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Physiotherapy for Recovery and Return to Work

Physiotherapy for Recovery and Return to Work

Physiotherapy for Recovery and Return to Work

Work

Work is a positive health behaviour. Work not only provides income to sustain living and service a lifestyle, but a range of other health benefits. Conversely, long term absence from work is associated with physical, psychosocial and financial health risks to injured worker and his/her family. Wherever practical and safe, remaining at work while recovering from injury, or returning to work as soon as possible, maximises the injured worker’s recovery potential. Return-to-work is as essential for recovery, as recovery is for return-to-work.

Work injury, and work absence due to injury, are a huge burden on the injured worker and his/her family, employer and community in general. 

All stakeholders including worker, employer, insurer and practitioners etc should work collaboratively with the common goals of hastening recovery and return-to-work in the knowledge that chronicity is a cancer that erodes recovery potential and causes pain and cost blow-out for all stakeholders.
Women professional working with a smile

Pain

Pain is the language in which the injured worker’s body conveys messages of damage, discomfort, disempowerment and displeasure. All pain is a biopsychosocial construct. All pain is an output of the brain in response to the threat of actual or perceived harm and the intuitive need to protect the body. All pain is real.

Pain can be triggered by mechanical, thermal or chemical tissue damage as result of injury. This type of pain response is both adaptive and essential to self-preservation; this is called nociceptive pain.

The brain however can continue to produce pain long after the injured tissues have healed, or where there’s been an innocuous injury or stimulus, or in the absence of clinical and radiological findings. This pain is still real pain but it cannot be explained in terms of tissue damage or actual harm and so is called central-sensitisation pain. This pain may be a product of neurophysiological dysfunction at various pain-processing locations in the body tissues and nervous system. Other experiential, cognitive, sociocultural, emotional, behavioural, motivational and context-specific variables contribute to the modulation of centrally-sensitised pain. 

Nociceptive and central-sensitisation pain mechanisms are not mutually exclusive and can co-exist. It is incumbent on the treating practitioner to identify the primary pain mechanism/driver of pain so the most appropriate therapeutic strategies can be deployed to achieve positive outcomes.
Pain is the language in which the injured worker’s body conveys messages of damage, discomfort, disempowerment and displeasure. All pain is a biopsychosocial construct, ie. a function of the somatic (body tissues), psychological and social context. All pain is an output of the brain in response to the threat of actual or perceived harm, and the intuitive need to protect the body. All pain is real.

Pain can be triggered by mechanical, thermal or chemical tissue damage as result of injury. This type of pain response is both adaptive and essential to self-preservation; this is called nociceptive pain.

The brain however can continue to produce pain long after the injured tissues have healed, or where there’s been an innocuous injury or insult, or in the absence of clinical and radiological findings. This pain is still real pain but it cannot be explained in terms of tissue damage or actual harm and so is called central-sensitisation pain. This pain may be a product of neurophysiological dysfunction at various pain-processing locations in the body tissues and nervous system. Other experiential, cognitive, sociocultural, emotional, behavioural, motivational and context-specific variables contribute to the up or down modulation of centrally-sensitised pain. 

Nociceptive and central-sensitisation pain mechanisms are not mutually exclusive and can co-exist. It is incumbent on the treating practitioner to identify the primary pain mechanism/driver of pain, so the most appropriate therapeutic strategies can be deployed to achieve positive outcomes for the injured worker.
Individual suffering from lower back pain


Moseley GL. Reconceptualising pain according to modern pain science. Physical Therapy Reviews 2007; 12: 169–178.
Smart K, Blake C, Staines A, Thacker M, Doody C. Mechanisms-based classification of musculoskeletal pain: Part 3 of 3: Symptoms and signs of nociceptive pain in patients with low back (+ leg) pain. Manual Therapy 17 (2012) 352-357.
Smart K, Blake C, Staines A, Thacker M, Doody C. Mechanisms-based classification of musculoskeletal pain: Part 1 of 3: Symptoms and signs of central sensitisation in patients with low back (+ leg) pain. Manual Therapy 17 (2012) 336-344.

Practitioners

Treating practitioners have a huge role to play in the injured worker’s recovery. This is not only in relation to the investigative and treatment services they administer, but in the  education and advice they impart which has potential to significantly fashion their patient’s knowledge and beliefs about the nature of their injury, its causes, their recovery potential, the meaning of pain, its treatment, the safety of physical activity, work participation etc, and ultimately, their coping responses and their propensity to recover.

There is an expectation that practitioners contributing to the rehabilitation of injured workers are familiar with and support industry-respected, best-practice policies and guidelines such as the Clinical Framework Guidelines and the AFOEM/RACP policy on the health benefits of work and preventing work disability etc. 
Professional explaining the report to the customer
These guidelines do not seek to micromanage practitioners but they do provide an evidence-based framework on which practitioners can design and administer effective and appropriate treatment that is tailored to their patient’s needs in promoting timely recovery and return-to-work.

