Pain management and injury adjustment interventions

In recent times there has been growing acceptance of the role of psychosocial issues in slowing or preventing injured workers returning to their jobs. Research has tended to back up intuitive observations that there are many workers who have “yellow flags” – psychosocial barriers that will impact significantly on their capacity to return to work and move on in their life.

Psychological and social problems may occur with or as a consequence of physical injuries. Some injured workers may be extremely worried, if not obsessed about their injury and physical discomfort to an extent that it can impede treatment progress and return to work capacity.

There are also a large number of injured workers whose symptoms may have persisted for longer than four or five months who weren’t initially preoccupied with their injury or symptoms, but became so because of changes in life that occurred as a consequence of their injury and having a workers compensation claim. Some of the changes in circumstance frequently experienced by the injured worker with a chronic injury include:

• Loss of income
• Difficulty in maintaining employment
• Loss of employment
• Difficulty coming to terms with the effect the injury has on their life – can’t do what they used to around the house, carry out hobbies and interests and impaired sex life
• Changed family dynamics
• Outdated belief systems about themselves and their situation in context of changes in their life as a result of injury
• Uncertainty about the future

Sometimes the psychological difficulties these people are experiencing can be readily classified into one of the DSM-IV classifications. Often however such individuals cannot be classified with one of the DSM-IV labels because of the narrowness and rigidity required to meet the criteria to earn a label. Sometimes they may be experiencing significant subjective discomfort, sufficient to slow down treatment progress and their readiness to return to work, however the symptoms may not be severe enough for them to meet the criteria for a DSM-IV label.

During 2002 the NSW Workcover Authority commissioned a report from Royal North Shore Hospital’s Pain Management Clinic into the role of physical conditioning and pain management programs of injured workers who do not experience “red flag” conditions (i.e. injuries with pathology requiring surgical interventions). The reports findings and conclusions were as follows:

While there is wide variation in the contents in programs, skills of staff as well as the clients/patients two broad conclusions are possible:

A.  Timing – Different levels and types of intervention are required at different stages after injury, dependent upon progress and obstacles

B.  Coordination/Collaboration – Collaboration, planning and implementation of interventions between treatment and rehabilitation advisors is critical

C.   When assessing an injured worker consideration needs to be given to the injury and history, but also the worker’s psychological state (his/her beliefs and moods), behavior and environment. Special attention needs to be given to issues taking place in the workplace

D.  Interventions – There is strong evidence that continuation of ordinary activities about daily living as much as possible despite pain symptoms is effective in early stages with non red flag injuries

Symptom relief measures can be used to assist the process but they shouldn’t interfere with the focus on activity-based rehabilitation. At the sub acute stage an emphasis needs to be upon education, reassurance, progressive fitness and pain management (an emphasis put upon behavioural principles). It is suggested that the interventions should be conducted at the workplace or linked to the workplace. As a worker becomes more disabled and off work more intensive versions of the sub acute program should be employed. Psychosocial aspects are likely to become more entrenched as time passes and if pain is a significant barrier to rehabilitation. In such situations more specific pain management programs are required. Suggestions were made that programs were based on cognitive behavioural methods only and that content of these programs be controlled carefully

E. Staffing of providers – Emphasis was made on a multi-disciplinary approach as no one discipline has all the skills required

F.  General practitioner should be responsible for treatment and planning coordination with health providers. Physiotherapists should indicate the exercises and basic education elements of programs and others e.g. chiropractors, can play a role

G.  Additional training in the assessment of psychosocial factors and CBT is advisable for those working in the area. Some cases will require expert psychological intervention

The NSW Workcover Authority released a discussion paper on guidelines for prevention of long-term disability in workers that experience injuries with yellow flag conditions, based primarily on the recommendations of the RNSH report and largely unchanged despite comments and submissions from other stakeholders. The key points of the guidelines include:

• Return to work is the primary aim of activity programs to be undertaken by injured workers and the program of first choice

