more than 50 days of disability, with a focus on the co-worker, supervisor, and employer actions that supported their return.
Methods
Workers in Saskatchewan, Canada, with a work-related psychological or musculoskeletal injury, subsequent disability, and who returned to work in the last three years, were invited to complete an online survey comprising of free-text questions. Thematic analysis was used to explore participants’ experiences.
Results
Responses from 93 individuals were analysed. These revealed that persistent pain, emotional distress, and loss of normal abilities were present during and beyond returning to work. Almost two-thirds indicated that the supervisors’ and co-workers’ support was critical to a sustained return to work: their needs were recognized and they received autonomy and support to manage work demands. By contrast, one-third indicated that the support they expected and needed from supervisors and employers was lacking.
Conclusions
Workers returning to work lacked personal resources but co-workers’ and supervisors’ support helped improve confidence in their ability to RTW. Supervisors and employers should acknowledge workers’ experiences and offer support and autonomy. Likewise, workers can expect challenges when returning to work and may benefit from cultivating supportive relationships with co-workers and supervisors.
... We recommend rigorous assessment for the various neurological symptoms identified in this study, with specific questions related to restless legs syndrome, the treatment of which may improve recovery by improving sleep [37] . Above all, the optimal management of chronic pain-related disability after EI requires the multidisciplinary, biopsychosocial [5][6][7] approach of a designated chronic pain service. ...
Introduction and Aims
: We aimed in this case series to identify shortcomings in assessment of long-term painful and psychosocial consequences of EI and to demonstrate the value of biopsychosocial assessment and the commonalities in outcomes.
Methods
: We retrospectively analyzed 15 cases from 2004 to 2019 of adult claimants assessed in a medico-legal practice for complex chronic pain disorders secondary to EI. Extensive biopsychosocial information, including 165 data items on pre- and post-injury observations, were collected on each. Cutaneous and deep pressure somatosensory examination was performed and questionnaires for psychological evaluation and restless legs syndrome completed. A comprehensive literature review and descriptive analysis was conducted.
Results
: Pre-injury, most claimants worked (12/15), did not receive government benefits (14/15) and had no primary pain disorder (9/15). EIs were severe (14/15), where chronic post-traumatic pain, typically high impact with nociplastic features, was regional in 5 and widespread in 10. Somatosensory signs in wide distribution in all cases implied central sensitization. Movement disorders included digital dyskinesia (5/15), involuntary muscle contractions (7/15) and restless legs syndrome in 7. Diagnostic and Statistical Manual of Mental Disorders (DSM-5) post-traumatic stress disorder (PTSD) criteria were met in 12/15, and 14/15 experienced depression and impaired sleep. Severe social impacts, notably including loss of employment resulting in financial stresses, were common.
Conclusions
: Biological, psychological and social consequences of EI revealed extensive similarities. Disability was generally severe, moreso than indicated in clinical records, influenced by relative paucity of primary pathology, inadequate pain-orientated somatosensory testing and insufficient application of biopsychosocial assessment and management.
... There is also a link between unemployment and increased mortality rates, as well as increased health service utilisation [11]. In addition, work is considered to be therapeutic-this is a founding principle of work disability management [12]. ...
Musculoskeletal injuries occur frequently after road traffic crashes (RTCs), and the effect on work participation is not fully understood. The primary aim of this review was to determine the impact of sustaining a musculoskeletal injury during an RTC on the rate of return to work (RTW), sick leave, and other work outcomes. The secondary aim was to determine factors associated with these work-related outcomes. An electronic search of relevant databases to identify observational studies related to work and employment, RTC, and musculoskeletal injuries was conducted. Where possible, outcome data were pooled by follow-up period to answer the primary aim. Fifty-three studies were included in this review, of which 28 were included in meta-analyses. The pooled rate of RTW was 70% at 1 month, 67% at 3 months, 76% at 6 months, 83% at 12 months, and 70% at 24 months. Twenty-seven percent of participants took some sick leave by one month follow-up, 13% by 3 months, 23% by 6 months, 36% by 12 months, and 22% by 24 months. Most of the factors identified as associated with work outcomes were health-related, with some evidence also for sociodemographic factors. While 70% of people with RTC-related musculoskeletal injury RTW shortly after accident, many still have not RTW two years later.
... 6,19 Little is known about the perceptions held by registered health professionals employed by social insurance organisations. [20][21][22] For this study, we surveyed perceptions of clinical governance held by NZ registered health professionals employed by the ACC. We compared these results to those from staff directly delivering health care (in NZ DHBs). ...
Objective
Effective clinical governance can improve delivery of health outcomes. This exploratory study compared perceptions of clinical governance development held by registered health professionals employed by two different but interrelated health organisations in the broader New Zealand (NZ) health system. Most staff in public sector healthcare service delivery organisations (i.e. District Health Boards (DHBs)) are registered health professionals, whereas these clinical staff represent a small minority (5%) in social insurance organisations (i.e. the Accident Compensation Corporation (ACC)). Given these different contexts, comparison of results from three surveys of clinical governance perceptions identified key learnings for the development of clinical governance.Methods
The Clinical Governance Development Index (CGDI) was administered to registered health professional staff in NZ DHBs and ACC, at different time points. The data were explored, compared and reported.ResultsResponses to survey items completed by NZ DHB staff and registered health professionals employed by ACC were compared. For each administration, there was a similar profile of positive responses across the seven CGDI items. The 2020 ACC survey results for one item were clearly different. This item asked about perceptions of full and active involvement in organisational processes and decision making (i.e. clinical engagement).Conclusions
Perceptions of registered health professionals working in the NZ public sector delivering health services were compared with those held by staff employed by a NZ social insurer predominantly commissioning and influencing care. The results indicated similar levels of clinical governance development. Clinical governance development in the ACC context can benefit from clear communication, building strong supporting structures and greater management-clinical provider partnerships. Clinical governance development drives health outcomes and regular measurement of developmental progress can provide momentum. There is room across the NZ health system to raise awareness and leverage clinical governance to deliver improved health outcomes.What is known about the topic?Little is known about the perceptions held by registered health professionals employed by social insurance organisations. There are no published comparative studies exploring differences in perceptions between registered health professionals across two different organisational contexts, both with a goal of improving health outcomes.What does this paper add?Effective clinical governance drives coordinated, quality systems that promote optimal health outcomes. Social insurance organisations predominantly commission healthcare providers to deliver health outcomes. Although registered health professionals employed by social insurance organisations represent a small total number of staff, their perspective on clinical governance, as reported via survey, indicated there is most to be gained in the development of partnerships between management and clinical providers. This exploratory study fills a gap in the existing clinical governance development literature and evidence base.What are the implications for practitioners?Any health organisation can leverage clinical governance to deliver improved health outcomes. Effective clinical governance interventions are targeted to specific organisational context and culture. For ACC, a clear definition, enhanced management-clinical provider partnerships and strong supporting structures or organisational arrangements can be further developed. The survey results indicated that a focus on management-clinical provider partnerships is a clear priority for ACC clinical governance development. Partnerships based in empowered collaboration require greater clinical engagement, as well as increased capability for aligning with organisational priorities. Effective clinical governance development requires attention to context and culture. It can improve delivery of health outcomes.
... 31,32 At the organizational and systems levels, a bio-psychosocial health service model for runners can support measures aimed at disbanding structural clusters of risk factors in the sport. 33 For instance, mandatory health insurance plans can be introduced to prevent that economic pressures force runners to take unnecessary health risks. In the realization of such measures at the systems level, the active participation of the key occupational stakeholders is needed, ranging from sports agents and race organizers to national and international sports federations. ...
Objectives:
To investigate champion long-distance runners' strategies for managing injury and illness symptoms and staying well.
Design:
Qualitative research study.
Methods:
Twelve long-distance runners were interviewed immediately after having competed in World Championships finals. Thematic analysis was used to categorise and structure the data. The results were presented as primary themes and overarching constructs representing connections between the primary themes.
Results:
The champion runners' basic tactic to manage symptoms of ill health was characterized by rapid adjustment of sports load and a strong incentive to learn from experience and professional advice. This tactic was named here educated flexibility. A secondary exigency tactic was associated with reaching short-term goals and a consequential acceptance of health hazards. The runners used economic and other environmental strain to explain use of the exigency tactic. Most champion runners' long-term strategy to stay well included both tactics successfully combined to maintain a performance level assuring a regular income. Avoidance of letting environmental strain and health problems create vicious circles was at the centre of these strategies.
Conclusions:
Champion runners' main strategy to stay well and sustain their superiority in performance was characterized by constantly paying attention to symptoms of ill health, listening to medical advice, and not letting environmental strain interfere with adjustment of sports load. Many top-level runners originate from global regions where formal education programs and health insurance plans are poorly regulated and supported. Bio-psychosocial models including empowerment at individual and systems levels should be considered when health services are planned for professional runners.
... A better approach, at least for musculoskeletal disorders, may be educating people that the physical activities of work are, on the whole, good for us (81,82) and that odd aches and pains are a normal part of living. Understanding nocebo effects and limiting their influence has been flagged as an important consideration for models of care in the compensation arena (83). After all, one of the reasons we walk upright is to allow us to use tools and lift and carry things. ...
Many of today’s occupational health and safety professionals may not be aware
of the unprecedented industrial epidemic that struck Australia in the
mid-1980s, and those who were involved may prefer to forget it. Work-related
claims for what became known as repetitive strain injuries (RSI) climbed
dramatically through the first half of the decade only to decline in the second
half. This review revisits the epidemic and its lessons. Although initially
blamed on new technology, in particular computer workstations, the epidemic
was the result of the complex and interwoven sociotechnological system of
health care practice, the compensation and legal system, industrial relations,
the media and the social and political environment at the time. There are
important lessons we can take from this epidemic that apply to public health
practice today, particularly the nocebo effect of negative communications on
the beliefs and expectations that can develop within the sociotechnological
system.
... Our results suggest that patients may need more evidence-informed information about the mechanisms of LBP and its natural history and the effectiveness of current therapies for LBP. 108 ...
Objectives
Allied health and complementary and alternative medicines (CAM) are therapeutic therapies commonly accessed by consumers to manage low back pain (LBP). We aimed to identify the literature regarding patients' perceived needs for physiotherapy, chiropractic therapy and CAM for the management of LBP.
Methods
A systematic scoping review of MEDLINE, EMBASE, CINAHL and PsycINFO (1990‐2016) was conducted to identify studies examining patients' perceived needs for allied health and CAM for LBP. Data regarding study design and methodology were extracted. Areas of patients' perceived need for allied health and CAM were aggregated.