The principles against which a practitioner’s therapeutic contribution is determined to be “reasonably incurred” (per Return to Work Act 2014), appropriate and necessary are:
✓
Maintain an awareness of the health risks of chronicity of claim; pursue timely recovery and return-to-work outcomes. Endeavour to hasten the injured worker’s graduation beyond the workers’ compensation scheme to a normal lifestyle, in a physiologically sensible timeframe.
✓
Promote the health benefits of sensible ongoing physical activity and work participation, and limit recommendation for rest and unfit certification to that which is medically-essential. 
✓
Adopt a biopsychosocial approach to examination and treatment; maintain an awareness that an injured worker’s beliefs and behaviours can significantly influence their experience and expression of pain, and their propensity to recover and return-to-work.
✓
Provide accurate, wholesome and non-threatening medical information about their condition that allays any unnecessary fear and empowers the injured worker to understand their problem and contribute constructively to recovery.
✓
Avoid medicalisation of common health problems. Provide balanced causation opinions so both work and non-work-related variables (eg. age, genetics, prior injury, and preventable lifestyle risk factors for injury such as BMI, smoking and inactivity) are appropriately and proportionately considered.This is to ensure that the injured worker’s attention is not disproportionately focused on work variables, which can potentially leads to work fear-avoidance and poorer outcomes. The injured worker's attention should be appropriately focused on any variables within their realm and responsibility of control, that if addressed, have potential to positively influence their recovery.
✓
Judiciously utilise investigative and treatment services, ensuring those services are clinically-indicated, evidence-based, proportionate, necessary and appropriate to achieve best outcomes. Be aware of and actively avoid over-medicalisation, treatment dependence and iatrogenic illness etc. 
✓
Promote active rather than passive management, and pain-related self-efficacy, self-determination, resilience and independence.
✓
Measure and demonstrate of the benefit of treatment in advancing recovery. Recognise the correct time to wind-down treatment when no ongoing benefit can be demonstrated.
✓
While ensuring injured workers receive highest quality care, be aware that interests of workers and employers should be reasonably balanced and that costs are contained so as to minimise overall social and economic costs to community.
✓
Work collaboratively with other stakeholders in a shared vision to promote timely recovery and return-to-work.
✓
Maintain an awareness of the health risks of chronicity of claim; pursue timely recovery and return-to-work outcomes. Endeavour to hasten the injured worker’s graduation beyond the workers’ compensation scheme to a normal lifestyle, in a physiologically sensible timeframe.
✓
Promote the health benefits of sensible ongoing physical activity and work participation, and limit recommendation for rest and unfit certification to that which is medically-essential. 
✓
Adopt a biopsychosocial approach to examination and treatment; maintain an awareness that an injured worker’s beliefs and behaviours can significantly influence their experience and expression of pain, and their propensity to recover and return-to-work.
✓
Avoid medicalisation of common health problems. Provide balanced causation opinions so both work and non-work-related variables (eg. age, genetics, prior injury, and preventable lifestyle risk factors for injury such as BMI, smoking and inactivity) are appropriately and proportionately considered.This is to ensure that the injured worker’s attention is not disproportionately focused on work variables, which can potentially leads to work fear-avoidance and poorer outcomes. The injured worker's attention should be appropriately focused on any variables within their realm and responsibility of control, that if addressed, have potential to positively influence their recovery.
✓
Judiciously utilise investigative and treatment services, ensuring those services are clinically-indicated, evidence-based, proportionate, necessary and appropriate to achieve best outcomes. Be aware of and actively avoid over-medicalisation, treatment dependence and iatrogenic illness etc. 
✓
Promote active rather than passive management, and pain-related self-efficacy, self-determination, resilience and independence.
✓
Measure and demonstrate of the benefit of treatment in advancing recovery. Recognise the correct time to wind-down treatment when no ongoing benefit can be demonstrated.
✓
While ensuring injured workers receive highest quality care, be aware that interests of workers and employers should be reasonably balanced and that costs are contained so as to minimise overall social and economic costs to community.
✓
Work collaboratively with other stakeholders in a shared vision to promote timely recovery and return-to-work.

Darlow B, Fullen BM, Dean S, Hurley DA, Baxter GD, Dowell A. The association between health care professional attitudes and beliefs and the attitudes and beliefs, clinical management, and outcomes of patients with low back pain: a systematic review. Eur J Pain. 2012 Jan;16(1):3-17.
Turner J, Franklin G, Fulton-Kehoe D, Sheppard L, Wickizer T, Wu R, Gluck J, Egan K. Worker Recovery Expectations and Fear-Avoidance Predict Work Disability in a Population-Based Workers’ Compensation Back Pain Sample. Spine: 15 March 2006, volume 31, issue 6, pp. 682-689

David Annells Consulting  
acknowledges the following websites for their contribution to information and/or research about pain and evidence-based management.
Professional explaining the report to the customer
Professional explaining the report to the customer
David Annells Consulting | dacon
Physiotherapy for Recovery and Return to Work
08 8357 9000