Management of musculoskeletal pain in a compensable environment: Implementation of helpful and unhelpful Models of Care in supporting recovery and return to work

"I'm pulling through because of you": injured workers' perspective of workplace factors supporting return to work under the Saskatchewan Workers' Compensation Board scheme

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.

Implementation of the "clinical framework for the delivery of health services" by treating healthcare professionals: perspectives of regulators and insurers

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.

Wellbeing After Finalization of a Workers' Compensation Claim: A Systematic Scoping Review

OBJECTIVE

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.

METHODS

A systematic scoping review was conducted.

RESULTS

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.

CONCLUSION

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.

Exploration of the Usual Care Pathway for Rotator Cuff Related Shoulder Pain in the Western Australian Workers' Compensation System

PURPOSE

Investigate 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.

RESULTS

80% 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.

Biopsychosocial sequelae of chronically painful injuries sustained in motor vehicle accidents contributing to non-recovery: A retrospective cohort study

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.

Electrical injury: Chronic pain, somatosensory dysfunction, post traumatic stress and movement disorders

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.

What Injured Workers With Complex Claims Look For in Online Communities: Netnographic Analysis

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.

The Predictive Ability of the Full and Short Versions of the Orebro Questionnaire for Absenteeism and Presenteeism Over the Subsequent 12 Months, in a Cohort of Young Community-Based Adult Workers

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 four 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.

Lumbar spinal fusion surgery outcomes in a cohort of injured workers in the Victorian workers' compensation system

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.

The Impact of Musculoskeletal Injuries Sustained in Road Traffic Crashes on Work-Related Outcomes: A Systematic Review

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.

Staying at work with musculoskeletal pain: What supporting resources do people need?

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.

Clinical governance in New Zealand: perceptions from registered health professionals in health care delivery compared with social insurance

ObjectiveEffective 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.MethodsThe 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).ConclusionsPerceptions 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.

Utilisation of exercise as part of guideline-based care for hip pain in the Australian workers' compensation environment

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.

Hand therapists' perspectives and practices related to musculoskeletal pain: A biopsychosocial lens

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.

The Contribution of Onsite Physiotherapy to an Integrated Model for Managing Work Injuries: A Follow Up Study

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.

Masterclass: A pragmatic approach to pain sensitivity in people with musculoskeletal disorders and implications for clinical management for musculoskeletal clinicians

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.

Understanding and managing pelvic girdle pain from a person-centred biopsychosocial perspective

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 behaviour 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.

Supporting return to work through appropriate certification: a systematic approach for Australian primary 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.

Implementation of Questionnaire-Based Risk Profiling for Clients in a Workers' Compensation Environment: An Example in Australian Physiotherapy Practice

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.

UNDERSTANDING HOW PRIMARY CARE CLINICIANS MAKE SENSE OF CHRONIC PAIN

Chronic pain leads to reduced quality of life for patients, and strains health systems worldwide. In the U.S. and some other countries, the complexities of caring for chronic pain are exacerbated by individual and public health risks associated with commonly used opioid analgesics. To help understand and improve pain care, this article uses the data-frame theory of sensemaking to explore how primary care clinicians in the U.S. manage their patients with chronic noncancer pain. We conducted Critical Decision Method interviews with 10 primary care clinicians about 30 individual patients with chronic pain. In these interviews, we identified several patient, social/environmental, and clinician factors that influence the frames clinicians use to assess their patients and determine a pain management plan. Findings suggest significant ambiguity and uncertainty in clinical pain management decision making. Therefore, interventions to improve pain care might focus on supporting sensemaking in the context of clinical evidence rather than attempting to provide clinicians with decontextualized and/or algorithm-based decision rules. Interventions might focus on delivering convenient and easily interpreted patient and social/environmental information in the context of clinical practice guidelines.

Patients' perceived needs for allied health, and complementary and alternative medicines for low back pain: A systematic scoping review

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.

Are group size and composition associated with treatment outcomes in group cognitive behavioural therapy for chronic pain?

This study explored whether group size and group member characteristics (age, sex, and compensation status) were associated with patient outcomes (changes in pain and disability). Retrospective analyses of outcome data obtained from 2 independently run group cognitive behavioural therapy (CBT) programs for chronic pain (Program A: N = 317 and Program B: N = 693) were conducted. Intracluster correlations 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, sex, 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.

Insurance workers' and physiotherapists' perceptions of their roles in the management of workers with injuries in the Western Australian workers' compensation system

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.