Results
Forty‐four studies from 2202 were included: 25 qualitative, 18 quantitative and 1 mixed‐methods study. Three areas of need emerged: (i) physiotherapy was viewed as important, particularly when individually tailored. However, patients had concerns about adherence, adverse outcomes and correct exercise technique. (ii) Chiropractic therapy was perceived to be effective and needed by some patients, but others were concerned about adverse outcomes. (iii) An inconsistent need for CAM was identified with some patients perceiving a need, while others questioning the legitimacy and short‐term duration of these therapies.
Conclusions
Our findings regarding patients' perceived needs for allied health and CAM for LBP may assist in informing development of more patient‐centred guidelines and service models for LBP. Understanding patients' concerns regarding active‐based physiotherapy, which is recommended in most guidelines, and issues surrounding chiropractic and CAM, which are generally not, may help inform management that better aligns patient's perceived needs with effective treatments, to improve outcomes for both patients and the health‐care system.
... To ensure that people are able to continue participating in work and other activities, it is important to target negative behavioral responses to spinal pain which are known to affect work participation. This approach aligns with contemporary models of care for the management of musculoskeletal pain disorders among workers (17). To facilitate positive behaviors, more knowledge on the etiology and development of these behaviors is needed, in particular early in their development (18). ...
Objectives: Spinal (ie, back and neck) pain often develops as early as during adolescence and can set a trajectory for later life. However, whether early-life spinal-pain-related behavioral responses of missing school/work are predictive of future work absenteeism is yet unknown. We assessed the association of adolescent spinal-painrelated work or school absenteeism with early adulthood work absenteeism in a prospective population-based cohort.
Methods: Six year follow-up data from the Western Australian Pregnancy Cohort (Raine) study were used (N=476; with a 54% response rate). At age 17, participants reported spinal pain (using the Nordic questionnaire) and adolescent spinal-pain-related work/school absenteeism (with a single item question). Annual total and health-related work absenteeism was assessed with the Health and Work Performance questionnaire distributed in four quarterly text messages during the 23rd year of age. We modelled the association of adolescent spinalpain-related absenteeism with work absenteeism during early adulthood, using negative binomial regression adjusting for sex, occupation and comorbidities.
Results: Participants with adolescent low-back or neck pain with work/school absenteeism reported higher total work absenteeism in early adulthood [148.7, standard deviation (SD) 243.4 hours/year], than those without pain [43.7 (SD 95.2) hours/year); incidence rate ratio 3.4 (95% CI 1.2–9.2)]. Comparable findings were found when considering low-back and neck separately, and when considering health-related absenteeism.
Conclusions: We found a more than three-fold higher risk of work absenteeism in early adulthood among those with adolescent spinal-pain-related absenteeism, compared to those without. These findings suggest that, to keep a sustainable workforce, pain prevention and management should focus on pain-related behaviors as early as in adolescence.
... Good communication should be inherent in stakeholder interactions, consistent with optimal models of care in the compensable environment that ultimately avoid negative context for a worker with an injury [53]. Perceptions identified in this study could be used to inform educational interventions to improve communication between stakeholders and ultimately outcomes in the return to work process. ...
Background:
Insurance workers and physiotherapists are important stakeholders in the rehabilitation of workers with an injury and subsequent musculoskeletal pain. Understanding perceptions of roles may facilitate communication between these stakeholders.
Objective:
Increase knowledge around, (i) the self-perception of and (ii) the external perception of the insurance workers and physiotherapists roles in the management of a worker with an injury in an Australian workers' compensation environment.
Methods:
A cross-sectional study assessed the perceptions of insurance workers and physiotherapists related to the roles of these two professions in managing a worker with an injury via questionnaire. Respondents were also asked about potential communication barriers.
Results:
Insurance workers (n = 48) and physiotherapists (n = 80) reported contrasting role perceptions, with their perception of the other profession leaning towards negative attributes. There was greater alignment of their beliefs of roles in the 'ideal' situation. The perception of barriers to communication also differed between the two professions. Effective and efficient communication was identified as a central component of mismatched role perceptions between stakeholders, but recognised as a critical attribute of 'ideal' stakeholder roles.
Conclusion:
Insurance workers and physiotherapists self-perception of their roles differs from external perceptions. This information highlights the importance of a shared understanding of stakeholder roles in the management of a worker with an injury.
... 10 A range of physical, psychological, social factors and, in the context of workers compensation, regulatory and legislative and system factors influence an early, safe and durable RTW following a work-related injury or illness. 7,13 Within this milieu, the role of the primary care providers in accurate and consistent certification of capacity is critical, as is interdisciplinary communication between the certifying practitioner and those other practitioners involved in the worker's care. ...
Primary care practitioners play a critical role in supporting return to work (RTW) and minimising the detrimental physical and psychosocial sequelae of unnecessary and prolonged work absence in injured and ill workers. Accurate and consistent certification of capacity is an essential component of this role that has been scrutinised recently given the identified variation in certification practices between and within professions. This Perspective outlines the importance of correct certification of capacity for injured workers and provides a RTW flowchart to support systematised and appropriate certification. The flowchart is aimed at primary care practitioners (e.g. general practitioners or physiotherapists). The flowchart was developed at the Transport Accident Commission and WorkSafe Victoria as a guide for Australian primary care practitioners when certifying capacity. A more systematised approach to certification coupled with professional education and support may reduce variations and inaccuracies in certification, improve RTW rates and reduce the increasing burden of disease related to workplace injuries.
Purpose:
To understand the current utilisation of the clinical framework for delivery of health services to manage compensable musculoskeletal injuries from the perspectives of insurer case managers and clinical panel members.
Materials and methods:
Using a qualitative descriptive approach, 15 semi-structured interviews were conducted with members of key organisations including WorkSafe Victoria and Transport Accident Commission Victoria. All interviews were recorded and transcribed verbatim and analysed using thematic analysis.
Results:
Four over-arching themes were identified: (i) current use of the framework and principles is suboptimal leading to several problems including lack of evidence-based treatment by clinicians; (ii) barriers to optimal use of the framework include lack of adequate training of healthcare professionals on the framework principles and financial aspects of the compensation system; (iii) utilisation of the framework could be improved with training from peak associations, insurers, and regulating bodies; and (iv) optimal use of the framework will result in better health and work outcomes.
Conclusions:
The current use of the framework and its principles is suboptimal but can be improved by addressing the identified barriers.IMPLICATIONS FOR REHABILITATIONRehabilitation of compensable musculoskeletal injuries is often complex.Implementing the "Clinical Framework for Delivery of Health Services" can lead to provision of time and cost effective, evidence-based rehabilitation for compensable injuries, ultimately improving patient outcomes.Clinicians can enhance the implementation of the framework principles by integrating evidence-based practice and recommendations from clinical practice guidelines in treatment of compensable musculoskeletal injuries.Implementation of the framework principles may be enhanced by reviewing the compensation funding model to allow the healthcare practitioners adequate time and remuneration to adopt the framework principles when treating persons with compensable injuries.
Background
Improved understanding of social constructs around injury may help insurance case managers to understand how best to support people after injury.
Objective
This study sought to explore what people who sustain work-related injuries may seek from online communities. The study highlights potential opportunities for improved engagement with insurance case management practice.
Methods
An observational netnographic analysis was undertaken on anonymous, publicly available messages posted on Australian message boards. All research data were drawn from anonymous, online communities. A person (author SM) with experience of making a claim through an Australian workers’ compensation system and online engagement was involved in study conception, design, and analysis. Data were analyzed using NVivo12 in an iterative, multistage process including coding, journaling, and member checking. A total of 141 people were engaged in discussion across 47 threads housed on 4 Australian forums.
Results
In this qualitative study, themes emerged from the data, describing how injured workers use online communities to help make decisions, get support, and solve problems. The key motivators for action and engagement were seeking information, connection, or justice. Establishment of relationships was a key mediator of each of these parameters.
Conclusions
Some work-related injuries may involve medical and medicolegal complexity as well as changed lifestyle and routine during convalescence and recovery. The mechanism used by some injured workers to seek information and problem solve suggests a capacity for self-management and self-care after work-related injury. Netnography provides information on a community that may not regularly engage with research because of the complexity of their situation and their vulnerability.
Background
Lumbar spinal fusion (LSF) outcomes for workers' compensation patients are worse than for the general population. The objectives were to examine the long-term work capacity, opioid prescription and mental health outcomes of injured workers who have undergone LSF surgery in Victoria, Australia, and to identify demographic and pre- and post-operative characteristics associated with these outcomes.
Methods
Retrospective study of 874 injured workers receiving elective LSF from 2008 to 2016 in the Victorian workers' compensation system. WorkSafe Victoria's claims data were used to infer outcomes for recovery. Association of demographics, pre-surgery and surgery variables with outcomes were modelled using multivariate multinomial logistic regression analyses.
Results
Twenty-four months after LSF surgery, 282 (32.3%) of the 874 injured workers had substantial work capacity, 388 (44.4%) were prescribed opioids, and 330 (37.8%) were receiving mental health treatment.
Opioid prescription and limited work capacity before surgery were independent strong predictors of opioid prescription, reduced work capacity and mental health treatment 24 months after LSF. Pre-operative mental health treatment was associated with the use of mental health treatment at 24 months. Other predictors for poor outcomes included a greater than 12-month duration from injury to surgery, LSF re-operation and common law or impairment benefit lodgement before surgery.
Conclusion
An association between pre-operative factors and post-operative outcomes after LSF in a Victorian workers' compensation population was identified, suggesting that pre-operative status may influence outcomes and should be considered in LSF decisions. The high opioid use indicates that opioid management before and after surgery needs urgent review.
Introduction
Maintaining productive employment can be challenging for people with ongoing low back pain (LBP) or neck pain (NP) due to pain, function and participation sequelae. Resources and information to support them staying at work may be beneficial, although preferences for the nature and accessibility of resources remain uncertain. The current study aimed to explore the work experiences and information-seeking behaviours of employed individuals with ongoing LBP or NP, to support them in staying at work.
Method
Semi-structured interviews were undertaken with 40 participants currently employed with ongoing LBP or NP. The interview schedule covered participants' experience of managing their LBP or NP at work, resources sought to assist with finding or maintaining employment, and where they accessed these resources. Interviews were recorded and analysed using thematic analysis.
Results
Participants were employed in a wide range of job types and most reported a decrease in productivity. Five key themes were identified: (1) the meaning of work, (2) to disclose or not, (3) information seeking, (4) gaps in resources, (5) trusted sources. Work was highly valued by participants, despite the challenges in maintaining employment with ongoing LBP or NP. To support staying at work a range of information was sought by participants, but challenges in accessing reputable resources and trusting the sources were identified as key issues.
