Our most recent blog examined the impact of stress and anxiety on worker’s compensation outcomes. Since it is well documented that outcomes “among workers’ compensation patients have traditionally been found to be worse than those of non-workers’ compensation patients,1” and that stress contributes to these poor outcomes 2, our recent discussion focused around employer strategies to reduce employee stress, while demonstrating empathy. As outlined in this prior blog, this approach has yielded a myriad of benefits, including a 40% decrease in average claim cost2. As with most complex problems, a multimodal approach is more likely to produce an optimal outcome. So while an employer’s empathetic approach is integral, partnering with a good physical therapy provider like Results Physiotherapy can further facilitate positive outcomes. While a physical therapist’s role was briefly discussed in the prior blog, our focus of this blog is to outline strategies implemented by physical therapist as a means to reducing stress and anxiety for injured workers.
Effective communication and interaction between patient and healthcare provider is crucial to building trust while subsequently reducing stress. One evidence-based approach to effective communication for healthcare providers to implement is a biopsychosocial approach to the intervention. Before diving further into what this means, let’s first define the two terms above: Biopsychosocial and Biomedical.
A biomedical approach “hold[s] that a structural or pathoanatomical anomaly (or “pain generator”) causes [pain] and that if “fixed,” pain will be eliminated or reduced3.” To summarize, let’s explore a relatively common occurrence in 21st century medicine:
A low back injury occurs at work. A healthcare provider orders an MRI of the low back. The MRI shows 2 bulging discs. The healthcare provider educates the patient on these disc bulges, and states that these are the source of the patient’s pain. The patient, after seeing the images and hearing the description from the healthcare provider, “buys in” that the discs are the source of pain. As opposed to trying any conservative treatment options, surgery is scheduled (despite the absence of any neurologic signs suggesting severe neural compression). The patient undergoes surgery (a risky and expensive intervention), but symptoms continue to persist. The healthcare team is unable to explain the failure (since the “symptoms causing” discs were removed) and the patient feels stressed/anxious that the proposed solution has failed. The patient assumes that something must be “wrong” with them. Additional treatment interventions yield minimal gains, often because the symptoms have become chronic, and there are now strong psychosocial drivers. Referral to pain management occurs, and return to work is improbable.
If you’ve been involved in the care and management of a worker’s compensation injury, you’ve seen this scenario. While there are a multitude of factors contributing to the story (and poor outcome) above, it’s worth noting that “in practice surgical “fixing” of [pain] is notoriously unhelpful (with exceptions, such as hip or knee replacement). Indeed, failing to appreciate and deal with the context in which [pain] arises and is propagated is likely to be met with multiple treatment failures…4” Considering the above information, we as healthcare providers need to shift our approach to a biopsychosocial model. This will allow for enhanced patient interaction and will drive better outcomes.
A biopsychosocial approach “recognizes disease/pain as a consequence of the interaction of various social, psychological, and biological factors. It takes into account the entire scope of the patient’s well-being and recognizes the effect of such factors as strain and stress, emotion, and environmental surroundings on the occurrence of illness and disease3.” Do you notice a common thread to last week’s blog post?! So how can physical therapists intervene to implement this biopsychosocial approach? Let’s examine a few strategies.
1. Make examination decisions on significant and reproducible objective findings.
As discussed in prior blog posts, medical imaging is not a reliable tool for drawing clear correlation between findings and symptoms. A thorough musculoskeletal exam, with the therapist searching for the patient’s “familiar” symptoms, must guide treatment interventions. Even if an image shows a disc herniation, but the physical exam shows no objective sign that the disc herniation is contributing to symptoms, then the physical therapist should educate and treat based on objective and reproducible findings. By doing so, the therapists is able to positively impact symptoms, demonstrate value, and spark hope (while reducing stress) for the injured worker that symptom relief and return to function is on the horizon.
2. Avoid unnecessary and unhelpful fear inducing messages that feed into patient’s perception of pain and tissue damage.
It is not uncommon to see patients in clinic who state that “I cannot bend forward anymore.” When asked for clarification, the patient states that a healthcare provider years ago informed them that “bending forward may cause their discs to herniate further, which would require surgery.” The patient, out of fear of symptoms worsening and tissue being damaged, has avoided bending for years! This lack of movement typically creates more problems than it solves (as the body is designed to move for optimal health). As physical therapists, it is our job to educate on how the body heals, how strong the body (discs, ligaments, muscles, and joints) really is, and that by moving, we actually promote healing and optimal health.
3. Maintain consistent messaging.
Nothing can be more stressful for an injured worker than hearing from multiple healthcare providers a variety of diagnoses. It sows seeds of doubt, adds stress by creating a narrative that their injury is worsening/evolving, and at times makes injured workers feel as though healthcare providers (or the worker’s compensation system) are hiding findings or mismanaging their care. As physical therapists, we have time/expertise to educate on the biomedical diagnoses, while adding biopsychosocial content. This, combined with our ability to directly impact symptoms within session helps to build buy-in, reduce stress, and drive better outcomes.
As you’ve likely noted in the paragraphs above, one word continues to be a focus: educate. Therapists, by means of the time we get to spend with patients, have an opportunity to teach, share, and listen, placing us in a position to truly understand our patient’s stressors, and look to address them in language and nuance they can understand. This is further supported by research, which emphasizes that if physical therapists hear or see indicators that the patient has a strong belief in the biomedical approach, we must have “as [our] core objective, [an emphasis on] belief shifting.
The conceptualization of pain is proposed to shift from a marker of tissue damage or disease [biomedical model] to instead the perceived need to protect bodily tissue4.” In short, therapists must reshape an injured worker’s perspective of what pain is, and in doing so can improve symptoms, reduce stress, facilitate progression in therapy, and promote faster return to work.
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