Frequently in health care there is a disconnect between demonstrated evidence-based best practices and the systems that deliver the actual care. That is very true in the world of Workers’ Compensation, where traditional constructs prevail over new thoughts and ideas more often than not. A recent 2016 article by Beales et al. in Best Practice and Research Clinical Rheumatology outlines how more helpful models of care can be introduced to workers within a compensable environment. Our next few blog posts will summarize their findings and ideas on practice models while scrutinizing our current thought processes on dealing with injured workers. We will also discuss ways we can practically apply their findings in the current Workers’ Compensation system.
The authors of this article focus on identifying the models of care best demonstrated to manage musculoskeletal pain in a compensable environment to address worker disability. They propose that the best models of care should align to the multidimensional biopsychosocial nature of pain while understanding the contemporary view of pain biology. They also stress that the idea that work is good for your well-being and is overall therapeutic to the injured worker.
As Physical Therapists we frequently see patients that present to us with a diagnosis based on radiological findings, yet the patient’s symptomatic and objective findings do not match the identified pathology.
These thoughts have been well founded in the research, yet the uptake in to clinical practice and commitment to further research has been limited. Our current most utilized practice models in the compensation environment focus on the biomedical and pathoanatomical approaches. This approach is prevalent in the thoughts of injured workers, the stakeholders making decisions in the compensation system (employer, insurer, etc.), and the legal basis of the compensation system. In short, all stakeholders must have a better understanding of pain biology and realize that pain may not always have an exact biomedical, pathoanatomical explanation. There is too much focus on attempting to find a concrete structural cause for the pain.
For example: how many diagnostic imaging tests have been done that have either not found the source of the pain or identified something that was not the source of the patient’s actual pain? In many cases the diagnostic imaging results in unintended adverse effects to the injured worker’s case. As Physical Therapists we frequently see patients that present to us with a diagnosis based on radiological findings, yet the patient’s symptomatic and objective findings do not match the identified pathology. In current models a biomedical explanation is expected for each incidence of musculoskeletal pain in order to drive the best choice of case management. Having a better understanding that pain is a complex and multifactorial biopsychosocial experience can be a helpful perspective for all stakeholders in a workers’ compensation case, including the patient.
The second overarching concept addressed by the authors is the understanding that return to work is not only an outcome but a part of the therapeutic process. There is a significant amount of evidence that supports that the longer a worker is absent from work, the overall return to work outcome becomes poorer. This can be addressed at multiple levels, particularly at the employer and patient level. Every opportunity to offer alternative duties at work should be afforded.
Continuing to work is not only good for the patient’s physical well-being, but also for their overall workplace engagement. Being out of work can mentally isolate the employee, which can extend their absence and make their reintegration to the work environment more difficult. Studies have shown that long periods of absence from work yielded numerous side effects including insomnia, depression, chronic pain, smoking, increased alcohol use, illicit drug use and risky sexual behavior. Gordon Waddell, the famed Scottish Orthopedic Surgeon, wrote extensively on this topic in Is Work Good for Your Health and Well Being in 2006. Dr. Waddell concluded “the beneficial effects of work outweigh the risks of work, and are greater than the harmful effects of long-term unemployment or prolonged sickness absence. Work is generally good for health and well-being. “
In general the authors of this article confirm that the Worker’s Compensation system has a long way to go philosophically if we want to provide evidence based best practices to our patients. In future posts we will address how Workers Compensation systems, organizations and individuals (medical practitioners and patients) need to change their perspectives and behaviors around management of musculoskeletal pain in order to become more effective.