Conclusion
Opportunities exist for easily accessible, multi-level information from trustworthy sources targeted at the employer organisations, individuals and clinicians to support people in staying at work with ongoing LBP or NP.
Objective:
The primary purpose of this study was to investigate the predictive ability of the Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ) in regard to work productivity (absenteeism and presenteeism) in early adulthood.
Methods:
A prospective study was performed using data from the Raine Study Generation 2 (Gen2) 22-year follow-up. The ÖMPSQ was completed at baseline, and absenteeism and presenteeism assessed at 4 intervals over the following 12 months.
Results:
In early adulthood, the full and short versions of the ÖMPSQ showed some predictive ability for work absenteeism but the Receiver Operator Characteristic demonstrated poor discrimination. There was no evidence of predictive ability for presenteeism.
Conclusion:
Further work is required to increase the fidelity of screening for risk of reduced work productivity at the population level.
Background
While the biopsychosocial model is advocated for pain management, biomedical approaches continue to dominate in practice. Understanding musculoskeletal clinicians’ perspectives and practices related to pain can inform training needs to optimize care. Little is known regarding the viewpoint of hand therapists who may not have exposure to modern pain models.
Objective
To explore hand therapists’ perspectives and practices related to musculoskeletal pain using a biopsychosocial lens.
Methods
This interpretive descriptive qualitative study was embedded in an explanatory sequential mixed methods design. Thirteen hand therapists in the United States were purposefully sampled based on low and high scores on the Revised Neurophysiology of Pain Questionnaire. Each therapist participated in one semi-structured virtual interview. Data were analyzed using open and a priori codes, which were synthesized into themes that aligned with each domain of the biopsychosocial model.
Findings
Participants described “balancing local tissues and the brain,” “empowering through education and function,” and “looking beyond the individual.” Recognition of multidimensional components of pain reinforced participants’ awareness that “pain is always real.”
Discussion
Hand therapists appreciated pain as a multidimensional phenomenon, with biological, psychological, and social facets. However, a potential bias toward structural pathology warrants additional training to promote high-value musculoskeletal care.
Introduction
Research on musculoskeletal disorders indicates that pain sensitivity can be an important consideration for musculoskeletal clinicians in the holistic view of a patient presentation. However, diversity in research findings in this field can make this a difficult concept for clinicians to navigate. Limited integration of the concept of pain sensitivity into clinical practice for musculoskeletal clinicians has been noted.
Purpose
The purpose of this masterclass is to provide a framework for the consideration of pain sensitivity as a contributing factor in the presentation of people with musculoskeletal pain. It provides pragmatic synthesis of the literature related to pain sensitivity through a lens of how this information can inform clinical practice for musculoskeletal clinicians. Guidance is provided in a ‘how to’ format for integration of this knowledge into the clinical encounter to facilitate personalised care.
Implications
The relationship of pain sensitivity with pain and disability is not clear or linear. The real importance of pain sensitivity in a clinical presentation may be: (1) the potential for pain sensitivity to modify the effect of common treatments utilised by musculoskeletal clinicians, or (2) the effect of pain sensitivity on the prognosis/course of a disorder. Screening tools and subjective features have been highlighted to indicate when physical assessment of pain sensitivity should be prioritised in the physical examination. A pragmatic blueprint for specific assessment related to pain sensitivity has been outlined. A framework for integrating assessment findings into clinical reasoning to formulate management plans for the pain sensitive patient is provided.
This study explored whether group size and group member characteristics (age, gender, compensation status) were associated with patient outcomes (changes in pain and disability). Retrospective analyses of outcome data obtained from two independently run group Cognitive Behavioural Therapy (CBT) programs for chronic pain (Program A: N = 317 and Program B: N = 693) were conducted. Intracluster correlations (ICCs) were significant in both studies, indicating group-level effects on patient outcomes in both group CBT programs for chronic pain. Mixed modelling revealed that group size and group member characteristics (age, gender, and compensation status) were related to patient outcomes, but not consistently across programs. The results of our analyses confirm the contribution of group composition to individual treatment outcomes in group CBT for chronic pain, and highlight factors that have the potential to contribute to group-level variability in patient outcomes. Further research is needed to identify the mechanisms that account for the impact of group characteristics on the efficacy of CBT for chronic pain.
BACKGROUND: Biopsychosocially informed education is associated with improved back pain beliefs and positive changes in health care practitioners’ practice behaviours.
OBJECTIVE: Assess the effect of this type of education for insurance workers who are important non-clinical stakeholders in the rehabilitation of injured workers.
METHODS: Insurance workers operating in the Western Australian workers’ compensation system underwent two, 1.5 hour sessions of biopsychosocially informed education focusing on understanding and identifying barriers to recovery of injured workers with musculoskeletal conditions. Back pain beliefs were assessed pre-education, immediately post-education and at three-month follow-up (n = 32). Self-reported and Injury Management Advisor-reported assessment of change in claims management behaviours were collected at the three-month follow-up.
RESULTS: There were positive changes in the Health Care Providers’ Pain and Impairment Relationship Scale (p = 0.009) and Back Beliefs Questionnaire (p = 0.049) immediately following the education that were sustained at three-month follow-up. Positive changes in claims management behaviours were supported by self-reported and Injury Management Advisor-reported data.
CONCLUSION: This study provides preliminary support that a brief biopsychosocially informed education program can positively influence insurance workers’ beliefs regarding back pain, with concurrent positive changes in claims management behaviours. Further research is required to ascertain if these changes result in improved claims management outcomes.
A systematic analysis of the literature was undertaken to determine which characteristics of workplace interventions are most effective in assisting people with persistent musculoskeletal pain (PMP) to remain productively employed. Databases of Medline, PsychINFO, CINAHL and Embase were searched using MeSH and other relevant terms. Studies that reported on interventions at, or involving, the workplace were included. Interventions were considered as either focused on the individual or multilevel. Outcome measures assessed included: job loss, productivity, sick leave, pain and cost benefit. A quality assessment was undertaken using GRADE criteria with development of impact statements to synthesise the results. Eighteen relevant articles (14 studies) were identified for inclusion in the review. No high-level evidence for workplace interventions to assist people with PMP were identified. Low numbers of participants and limited studies resulted in downgrading of evidence. However, individually focused interventions will probably reduce job loss and sick leave, but are unlikely to reduce pain. Multilevel focused interventions will probably result in decreased sick leave and provide some cost benefit. The evidence on productivity was limited and of poor quality. Further research is required because sustainable employment for individuals with PMP is important and understanding what works is necessary to ensure effective workplace interventions are developed.
Objective:
To analyse attitudes and beliefs about movement and physical activity in people with low back pain (LBP) and compare these beliefs between people with acute and chronic LBP.
Design:
Qualitative inductive analysis of data collected via face-to-face semi-structured interviews.
Setting:
Twelve participants with acute LBP (<6 weeks) and eleven participants with chronic LBP (>3 months) were purposively recruited from one region of New Zealand. Interviews were audio-recorded and transcribed verbatim.
Interventions:
Not-applicable.
Main outcome measure:
Themes which emerged from participant interview transcripts using analysis based on Interpretative Description.
Results:
Participants with acute and chronic LBP made judgements about physical activity and rest using the same conceptual model. Concerns about creating more pain, tissue damage, or impairment influenced the physical activity judgements of most participants with acute and chronic LBP. These perceived risks were balanced against the perceived benefits, the most important of which were psychological or social rather than physical. Judgements made by those with acute and chronic LBP were context dependent and influenced by the nature and duration of pain, the type of physical activity, the importance of the activity, and the participant's previous experience. Participants with acute pain who had not experienced back pain previously often expressed more uncertainty whereas those with chronic LBP appeared to have developed cognitive rules which determined physical activity decisions.
Conclusions:
Exploring the perceived risks, benefits, and contextual factors which influence decisions about physical activity and rest may help clinicians to understand the behaviour of patients with acute and chronic LBP. Clinicians may best support their patients to engage in physical activity by providing an informed assessment of risks and explanation about the range of potential benefits.
Purpose There is a clear need for interventions that successfully prevent the development of disability due to back pain. We hypothesized that an intervention aimed at both the worker and the workplace could be effective. Hence, we tested the effects of a new early intervention, based on the misdirected problem solving model, aimed at both workers at risk of long-term impairments and their workplace. Methods Supervisors of volunteers with back pain, no red flags, and a high score on a screen (Örebro Musculoskeletal Screening Questionnaire) were randomized to either an evidence based treatment as usual (TAU) or to a worker and workplace package (WWP). The WWP intervention included communication and problem solving skills for the patient and their immediate supervisor. The key outcome variables of work absence due to pain, health-care utilization, perceived health, and pain intensity were collected before, after and at a 6 month follow up. Results The WWP showed significantly larger improvements relative to the TAU for work absence due to pain, perceived health, and health-care utilization. Both groups improved on pain ratings but there was no significant difference between the groups. The WWP not only had significantly fewer participants utilizing health care and work absence due to pain, but the number of health care visits and days absent were also significantly lower than the TAU. Conclusions The WWP with problem solving and communication skills resulted in fewer days off work, fewer health care visits and better perceived health. This supports the misdirected problem solving model and indicates that screening combined with an active intervention to enhance skills is quite successful and likely cost-effective. Future research should replicate and extend these findings with health-economic analyses.
The implementation of research findings into healthcare practice has become increasingly recognised as a major priority for researchers, service providers, research funders and policymakers over the past decade. Nine years after its establishment, Implementation Science, an international online open access journal, currently publishes over 150 articles each year. This is fewer than 30% of those submitted for publication. The majority of manuscript rejections occur at the point of initial editorial screening, frequently because we judge them to fall outside of journal scope. There are a number of common reasons as to why manuscripts are rejected on grounds of scope. Furthermore, as the field of implementation research has evolved and our journal submissions have risen, we have, out of necessity, had to become more selective in what we publish. We have also expanded our scope, particularly around patient-mediated and population health interventions, and will monitor the impact of such changes. We hope this editorial on our evolving priorities and common reasons for rejection without peer review will help authors to better judge the relevance of their papers to Implementation Science.
Implementation science has progressed towards increased use of theoretical approaches to provide better understanding and explanation of how and why implementation succeeds or fails. The aim of this article is to propose a taxonomy that distinguishes between different categories of theories, models and frameworks in implementation science, to facilitate appropriate selection and application of relevant approaches in implementation research and practice and to foster cross-disciplinary dialogue among implementation researchers.