• When proposing alternate work related activity programs, rehabilitation providers must undertake initial need assessment including workplace assessment and develop RTW-SD plan. Any risk factors identified must be addressed

• Psychosocial factors must be screened for, assessed and managed early

• Treatment of psychosocial factors is integral to the management of the musculo-skeletal injury. It does not mean that the injured worker has a separate claim for psychological injury however

• The type, content and delivery of activity programs are planned on an individual needs basis based upon a number of significant psychosocial factors present, the level of disability of the worker, their level of distress and duration of the injury

• Activity programs need to demonstrate that they link to the worker’s job

• Activity programs provide with occupational rehabilitation providers to facilitate the transition to suitable duties

• Insurers need to assume a serious risk assessment with case manager, coordination and communication

Recommendations are made of the type of programs that are suitable at different stages and the type of support needed for the programs that are recommended. They are outlined below:

1. 0-12 weeks where there are no red flags and good prognosis for returning to work. Emphasis is placed upon usual due care, reassurance and encouragement to resume normal activities of daily living and return to work. Activity programs are to be developed in conjunction with the treatment rehabilitation provider and GP upgrading to pre-injury duties

2. 3-12 weeks – no red flags present but some mild yellow flags. At this stage emphasis is placed upon the worker developing or continuing in work related activity interventions including screening of psychosocial issues. The activity program (which may be carried out by a physiotherapist, chiropractor) also needs to incorporate cognitive behavioural approach. The program should have strong links to typical job demands of the worker’s job

3. More than 12 weeks with moderate yellow flags and injury related distress. Recommendations are made for a coordinated multi-disciplinary program for twelve to sixteen hours over six to eight weeks. Programs must be linked to the workplace and include a graded exercise program, education component and strategies for managing psychosocial factors and pain. A psychologist needs to be centrally involved in this program and cognitive behavioural principles need to be employed

4. More than 12 weeks or highly significant yellow flags and disability. Multi-disciplinary pain and activity program that is 12 to 15 days or 120 hours over three to five weeks. Only health professionals experienced with postgraduate studies of pain should be involved in the administration of such programs

The practical implications of recommendations were made in WorkCover’s discussion paper. The commissioned report and guidelines provide a useful overview of many of the current inadequacies in service delivery in pain management and functional restoration programs and proposes a road map forward. Closer analysis of the report however reveals some significant flaws in analysis, conclusions that are not supported by the relevant research and recommendations that could be difficult if not impossible to implement because of costs, and resource issues.

These are summarised in the following section:

• The studies cited to support the types of group programs recommended for more serious yellow flag conditions have concentrated on studies of group pain management programs where a cognitive behavioural approach has been applied. There were no studies evaluated where alternate forms of psychological approach were used. Only one study was cited where an individual program was used yet recommendations were made that only multi-disciplinary group programs utilizing a cognitive behavioural approach will work and should be funded

• In presenting the arguments for the types of qualifications practitioners should have and the approaches they should adopt there is no acknowledgement (or consideration given) to the repeated findings in health outcome research that has consistently found that the relationship between client and therapist is the critical determinant of outcome, irrespective of the type of therapy used

Practical Implications

There is inadequate consideration for the practical implications of recommending most pain management and functional restoration programs be group programs. Potential problem areas include:

1. Workers unwillingness to participate in a group program. Many workers with complex problems do not feel comfortable with discussing their difficulties in a group forum or being involved in a group program
2. Difficulty with access to programs. Programs usually have fixed start and finishing days and there can be delays and waiting lists. There can be problems with over crowding. Conversely, inappropriate participants maybe accepted when there are seats needing to be filled
3. High costs group pain management programs, particularly the MDPMAIP type programs recommended by Workcover are usually expensive – at least $4000 - $7000. In some cases similar outcomes could be achieved through cheaper programs still combining a multi-disciplinary approach but one that is less structured and formal

Consideration should be given to alternate programs when other forms of injury adjustment / pain management have not been attempted and when the worker is very hesitant about being involved in a group program.

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