Significance of work-related factors missing
Rose Boucaut, FACP, Kaat Goorts and Ross Iles believe discussion of workplace factors was needed in a case study published in last year’s August InMotion.
The cervical radiculopathy case study (Wray 2019) clearly demonstrated highly skilled clinical reasoning in physiotherapy practice; however, important workplace (and leisure) factors were not discussed in depth. We understand word limits can restrict aspects of a detailed case description. In the spirit of collegiality, we would like to share our perspective on the significance of work in this scenario.
When examining and treating patients who have a job, their work and workplace are key considerations for rehabilitation, particularly when job and presenting complaints are linked. Specific guidance equips clinical physiotherapists to facilitate conversations about work (Shaw et al 2011). Conversations enable physiotherapists to start understanding what the person is required to do at work and establish the context.
The case study office worker attributed insidious onset symptoms to poor work postures from computer work (Stokes et al 1982, APA 2012). Identifying potential alternatives for return to work (RTW) without performing the role that is the perceived aggravator could speed recovery and avoid detachment from the workplace. A worksite visit may be valuable.
Treatment took 12 weeks and the computer work Patient Specific Functional Scale item improved from 5–8/10 over that time (Wray 2019), as did other activities. We do not know if the person was off work for that time, or if they were in the workplace, perhaps dealing with the complexities of alternative duties, working with the RTW coordinator/supervisor, performing the aggravating activity, dealing with supportive or unsupportive colleagues, all while maintaining the treatment regimen recommended by the therapist. These factors can influence the success or otherwise of recovery from any injury, and require consideration.
The APA supports the Clinical Framework for the Delivery of Health Services (WorkSafe Victoria 2012), which has five elements. In brief, we list three in relation to the case study (Wray 2019).
Screening tools such as the short form Orebro Musculoskeletal Pain Screening Questionnaire (Linton et al 2011), used in the case study, help identify psychosocial factors that should be addressed as part of treatment. Patient distress about imaging reports and financial implications are yellow and black flags respectively.
In the workers compensation context, an injured worker will have a case manager who, provided with appropriate information, can activate appropriate professional help outside of the physiotherapy scope of practice. Psychosocial determinants and environmental factors are as important for RTW as the injury itself (Cancelliere et al 2016, Main & George 2011).
Empower person to manage their injury
Pain education was provided, but not education about the health benefits of work (Australian Faculty of Occupational and Environmental Medicine 2015). Both are important and evidence based, and the latter would include safe early participation in work despite injury. Empowering patients to remain part of the workplace while addressing factors described in the case study, such as fear avoidance and posture, is essential.
Focus goals on optimising function, participation and RTW Graded work activities can enable RTW, and form a measure of treatment efficacy. A SMART goal (WorkSafe Victoria 2012) example is RTW in five days, for three half days on modified duties. Restrict computer time (using mouse and keyboard) to 10 minutes per half hour and alternative duties for 20 minutes, for example, reception phone duties.
Setting such goals requires an understanding of the workplace and conversations with the supervisor/RTW coordinator to determine whether this is even possible within the person’s role. If it is not, a different approach must be taken, which may impact the whole treatment timeline.
In conclusion, we appreciate the clinical skills evident in the case study. We courteously suggest a comprehensive description of work-related factors is needed alongside clinical (and other relevant) factors—both are essential for successful patient outcomes.
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APA Musculoskeletal Physiotherapist Jonathan Wray responds.
I would like to thank Rose Boucaut and colleagues for their interest in my case study on cervical radiculopathy. As they suggested, constraints regarding word count did not allow full detail of the whole case study to be presented, other than along a specific narrative. I was not able to include information about the patient’s back-to-work process, as the emphasis was on conservative management versus surgery in a patient with cervical radiculopathy presenting with hard neural signs.
It is commonplace in case study reports such as these that the clinical focus often carries the most detail while omitting other information (Reid et al 2018, Rebbeck & Liebert 2014). However, I think care needs to be taken when judging whether this information, although not detailed, was or was not included in the management process.
Boucaut et al state that although pain neuroscience education was included in the management process, education on the health benefits of work was not. This is far from correct. As part of pain science education, advice and information was given about all aspects of the patient’s life and how resuming normal roles and routines was an important element of the recovery process.
Boucaut and colleagues recommend a detailed, specific back-to-work program with graded exposure and activity modification included, alongside the clinical commentary. While this is an important part of a patient rehabilitative process, we have to be cognisant that workplace factors can be drivers of musculoskeletal pain, especially when it is associated with psychological stress (Linaker & Walker-Bone 2016, Nahit et al 2003), which was the case with this patient. Therefore, a one-size-fits-all approach in regard to RTW may not be appropriate.
There is also discrepancy in the literature to support this approach, with doubt about the cost effectiveness of workplace interventions (Palmer & Harris 2012), and systematic reviews often concluding no significant differences in outcome with RTW programs versus usual care (Vogel et al 2017).
Many authors have shown that recovery is a social process that takes place among the everyday occupations in a person’s life (Blank et al 2015). An exclusive focus on RTW as a successful outcome, regardless of the employment role, could overshadow participating in other activities that offer similar attributes of socialisation, belonging, sense of self and daily structure (Blank et al 2015, Borell et al 2016).
The World Health Organization’s International Classification of Function Disability and Health (WHO 2002) has long been criticised for lacking subjective information about the patient’s perspective in occupational participation (Hemmingsson & Jonsson 2005); therefore, it could be argued that purely focusing on RTW if it is not contextually meaningful to the patient, is not patient-centred and undervalues what is meaningful participation (Borell et al 2016).
In this response I have tried to highlight that the process of RTW is not as simplistic as described by Boucaut et al but a complex process often requiring multidisciplinary care. The detail involved to do justice to this aspect of patient management was unfortunately beyond the confines of the narrative around this case study and the acceptable word count allowed in publication.
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