Theoretical approaches used in implementation science have three overarching aims: describing and/or guiding the process of translating research into practice (process models); understanding and/or explaining what influences implementation outcomes (determinant frameworks, classic theories, implementation theories); and evaluating implementation (evaluation frameworks). This article proposes five categories of theoretical approaches to achieve three overarching aims. These categories are not always recognized as separate types of approaches in the literature. While there is overlap between some of the theories, models and frameworks, awareness of the differences is important to facilitate the selection of relevant approaches. Most determinant frameworks provide limited "how-to" support for carrying out implementation endeavours since the determinants usually are too generic to provide sufficient detail for guiding an implementation process. And while the relevance of addressing barriers and enablers to translating research into practice is mentioned in many process models, these models do not identify or systematically structure specific determinants associated with implementation success. Furthermore, process models recognize a temporal sequence of implementation endeavours, whereas determinant frameworks do not explicitly take a process perspective of implementation.
What are physiotherapists' perceptions about identifying and managing the cognitive, psychological and social factors that may act as barriers to recovery for people with low back pain (LBP)?
Systematic review and qualitative metasynthesis of qualitative studies in which physiotherapists were questioned, using focus groups or semi-structured interviews, about identifying and managing cognitive, psychological and social factors in people with LBP.
Qualified physiotherapists with experience in treating patients with LBP.
Studies were synthesised in narrative format and thematic analysis was used to provide a collective insight into the physiotherapists' perceptions.
Three main themes emerged: physiotherapists only partially recognised cognitive, psychological and social factors in LBP, with most discussion around factors such as family, work and unhelpful patient expectations; some physiotherapists stigmatised patients with LBP as demanding, attention-seeking and poorly motivated when they presented with behaviours suggestive of these factors; and physiotherapists questioned the relevance of screening for these factors because they were perceived to extend beyond their scope of practice, with many feeling under-skilled in addressing them.
Physiotherapists partially recognised cognitive, psychological and social factors in people with LBP. Physiotherapists expressed a preference for dealing with the more mechanical aspects of LBP, and some stigmatised the behaviours suggestive of cognitive, psychological and social contributions to LBP. Physiotherapists perceived that neither their initial training, nor currently available professional development training, instilled them with the requisite skills and confidence to successfully address and treat the multidimensional pain presentations seen in LBP. Registration: CRD 42014009964. [Synnott A, O'Keeffe M, Bunzli S, Dankaerts W, O'Sullivan P, O'Sullivan K (2015) Physiotherapists may stigmatise or feel unprepared to treat people with low back pain and psychosocial factors that influence recovery: a systematic review.Journal of PhysiotherapyXX: XX-XX].
Copyright © 2015. Published by Elsevier B.V.
The effect of financial compensation on health outcomes following musculoskeletal injury requires further exploration because results to date are varied and controversial. This systematic review identifies compensation related factors associated with poorer health outcomes following musculoskeletal injury. Searches were conducted using electronic medical journal databases (Medline, CINAHL, Embase, Informit, Web of Science) for prospective studies published up to October 2012. Selection criteria included: prognostic factors associated with validated health outcomes; six or more months follow up; and multivariate statistical analysis. Studies solely measuring return to work outcomes were excluded. Twenty nine articles were synthesised and then assessed using GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology to determine evidence levels. The results were mixed. There was strong evidence of an association between compensation status and poorer psychological function; and legal representation and poorer physical function. There was moderate evidence of an association between compensation status and poorer physical function; and legal representation and poorer psychological function. There was limited evidence of an association between compensation status and increased pain. In seven studies the association depended on the outcome measured. No studies reported an association between compensation related factors and improved health outcomes. Further research is needed to find plausible reasons why compensation related factors are associated with poorer health following musculoskeletal injury.
Musculoskeletal health conditions such as arthritis, osteoporosis and pain syndromes impart a profound socioeconomic burden worldwide, particularly in developed nations such as Australia. Despite the identified burden, substantial evidence-practice and care disparity gaps remain in service delivery and access that limit the potential for improved consumer outcomes and system efficiencies. Addressing these gaps requires a whole-of-sector response, supported by evidence-informed health policy. Models of care (MoCs) serve as a policy vehicle to embed evidence into health policy and guide practice through changes in service delivery systems and clinician behaviour. In Australia, MoCs for musculoskeletal health have been developed by networks of multidisciplinary stakeholders and are incrementally being implemented across health services, facilitated by dedicated policy units and clinical champions. A web of evidence is now emerging to support this approach to driving evidence into health policy and practice. Understanding the vernacular of MoCs and the development and implementation of MoCs is important to embracing this approach to health policy.
Introduction:
Healthcare providers (HCPs) are influential in the injured worker's recovery process and fulfil many roles in the delivery of health services. Interactions between HCPs and insurers can also affect injured workers' engagement in rehabilitation and subsequently their recovery and return to work. Consideration of the injured workers' perceptions and experiences as consumers of medical and compensation services can provide vital information about the quality, efficacy and impact of such systems. The aim of this systematic review was to identify and synthesize published qualitative research that focused on the interactions between injured workers, HCPs and insurers in workers' compensation systems in order to identify processes or interactions which impact injured worker recovery.
Method:
A search of six electronic databases for literature published between 1985 and 2012 revealed 1,006 articles. Screening for relevance identified 27 studies which were assessed for quality against set criteria. A final 13 articles of medium and high quality were retained for data extraction.
Results:
Findings were synthesized using a meta-ethnographic approach. Injured workers reported that HCPs could play both healing and harming roles in their recovery. Supportive patient-centred interaction with HCPs is important for injured workers. Difficult interactions between HCPs and insurers were highlighted in themes of adversarial relations and organisational pressures. Insurer and compensation system processes exerted an influence on the therapeutic relationship. Recommendations to improve relationships included streamlining administrative demands and increasing education and communication between the parties.
Conclusion:
Injured workers with long term complex injuries experience difficulties with healthcare in the workers' compensation context. Changes in insurer administrative demands and compensation processes could increase HCP participation and job satisfaction. This in turn may improve injured worker recovery. Further research into experiences of distinct healthcare professions with workers' compensation systems is warranted.
Introduction:
Work-related injury is a major public health problem and a worker's recovery can be shaped by their interactions with employers, healthcare providers and the workers' compensation system. Most research on the effects of compensation has concentrated on examining outcomes rather than considering the compensation process itself. There has been little attention paid to the interactions between stakeholders and only recently has the client's view been considered as worthy of investigation. This systematic review aimed to identify and synthesize findings from peer reviewed qualitative studies that investigated injured workers interactions with insurers in workers' compensation systems.
Method:
A search of six electronic library databases revealed 1,006 articles. After screening for relevance, 18 articles were read in full and a search of those bibliographies revealed a further nine relevant articles. Quality assessment of the 27 studies resulted in a final 13 articles of medium and high quality being retained for data extraction.
Results:
Included studies focused mainly on experiences of injured workers, many of whom had long term claims. Findings were synthesized using a meta-ethnographic approach. Six themes were identified which characterised the interactions between insurers and injured workers. The majority of interactions were negative and resulted in considerable psychosocial consequences for injured workers. Positive interactions were less frequently reported and included respectful, understanding and supportive communication and efficient service from insurers.
Conclusion:
Findings from this synthesis support the growing consensus that involvement in compensation systems contributes to poorer outcomes for claimants. Interactions between insurers and injured workers were interwoven in cyclical and pathogenic relationships, which influence the development of secondary injury in the form of psychosocial consequences instead of fostering recovery of injured workers. This review suggests that further research is required to investigate positive interactions and identify mechanisms to better support and prevent secondary psychosocial harm to injured workers.
Purpose:
Line supervisors often play an important role in the return to work (RTW) process; whether they possess the competencies needed to carry out this work effectively is unknown. The aim of this research was to determine the competencies supervisors need in order to facilitate a worker's RTW following absence due to a mental health condition or a musculoskeletal disorder.
Methods:
Supervisors from five Australian industries with high rates of compensable claims participated in focus groups to elicit the knowledge, skills, and personal characteristics required to support returning workers. From a multi-stage analysis of responses, RTW competencies were developed, allocated to clusters of related items, and incorporated into an online survey administered to rehabilitation professionals.
Results:
29 supervisors participated in 1 of 5 focus groups. Analysis of focus group data identified 84 generic competencies, eight specific to mental health conditions, and two to musculoskeletal disorders, arranged in 11 clusters. Survey respondents (n = 344) represented a variety of rehabilitation professionals and jurisdictions. Nearly all agreed that supervisors should receive training to support RTW. Over 50 % of respondents rated 90 of 94 competencies as very important or essential. The highest ratings were for competencies relating to personal attributes, knowledge of RTW processes, and empathetic support of the worker.
Conclusions:
Supervisors and rehabilitation professionals perceive effective support of RTW requires supervisors to have a range of knowledge, skills, and personal characteristics. Our competency model should undergo workplace testing to evaluate its validity.
Background
Arthroscopic partial meniscectomy is one of the most common orthopedic procedures, yet rigorous evidence of its efficacy is lacking.
Methods
We conducted a multicenter, randomized, double-blind, sham-controlled trial in 146 patients 35 to 65 years of age who had knee symptoms consistent with a degenerative medial meniscus tear and no knee osteoarthritis. Patients were randomly assigned to arthroscopic partial meniscectomy or sham surgery. The primary outcomes were changes in the Lysholm and Western Ontario Meniscal Evaluation Tool (WOMET) scores (each ranging from 0 to 100, with lower scores indicating more severe symptoms) and in knee pain after exercise (rated on a scale from 0 to 10, with 0 denoting no pain) at 12 months after the procedure.
Results
In the intention-to-treat analysis, there were no significant between-group differ- ences in the change from baseline to 12 months in any primary outcome. The mean changes (improvements) in the primary outcome measures were as follows: Lysholm score, 21.7 points in the partial-meniscectomy group as compared with 23.3 points in the sham-surgery group (between-group difference, −1.6 points; 95% confi- dence interval [CI], −7.2 to 4.0); WOMET score, 24.6 and 27.1 points, respectively (between-group difference, −2.5 points; 95% CI, −9.2 to 4.1); and score for knee pain after exercise, 3.1 and 3.3 points, respectively (between-group difference, −0.1; 95% CI, −0.9 to 0.7). There were no significant differences between groups in the number of patients who required subsequent knee surgery (two in the partial- meniscectomy group and five in the sham-surgery group) or serious adverse events (one and zero, respectively).
Conclusions
In this trial involving patients without knee osteoarthritis but with symptoms of a degenerative medial meniscus tear, the outcomes after arthroscopic partial menis- cectomy were no better than those after a sham surgical procedure. (Funded by the Sigrid Juselius Foundation and others; ClinicalTrials.gov number, NCT00549172.)
Background:
Arthroscopic partial meniscectomy is one of the most common orthopedic procedures, yet rigorous evidence of its efficacy is lacking.
Methods:
We conducted a multicenter, randomized, double-blind, sham-controlled trial in 146 patients 35 to 65 years of age who had knee symptoms consistent with a degenerative medial meniscus tear and no knee osteoarthritis. Patients were randomly assigned to arthroscopic partial meniscectomy or sham surgery. The primary outcomes were changes in the Lysholm and Western Ontario Meniscal Evaluation Tool (WOMET) scores (each ranging from 0 to 100, with lower scores indicating more severe symptoms) and in knee pain after exercise (rated on a scale from 0 to 10, with 0 denoting no pain) at 12 months after the procedure.
Results:
In the intention-to-treat analysis, there were no significant between-group differences in the change from baseline to 12 months in any primary outcome. The mean changes (improvements) in the primary outcome measures were as follows: Lysholm score, 21.7 points in the partial-meniscectomy group as compared with 23.3 points in the sham-surgery group (between-group difference, -1.6 points; 95% confidence interval [CI], -7.2 to 4.0); WOMET score, 24.6 and 27.1 points, respectively (between-group difference, -2.5 points; 95% CI, -9.2 to 4.1); and score for knee pain after exercise, 3.1 and 3.3 points, respectively (between-group difference, -0.1; 95% CI, -0.9 to 0.7). There were no significant differences between groups in the number of patients who required subsequent knee surgery (two in the partial-meniscectomy group and five in the sham-surgery group) or serious adverse events (one and zero, respectively).
Conclusions:
In this trial involving patients without knee osteoarthritis but with symptoms of a degenerative medial meniscus tear, the outcomes after arthroscopic partial meniscectomy were no better than those after a sham surgical procedure. (Funded by the Sigrid Juselius Foundation and others; ClinicalTrials.gov number, NCT00549172.).
This cluster-randomised controlled trial determined the effectiveness of an evidence-based, pamphlet intervention in improving low back pain (LBP)-related beliefs among pharmacy consumers.
THIRTY FIVE COMMUNITY PHARMACIES WERE RANDOMISED TO THREE GROUPS: pamphlet+education intervention [n = 11]; pamphlet only intervention [n = 11]; control: usual care [n = 13]. Eligibility requirements for clusters included: community-based pharmacies and proprietor participation consent. Pharmacy consumers (N = 317) aged 18-65 years currently experiencing LBP participated. Intervention group allocation depended on the pharmacy attended. Individual-level outcomes were measured at pre-intervention (T0), at two (T1) and eight (T2) weeks post-intervention and included beliefs about LBP [Back Pain Beliefs Questionnaire (BBQ); Fear Avoidance Beliefs Questionnaire (FABQ)]. Secondary outcomes included pain severity, activity impairment and pamphlet perceived usefulness. Blinding to group allocation included primary investigators, outcome assessors and the statistician. Pharmacy staff and consumers were un-blinded.
Of 35 pharmacies recruited (317 consumers), no clusters were lost to follow-up. Follow-up was available for n = 24 at 2 weeks only; n = 38 at 8 weeks only; n = 148 at both time points, with n = 148+24+38 = 210 analysed (107 excluded: no follow up). Adjusting for baseline scores demonstrated no significant differences in beliefs (2 or at 8 weeks) between pamphlet (with or without education) versus control, or between 'pamphlet with' versus 'without' education. Work-related fear (FABQ) was significantly lower in consumers receiving pamphlet (with or without education) versus control (difference -2.3, 95%CI: -4.4 to -0.2). There was no significant difference between "pamphlet with" versus "pamphlet without" groups. Consumers receiving the "pamphlet with" reported greater perceived usefulness than consumers receiving the "pamphlet without" (difference 0.9 (95%CI: 0.0 to 1.8)).
Community pharmacies provided a feasible primary care portal for implementing evidence-based information. The associated improvement in work-related LBP-beliefs for consumers receiving the pamphlet suggests this simple intervention may be a useful component of care.
ACTR.org.au ACTRN12611000053921.
Objective
The objective of this project was to develop core competencies in pain assessment and management for prelicensure health professional education. Such core pain competencies common to all prelicensure health professionals have not been previously reported.
Methods
An interprofessional executive committee led a consensus-building process to develop the core competencies. An in-depth literature review was conducted followed by engagement of an interprofessional Competency Advisory Committee to critique competencies through an iterative process. A 2-day summit was held so that consensus could be reached.
Results
The consensus-derived competencies were categorized within four domains: multidimensional nature of pain, pain assessment and measurement, management of pain, and context of pain management. These domains address the fundamental concepts and complexity of pain; how pain is observed and assessed; collaborative approaches to treatment options; and application of competencies across the life span in the context of various settings, populations, and care team models. A set of values and guiding principles are embedded within each domain.
Conclusions
These competencies can serve as a foundation for developing, defining, and revising curricula and as a resource for the creation of learning activities across health professions designed to advance care that effectively responds to pain.
Background: Non-specific chronic low back pain disorders have been proven resistant to change, and there is still a lack of clear evidence for one specific treatment intervention being superior to another.
Methods: This randomized controlled trial aimed to investigate the efficacy of a behavioural approach to management, classification-based cognitive functional therapy, compared with traditional manual therapy and exercise. Linear mixed models were used to estimate the group differences in treatment effects. Primary outcomes at 12-month follow-up were Oswestry Disability Index and pain intensity, measured with numeric rating scale. Inclusion criteria were as follows: age between 18 and 65 years, diagnosed with non-specific chronic low back pain for >3 months, localized pain from T12 to gluteal folds, provoked with postures, movement and activities. Oswestry Disability Index had to be >14% and pain intensity last 14 days >2/10. A total of 121 patients were randomized to either classification-based cognitive functional therapy group n = 62) or manual therapy and exercise group (n > = 59).
Results: The classification-based cognitive functional therapy group displayed significantly superior outcomes to the manual therapy and exercise group, both statistically (p < 0.001) and clinically. For Oswestry Disability Index, the classification-based cognitive functional therapy group improved by 13.7 points, and the manual therapy and exercise group by 5.5 points. For pain intensity, the classification-based cognitive functional therapy improved by 3.2 points, and the manual therapy and exercise group by 1.5 points.
Conclusions: The classification-based cognitive functional therapy produced superior outcomes for non-specific chronic low back pain compared with traditional manual therapy and exercise.
This paper argues that the biology of pain is never really straightforward, even when it appears to be. It is proposed that understanding what is currently known about the biology of pain requires a reconceptualisation of what pain actually is, and how it serves our livelihood. There are four key points: (i) that pain does not provide a measure of the state of the tissues; (ii) that pain is modulated by many factors from across somatic, psychological and social domains; (iii) that the relationship between pain and the state of the tissues becomes less predictable as pain persists; and (iv) that pain can be conceptualised as a conscious correlate of the implicit perception that tissue is in danger. These issues raise conceptual and clinical implications, which are discussed with particular relevance to persistent pain. Finally, this conceptualisation is used as a framework for one approach to understanding complex regional pain syndrome.
Although compensation for occupational injuries and diseases is guaranteed in almost all nations, countries vary greatly with respect to how they organize workers' compensation systems. In this paper, we focus on three aspects of workers' compensation insurance in Organization for Economic Cooperation and Development (OECD) countries - types of systems, employers' funding mechanisms, and coverage for injured workers - and their impacts on the actual frequencies of occupational injuries and diseases.
We estimated a panel data fixed effect model with cross-country OECD and International Labor Organization data. We controlled for country fixed effects, relevant aggregate variables, and dummy variables representing the occupational accidents data source.
First, the use of a private insurance system is found to lower the occupational accidents. Second, the use of risk-based pricing for the payment of employer raises the occupational injuries and diseases. Finally, the wider the coverage of injured workers is, the less frequent the workplace accidents are.
Private insurance system, fixed flat rate employers' funding mechanism, and higher coverage of compensation scheme are significantly and positively correlated with lower level of occupational accidents compared with the public insurance system, risk-based funding system, and lower coverage of compensation scheme.
Pain is highly modifiable by psychological factors, including expectations. However, pain is a complex phenomenon, and expectations may work by influencing any number of processes that underlie the construction of pain. Neuroimaging has begun to provide a window into these brain processes, and how expectations influence them. In this article, we review findings regarding expectancy effects on brain markers of nociception and how expectations lead to changes in subjective pain. We address both expectations about treatments (placebo analgesia and nocebo effects) and expectations about the environment (e.g. expectations about pain itself). The body of work reviewed indicates that expectancies shape pain-intensity processing in the central nervous system, with strong effects on nociceptive portions of insula, cingulate and thalamus. Expectancy effects on subjective experience are driven by responses in these regions as well as regions less reliably activated by changes in noxious input, including the dorsolateral prefrontal cortex and the orbitofrontal cortex. Thus, multiple systems are likely to interact and mediate the pain-modulatory effects of expectancies. Finally, we address open questions regarding the psychological processes likely to play an intervening role in expectancy effects on pain.
Effective strategies for the primary prevention of low back pain (LBP) remain elusive with few large-scale clinical trials investigating exercise and education approaches. The purpose of this trial was to determine whether core stabilization alone or in combination with psychosocial education prevented incidence of low back pain in comparison to traditional lumbar exercise.
The Prevention of Low Back Pain in the Military study was a cluster randomized clinical study with four intervention arms and a two-year follow-up. Participants were recruited from a military training setting from 2007 to 2008. Soldiers in 20 consecutive companies were considered for eligibility (n = 7,616). Of those, 1,741 were ineligible and 1,550 were eligible but refused participation. For the 4,325 Soldiers enrolled with no previous history of LBP average age was 22.0 years (SD = 4.2) and there were 3,082 males (71.3%). Companies were randomly assigned to receive traditional lumbar exercise, traditional lumbar exercise with psychosocial education, core stabilization exercise, or core stabilization with psychosocial education, The psychosocial education session occurred during one session and the exercise programs were done daily for 5 minutes over 12 weeks. The primary outcome for this trial was incidence of low back pain resulting in the seeking of health care.
There were no adverse events reported. Evaluable patient analysis (4,147/4,325 provided data) indicated no differences in low back incidence resulting in the seeking of health care between those receiving the traditional exercise and core stabilization exercise programs. However, brief psychosocial education prevented low back pain episodes regardless of the assigned exercise approach, resulting in a 3.3% (95% CI: 1.1 to 5.5%) decrease over two years (numbers needed to treat (NNT) = 30.3, 95% CI = 18.2 to 90.9).
Core stabilization has been advocated as preventative, but offered no such benefit when compared to traditional lumbar exercise in this trial. Instead, a brief psychosocial education program that reduced fear and threat of low back pain decreased incidence of low back pain resulting in the seeking of health care. Since this trial was conducted in a military setting, future studies are necessary to determine if these findings can be translated into civilian populations.
NCT00373009 at ClinicalTrials.gov - http://clinicaltrials.gov/
Objective:
To develop a globally informed framework to evaluate readiness for implementation and success after implementation of musculoskeletal models of care (MOCs).
Methods:
Three phases were undertaken: 1) a qualitative study with 27 Australian subject matter experts (SMEs) to develop a draft framework; 2) an eDelphi study with an international panel of 93 SMEs across 30 nations to evaluate face validity, and refine and establish consensus on the framework components; and 3) translation of the framework into a user-focused resource and evaluation of its acceptability with the eDelphi panel.
Results:
A comprehensive evaluation framework was developed for judging the readiness and success of musculoskeletal MOCs. The framework consists of 9 domains, with each domain containing a number of themes underpinned by detailed elements. In the first Delphi round, scores of "partly agree" or "completely agree" with the draft framework ranged 96.7%-100%. In the second round, "essential" scores ranged 58.6%-98.9%, resulting in 14 of 34 themes being classified as essential. SMEs strongly agreed or agreed that the final framework was useful (98.8%), usable (95.1%), credible (100%) and appealing (93.9%). Overall, 96.3% strongly supported or supported the final structure of the framework as it was presented, while 100%, 96.3%, and 100% strongly supported or supported the content within the readiness, initiating implementation, and success streams, respectively.
Conclusion:
An empirically derived framework to evaluate the readiness and success of musculoskeletal MOCs was strongly supported by an international panel of SMEs. The framework provides an important internationally applicable benchmark for the development, implementation, and evaluation of musculoskeletal MOCs.
Introduction:
Placebo and nocebo represent complex and distinct psychoneurobiological phenomena in which behavioural and neurophysiological modifications occur together with the application of a treatment. Despite a better understanding of this topic in the medical field, little is known about their role in physiotherapy.
Purpose:
The aim of this review is: a) to elucidate the neurobiology behind placebo and nocebo effects, b) to describe the role of the contextual factors as modulators of the clinical outcomes in rehabilitation and c) to provide clinical and research guidelines on their uses.
Implications:
The physiotherapist's features, the patient's features, the patient-physiotherapist relationship, the characteristics of the treatment and the overall healthcare setting are all contextual factors influencing clinical outcomes. Since every physiotherapy treatment determines a specific and a contextual effect, physiotherapists should manage the contextual factors as a boosting element of any manual therapy to improve placebo effects and avoid detrimental nocebo effects.
The mantra 'work is good for health' is familiar to those assisting in the rehabilitation of injured workers and is well supported in the literature. Regulators, workers compensation insurers and health professional bodies have taken steps over the last few years to promote early and safe return to work after a workplace injury. Improving direct access to physiotherapy and extending the role of physiotherapists to authorise work capacity certificates for injured workers will potentially facilitate early intervention, reduce absence from work in a cost-effective system while maintaining patient satisfaction. Several challenges to advancing the role of physiotherapists exist but are not insurmountable.
Persistent pain, impaired mobility and function, and reduced quality of life and mental well-being are the most common experiences associated with musculoskeletal conditions, of which there are more than 150 types. The prevalence and impact of musculoskeletal conditions increase with aging. A profound burden of musculoskeletal disease exists in developed and developing nations. Notably, this burden far exceeds service capacity. Population growth, aging, and sedentary lifestyles, particularly in developing countries, will create a crisis for population health that requires a multisystem response with musculoskeletal health services as a critical component. Globally, there is an emphasis on maintaining an active lifestyle to reduce the impacts of obesity, cardiovascular conditions, cancer, osteoporosis, and diabetes in older people. Painful musculoskeletal conditions, however, profoundly limit the ability of people to make these lifestyle changes. A strong relationship exists between painful musculoskeletal conditions and a reduced capacity to engage in physical activity resulting in functional decline, frailty, reduced well-being, and loss of independence. Multilevel strategies and approaches to care that adopt a whole person approach are needed to address the impact of impaired musculoskeletal health and its sequelae. Effective strategies are available to address the impact of musculoskeletal conditions; some are of low cost (e.g., primary care-based interventions) but others are expensive and, as such, are usually only feasible for developed nations. In developing nations, it is crucial that any reform or development initiatives, including research, must adhere to the principles of development effectiveness to avoid doing harm to the health systems in these settings.
Chronic pain (persistent and recurrent) is a major cause of distress and disability in the community. Patients need to be comprehensively assessed to determine the biomedical, psychological, social and cultural contributions to their pain. Although drug therapy is only part of a multimodal approach to management, its role in modifying distress is important. Paracetamol, opioids and some antidepressants and anticonvulsants are used to treat chronic pain. A combination of these drugs is often needed for adequate pain relief. Parenteral and short-acting oral opioids should be avoided for long-term persistent pain. Drug treatment should be seen as a trial of therapy. Monitoring its effectiveness and safety and the patient's quality of life should guide treatment.
Background:
Work disability has serious consequences for individuals as well as society. It is possible to facilitate resumption of work by reducing barriers to return to work (RTW) and promoting collaboration with key stakeholders. This review was first published in 2009 and has now been updated to include studies published up to February 2015.
Objectives:
To determine the effectiveness of workplace interventions in preventing work disability among sick-listed workers, when compared to usual care or clinical interventions.
Search methods:
We searched the Cochrane Work Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO databases on 2 February 2015.
Selection criteria:
We included randomised controlled trials (RCTs) of workplace interventions that aimed to improve RTW for disabled workers. We only included studies where RTW or conversely sickness absence was reported as a continuous outcome.
Data collection and analysis:
Two review authors independently extracted data and assessed risk of bias of the studies. We performed meta-analysis where possible, and we assessed the quality of evidence according to GRADE criteria. We used standard methodological procedures expected by Cochrane.
Main results:
We included 14 RCTs with 1897 workers. Eight studies included workers with musculoskeletal disorders, five workers with mental health problems, and one workers with cancer. We judged six studies to have low risk of bias for the outcome sickness absence.Workplace interventions significantly improved time until first RTW compared to usual care, moderate-quality evidence (hazard ratio (HR) 1.55, 95% confidence interval (CI) 1.20 to 2.01). Workplace interventions did not considerably reduce time to lasting RTW compared to usual care, very low-quality evidence (HR 1.07, 95% CI 0.72 to 1.57). The effect on cumulative duration of sickness absence showed a mean difference of -33.33 (95% CI -49.54 to -17.12), favouring the workplace intervention, high-quality evidence. One study assessed recurrences of sick leave, and favoured usual care, moderate-quality evidence (HR 0.42, 95% CI 0.21 to 0.82). Overall, the effectiveness of workplace interventions on work disability showed varying results.In subgroup analyses, we found that workplace interventions reduced time to first and lasting RTW among workers with musculoskeletal disorders more than usual care (HR 1.44, 95% CI 1.15 to 1.82 and HR 1.77, 95% CI 1.37 to 2.29, respectively; both moderate-quality evidence). In studies of workers with musculoskeletal disorders, pain also improved (standardised mean difference (SMD) -0.26, 95% CI -0.47 to -0.06), as well as functional status (SMD -0.33, 95% CI -0.58 to -0.08). In studies of workers with mental health problems, there was a significant improvement in time until first RTW (HR 2.64, 95% CI 1.41 to 4.95), but no considerable reduction in lasting RTW (HR 0.79, 95% CI 0.54 to 1.17). One study of workers with cancer did not find a considerable reduction in lasting RTW (HR 0.88, 95% CI 0.53 to 1.47).In another subgroup analysis, we did not find evidence that offering a workplace intervention in combination with a cognitive behavioural intervention (HR 1.93, 95% CI 1.27 to 2.93) is considerably more effective than offering a workplace intervention alone (HR 1.35, 95% CI 1.01 to 1.82, test for subgroup differences P = 0.17).Workplace interventions did not considerably reduce time until first RTW compared with a clinical intervention in workers with mental health problems in one study (HR 2.65, 95% CI 1.42 to 4.95, very low-quality evidence).
Authors' conclusions:
We found moderate-quality evidence that workplace interventions reduce time to first RTW, high-quality evidence that workplace interventions reduce cumulative duration of sickness absence, very low-quality evidence that workplace interventions reduce time to lasting RTW, and moderate-quality evidence that workplace interventions increase recurrences of sick leave. Overall, the effectiveness of workplace interventions on work disability showed varying results. Workplace interventions reduce time to RTW and improve pain and functional status in workers with musculoskeletal disorders. We found no evidence of a considerable effect of workplace interventions on time to RTW in workers with mental health problems or cancer.We found moderate-quality evidence to support workplace interventions for workers with musculoskeletal disorders. The quality of the evidence on the effectiveness of workplace interventions for workers with mental health problems and cancer is low, and results do not show an effect of workplace interventions for these workers. Future research should expand the range of health conditions evaluated with high-quality studies.
In North America host-specific flea beetles (Aphthona spp.; Coleoptera: Chrysomelidae) from Europe have been introduced to suppress invasive populations of the exotic forb, leafy spurge, Euphorbia esula L. (Euphorbiaceae). Long term outcomes of such introduction were examined in 2013 for a spurge infested site (managed as elk winter range) in the mountain foothills of northern Utah where three species of flea beetles had been released two decades earlier, in the 1990s. The abundance of leafy spurge at the site had declined by 2013 to only 4% of its abundance in 1995. The three species of flea beetles (dominated by A. lacertosa Rosenhauer) persisted in low numbers at the site in 2013 [peaking at 7-8 adults (all species combined) per 100 stems and inflicting aboveground feeding damage to all spurge stems by late summer]; flea beetle abundance had declined by 89-97% from high numbers as sampled in 2001. Another biocontrol insect, the stem borer Oberea erythrocephala Schrank (Coleoptera: Cerambycidae), had immigrated on its own to the site (as first detected in 2008) and, by mid-July in 2013, had damaged all spurge stems (typically causing total loss of the inflorescence on flowering stems). With the collapse of the spurge population at the site, the biomass of grasses [dominated by the exotic Bromus inermis Leyss and Arrhenatherum elatius (L.)] and forbs increased by 269% and 507%, respectively, from 1995 to 2013. These increases in grasses and forbs at the site with insect suppression of leafy spurge have resulted in more favorable habitat for elk and other wildlife.
Retrospective cohort studyObjective. Evaluate prescription opioid utilization after lumbar fusion for degenerative disc disease (DDD) in a workers' compensation (WC) settingSummary of Background Data. Use of opioids for treating chronic low-back pain has increased greatly. Few studies have evaluated risk factors for chronic opioid therapy (COT) among the clinically-distinct WC population.
We utilized CPT and ICD-9 codes to identify 1002 Ohio WC subjects who underwent lumbar fusion for DDD from 1993-2013. Postoperative COT was defined as being supplied with opioid analgesics for greater than 1 year after the 6 week acute period following fusion. 575 subjects fit these criteria, forming the COT group. The remaining 427 subjects formed a temporary opioid group. To identify prognostic factors associated with COT after fusion, we utilized a multivariate logistic regression analysis.
Returning to work (RTW) was negatively associated with COT (p<0.001; OR 0.38). COT before fusion (p<0.001; OR 6.15), failed back syndrome (p<0.001; OR 3.40), additional surgery (p<0.001; OR 2.84), clinically diagnosed depression (p<0.001; OR 2.34), and extended work loss before fusion (p = 0.038; OR 1.61) were positively associated with COT. The rates of postoperative COT associated with these factors were 27.8%, 79.6%, 85.0%, 76.4%, 77.1%, and 61.3%, respectively. Higher preoperative opioid load (p<0.001) and duration of use (p<0.001) were positively associated with higher postoperative rates of postoperative COT. Within 3 years after fusion, the COT group was supplied with an average of 1083.4 days of opioids and 49.0 opioid prescriptions, 86.2% of which were Schedule II. The COT group had an 11.0% RTW rate, $27,952 higher medical costs per subject, 43.5% rate of psychiatric comorbidity, 16.7% rate of failed back syndrome, and 27.7% rate of additional lumbar surgery.
The majority of the study population was on COT after fusion. COT was associated with considerably worse outcomes. The poor outcomes of this study could suggest a more limited role for discogenic fusion among WC patients.
Unlabelled:
The pain field has been advocating for some time for the importance of teaching people how to live well with pain. Perhaps some, and maybe even for many, we might again consider the possibility that we can help people live well without pain. Explaining Pain (EP) refers to a range of educational interventions that aim to change one's understanding of the biological processes that are thought to underpin pain as a mechanism to reduce pain itself. It draws on educational psychology, in particular conceptual change strategies, to help patients understand current thought in pain biology. The core objective of the EP approach to treatment is to shift one's conceptualization of pain from that of a marker of tissue damage or disease to that of a marker of the perceived need to protect body tissue. Here, we describe the historical context and beginnings of EP, suggesting that it is a pragmatic application of the biopsychosocial model of pain, but differentiating it from cognitive behavioral therapy and educational components of early multidisciplinary pain management programs. We attempt to address common misconceptions of EP that have emerged over the last 15 years, highlighting that EP is not behavioral or cognitive advice, nor does it deny the potential contribution of peripheral nociceptive signals to pain. We contend that EP is grounded in strong theoretical frameworks, that its targeted effects are biologically plausible, and that available behavioral evidence is supportive. We update available meta-analyses with results of a systematic review of recent contributions to the field and propose future directions by which we might enhance the effects of EP as part of multimodal pain rehabilitation.
Perspective:
EP is a range of educational interventions. EP is grounded in conceptual change and instructional design theory. It increases knowledge of pain-related biology, decreases catastrophizing, and imparts short-term reductions in pain and disability. It presents the biological information that justifies a biopsychosocial approach to rehabilitation.
The current definition and management of medical conditions causing impairment and unnecessary disability in workers’ compensation (WC) systems are suboptimal. Fundamental problems include the failure to recognize and address the unique biopsychosocial diathesis of each individual; the powerful influence of human psychology in the genesis, perpetuation, and refractoriness to treatment of many conditions, including medically unexplained symptoms and chronic pain; the work relevance of even non-work-related conditions; the considerable effects of administrative and clinical iatrogenicity; and the plethora of complex factors potentially affecting the course of conditions treated in WC systems. Once claims are established in WC, administrative and medical management of both identifiable pathologic conditions and unexplained symptoms are fragmented, not based on available scientific evidence, and adherent to a biomedical care approach which is not appropriate for a significant number of cases. These obstacles prevent effective understanding and management of many WC cases and may contribute to eventual recovery failure and unnecessary work disability (UWD). This article explores biopsychosocial factors in WC claimants and elements that may contribute to or ameliorate progression to UWD. The author offers a heuristic diathesis stress model of work-related disability as a framework for general and specific interventions to improve system performance and outcomes for all stakeholders.
With musculoskeletal conditions now identified as the second highest cause of the morbidity-related global burden of disease, models of care for the prevention and management of disability related to musculoskeletal conditions are an imperative. Musculoskeletal models of care aim to describe how to operationalise evidence-based guidelines for musculoskeletal conditions and thus support implementation by clinical teams and their health systems. This review of models of care for musculoskeletal pain conditions, osteoarthritis, rheumatoid arthritis, osteoporosis and musculoskeletal injuries and trauma outlines health system and local implementation strategies to improve consumer outcomes, including supporting access to multidisciplinary teams, improving access for vulnerable populations and levering digital technologies to support access and self-management. However, the challenge remains of how to inform health system decision-makers and policy about the human and fiscal benefits for broad implementation across health services. Recommendations are made for potential solutions, as well as highlighting where further evidence is required.
A state's legislation dictates the expectations in the handling of work-related injuries. However, the reality is that positive outcomes depend more on a company's value system, such as whether an organization views its employees as assets rather than liabilities, than on legal protections. This article reviews the workers' compensation system in the United States and the false assumptions that create barriers to effective and timely resolution of claims. The United States workers' compensation system is a very reactive process. Professionals in the workers' compensation field who work with employers, medical providers, and insurance companies regularly encounter deeply ingrained assumptions that create unnecessary barriers to injured workers' opportunities to participate in transitional work and modified duty while recovering from a work-related injury. Regardless of the size or type of the employer, the jurisdiction where the injury occurred, or the type of claim management organization, these perceptions continue to permeate the industry. This article addresses these assumptions and offers suggestions for a more proactive approach to achieve quicker and more successful outcomes.
Placebo and nocebo effects are often regarded by clinicians as either a quaint reminiscence from the pre-therapeutic era, or simply as a technique for establishing the efficacy of therapeutic interventions within the locus of evidence-based practice. However, neither of these explanations sufficiently account for their complexity or their persistence and impact in clinical medicine. Placebo and nocebo effects are embedded in the very fabric of therapeutic relationships and are both a manifestation and outcome of the rituals that characterise clinical practice. They are also a stark reminder of the many personal and environmental factors, including the attitudes, beliefs and expectations of both doctor and patient, that shape the outcomes of health professional-patient interactions.
We describe how recent biological and neuropsychiatric data have clarified the operation of placebo and nocebo effects in clinical practice – demonstrating the ability of the therapeutic context to modulate endogenous biological processes in a targeted manner. This, in turn, illustrates the potent philosophical and sociocultural aspects of medical praxis.
To provide access to professional development opportunities for health care professionals, especially in rural Australian regions, consistent with recommendations in the Australian National Pain Strategy and state government policy.
A preliminary prospective, single-cohort study design, which aligned health policy with evidence-informed clinical practice, evaluated the implementation and effectiveness of an interprofessional, health care provider pain education program (hPEP) for management of nonspecific low back pain (nsLBP) in rural Western Australia.
The 6.5-hour hPEP intervention was delivered to 60 care providers (caseload nsLBP 19.8% ± 22.5) at four rural WA regions.
Outcomes were recorded at baseline and 2 months post-intervention regarding attitudes, beliefs (modified Health Care Providers Pain and Impairment Relationship Scale [HC-PAIRS]), Back Pain Beliefs Questionnaire [BBQ]), and self-reported evidence-based clinical practice (knowledge and skills regarding nsLBP, rated on a 5-point Likert scale with 1 = nil and 5 = excellent).
hPEP was feasible to implement. At 2 months post-hPEP, responders' (response rate 53%) improved evidence-based beliefs were indicated by HC-PAIRS scores: baseline mean (SD) [43.2 (9.3)]; mean difference (95% CI) [-5.9 (-8.6 to -3.1)]; and BBQ baseline [34.3 (6.8)]; mean difference [2.1 (0.5 to 3.6)]. Positive shifts were observed for all measures of clinical knowledge and skills (P < 0.001) and increased assistance with planning lifestyle changes (P < 0.001), advice on self-management (P = 0.010), and for decreased referrals for spinal imaging (P = 0.03).
This policy-into-practice educational program is feasible to implement in rural Western Australia (WA). While preliminary data are encouraging, a further randomized controlled trial is recommended.
Study Design. An integrated review of current knowledge about the biopsychosocial model of back pain for understanding aetiology, prognosis and interventions, as presented at the plenary sessions of theXII International Forum on LBP Research in Primary Care (Denmark 17-19 October 2012).Objective. To evaluate the utility of the model in reference to rising rates of back pain related disability, by identifying a) the most promising avenues for future research in biological, psychological and social approaches, b) promising combinations of all three approaches and c) obstacles to effective implementation of biopsychosocial based research and clinical practice.Summary of Background Data. The biopsychosocial model of back pain has become a dominant model in the conceptualisation of the aetiology and prognosis of back pain, and has led to the development and testing of many interventions. Despite this back pain remains a leading source of disability worldwide.Methods. The review is a synthesis based on the plenary sessions and discussions at the XII International Forum on LBP Research in Primary Care. The presentations included evidence-based reviews of the current state of knowledge in each of the three areas (biological, psychological and social), identification of obstacles to effective implementation and missed opportunities, and identification of the most promising paths for future research.Results. While there is good evidence for the role of biological, psychological and social factors in the aetiology and prognosis of back pain, synthesis of the three in research and clinical practice has been suboptimal.Conclusion. The utility of the biopsychosocial framework cannot be fully assessed until we truly adopt and apply it in research and clinical practice.
Objective: This study investigated beliefs related to ‘grey areas’ of in- jured worker management in the West Australian workers’ compen- sation system.
Methods: Six common scenarios related directly to the management of injured workers were devised with two main themes of ‘Reason- able Expenses’ and ‘Health Worker Roles’. The scenarios were fo- cused on musculoskeletal disorders. Eighty physiotherapists and 48 insurance workers (case managers, injury management advisors) par- ticipated in an online questionnaire. Level of agreement with each scenario was assessed and opportunity provided for individual com- ments.
Results: Differences were identified in the beliefs related to the six scenarios both between and within professions. Both professions had varied opinions as to when treatment under the workers’ com- pensation system should cease. There was a lack of consensus in both professions on the provision of treatment for comorbidity within the system. There were differing opinions between professions re- lated to the role of various stakeholders, with good communication emerging as a common theme to deal with potential role conflicts.
Conclusion: This study confirms the existence of a number of ‘grey areas’ directly related to injured worker management in the Western Australian workers’ compensation system. These ‘grey areas’ have the potential to result in inefficiencies, inconsistency in care, confu- sion and frustration for stakeholders.
It is well established that environmental factors can have impact upon an injured person's recovery and return-to-work outcomes. To date, there has been no cohesive model to provide theoretical understanding of the way in which these divergent factors combine to create disability behaviours.
Development of a conceptual model for understanding the development of disability behavior.
Interpolation from existing neuroplasticity theory to observed behaviors and studies of behavior in the workers' compensation environment, including existing research concerning predictors for disability.
The paper describes a conceptual model for understanding instances of disability that are not necessarily attributable to physical harm. Preliminary testing provides support for the model.
Factors that contribute to the formation of a neural network supporting the behavior of learned disability are described. From that description, intervention methods to prevent or resolve so-called "needless disability" are discussed.
Background:
Diagnostic MRI reports can be distressing for patients with limited health literacy. Humans tend to prepare for the worst particularly when we are in pain, and words like "tear" can make us feel damaged and in need of repair. Research on words used in provider-patient interactions have shown an affect on response to treatment and coping strategies, but the literature on this remains relatively sparse.
Questions/purposes:
The aim of this observational cross-sectional study is to determine whether rewording of MRI reports in understandable, more dispassionate language will result in better patient ratings of emotional response, satisfaction, usefulness, and understanding. Furthermore, we wanted to find out which type of report patients would choose to receive.
Methods:
One hundred patients visiting an orthopaedic hand and upper extremity outpatient office for reasons unrelated to the presented MRI report were enrolled. Four MRI reports, concerning upper extremity conditions, were reworded to an eighth-grade reading level and with the use of neutral descriptive words and the most optimistic interpretations based on current best evidence. After reading each report, emotional response was measured using the Self Assessment Manikin (SAM). Subjects also completed questions about satisfaction, usefulness, and understanding of the report.
Results:
According to the results of the SAM questionnaire, the reworded MRI reports resulted in significantly higher pleasure and dominance scores and lower arousal scores. The mean satisfaction, usefulness, and understanding scores of the reworded report were significantly higher compared with the original reports. Seventy percent of the patients preferred the reworded reports over the original reports.
Conclusions:
Emotional response, satisfaction, usefulness, and understanding were all superior in MRI reports reworded for lower reading level and optimal emotional content and optimism. Given that patients increasingly have access to their medical records and diagnostic reports, attention to health literacy and psychologic aspects of the report may help optimize health and patient satisfaction.
Chronic pain is a common presentation to general practice.
This article explores the role of the mind in the experience of pain and describes how mind-body techniques can be used in the management of chronic pain.
The mind, emotions and attention play an important role in the experience of pain. In patients with chronic pain, stress, fear and depression can amplify the perception of pain. Mind-body approaches act to change a person's mental or emotional state or utilise physical movement to train attention or produce mental relaxation. They are occasionally used as a sole treatment, but more commonly as adjuncts to other therapies. Mind-body approaches include progressive muscle relaxation, meditation, laughter, mindfulness based approaches, hypnosis, guided imagery, yoga, biofeedback and cognitive behavioural therapy. Studies have shown that mind-body approaches can be effective in various conditions associated with chronic pain, however levels of evidence vary. Group delivered courses with healthcare professional input may have more beneficial effects than individual therapy. General practitioners are well placed to recommend or learn and provide a range of mind-body approaches to improve outcomes for patients with chronic pain.
Objectives:
Chronic nonspecific low-back pain (CLBP) is a prevalent, costly condition that is remarkably resistant to intervention. Substantial evidence suggests that a mismatch exists between the biomedical beliefs held by clinicians and patients and the biopsychosocial nature of CLBP experience. The aim of this metasynthesis of qualitative studies was to provide clinicians with a richer understanding of their patients' CLBP experience to highlight the importance of moving away from biomedical paradigms in the clinical management of CLBP.
Methods:
Qualitative studies exploring the CLBP experience from the perspective of the individual were included. Twenty-five articles representing 18 studies involving 713 participants were subjected to the 3-stage analytic process of extraction/coding, grouping, and abstraction.
Results:
Three main themes emerged: the social construction of CLBP; the psychosocial impact of the nature of CLBP; and coping with CLBP.
Discussion:
The authors conceptualize the experience of CLBP as biographical suspension in which 3 aspects of suspension are described: suspended "wellness," suspended "self," and suspended "future". The implications of improved clinician understanding of the CLBP experience and directions for future research are discussed.
Mass media campaigns designed to alter societal views and individual behaviors about back pain have been undertaken and evaluated in multiple countries. In contrast to the original Australian campaign, subsequent campaigns have been less successful, with improvements observed in beliefs without the corresponding changes in related behaviors. This article summarizes the results of a literature review, expert panel, and workshop held at the Melbourne International Forum XI: Primary Care Research on Low Back Pain in March 2011 on the role and interplay of various social behavior change strategies, including public education, law and legislation, healthy public policy, and social marketing in achieving a sustained reduction in the societal burden of back pain. Given the complexities inherent to health-related behaviors change, the Rothschild framework is applied in which behavior change strategies are viewed on a continuum from public education at one end through law and health policy at the other. Educational endeavors should likely be augmented with social marketing endeavors and supportive laws and health policy to foster sustained change in outcomes such as work disability and health utilization. Practical suggestions are provided for future interventions aimed at changing back pain-related behaviors. Evaluation of previous back pain mass media campaigns reveals that education alone is unlikely to foster positive and persisting behavioral change without concomitant strategies.
Purpose:
To evaluate the return to work and health outcomes of a physiotherapy network provider programme.
Method:
A prospective case-control study was conducted with 21 clients of network occupational physiotherapy (OP) providers and 21 matched clients of non-network providers.
Outcome measures:
Health outcomes and return to work were recorded 3 and 6 months following the commencement of physiotherapy. Health outcomes included the Short Form (SF)-12, return to usual activities and the global perceived effect of treatment. Within-group changes and between-group differences were analysed.
Results:
Within-group changes showed the OP group improved significantly in physical functioning (p = 0.006), and the control group deteriorated in mental health status (p = 0.016) as measured by the SF-12. Mean change over time between groups from the 3-month to 6-month follow-ups showed a significant difference favouring the OP group for return to usual activities (p = 0.027) and the physical component of the SF-12 (p = 0.009). All job-attached participants returned to work following their accident, so there was no difference between the groups.
Conclusion:
The OP clients demonstrated a greater change in physical functioning health outcomes over time. This study provides preliminary support for the implementation of the OP scheme.
One might expect that injury compensation would leave injured parties better off than they would otherwise have been, yet many believe that compensation does more harm than good. This study systematically reviews the evidence on this "compensation hypothesis" in relation to compensable whiplash injuries. PubMed, CINAHL, EMBASE, PEDro, PsycInfo, CCTR, Lexis, and EconLit were searched from the date of their inception to April 2010 to locate longitudinal studies, published in English, comparing the health outcomes of adults exposed/not exposed to compensation-related factors. Studies concerning serious neck injuries, using claimants only, or using proxy measures of health outcomes were excluded. Eleven studies were included. These examined the effect of lawyer involvement, litigation, claim submission, or previous claims on pain and other health outcomes. Among the 16 results reported were 9 statistically significant negative associations between compensation-related factors and health outcomes. Irrespective of the compensation-related factor involved and the health outcome measured, the quality of these studies was similar to studies that did not find a significant negative association: most took some measures to address selection bias, confounding, and measurement bias, and none resolved the potential for reverse causality bias that arises in the relationship between compensation-related factors and health. Unless ambiguous causal pathways are addressed, one cannot draw conclusions from statistical associations, regardless of their statistical significance and the extent of measures to address other sources of bias. Consequently, there is no clear evidence to support the idea that compensation and its related processes lead to worse health.
To assess the impact of an aging workforce on (1) the incidence of work-related injury or disease and (2) the return-to-work (RTW) process.
Workers' compensation claims (from 2001 to 2004) from Victoria, Australia (n = 59,525) were analyzed. Time off work was defined in terms of time until first RTW, number of workdays compensated, and work disability recurrences.
The incidence of lost-time claims was 7.54 per 1000 worker-years; incidence increased with age to reach a maximum at ages 50 to 54 years. Days until first return also increased with age, as did the sum of compensated days. Recurrences were common (37%) and also increased with age.
The aging workforce will lead to substantial increase in work disability. Besides general disease and injury preventative practices, policies could aim to provide tailored RTW programs for aging workers.
Problems of poor quality and high costs are worse in the workers' compensation system than in the general medical care system, yet relatively little work has been done to improve performance in workers' compensation healthcare.
To evaluate the effect of a quality improvement intervention that provided financial incentives to providers to encourage adoption of best practices, coupled with organizational support and care management activities, aimed at reducing work disability for patients treated within the Washington State workers' compensation system.
Prospective nonrandomized intervention study with nonequivalent comparison group using difference-in-difference models to estimate the effect of the intervention.
Two cross-sections of data representing 33,910 workers' compensation claims filed in the baseline (preintervention) period from July 2001 to June 2003 and 71,696 claims filed in the postintervention period from July 2004 to June 2007 were analyzed. 46,928 (44%) of these 105,606 claims represent patients treated by over 275 providers recruited through Centers of Occupational Health and Education (COHEs) at 2 pilot regional sites.
Outcomes, measured at 1-year follow-up, included work disability status, number of disability days, disability cost, and medical cost.
COHE patients were less likely to be off work and on disability at 1 year postclaim receipt (OR=0.79, P=0.003). The average COHE patients experienced a reduction in disability days of 19.7% (P=0.005) and a reduction in total disability and medical costs of $510 per claim (P<0.01). For patients with back sprain, the reduction in disability days was 29.5% (P=0.003). Patients treated by providers who more often adopted occupational health best practices had, on average, 57% fewer disability days (P=0.001) compared with patients treated by providers who infrequently adopted best practices.
Financial incentives, coupled with care management support, can improve outcomes, prevent disability, and reduce costs for patients receiving occupational healthcare. Owing to important disability prevention capacity, workers' compensation healthcare may be especially fertile ground for continued quality improvement innovation.