OVERVIEW Improving outcomes: Integrated, active management of workers with soft tissue injury Purpose and objectives Integrated, active management aims to improve health, social and financial outcomes for workers with a work related soft tissue injury by promoting recovery, and preventing onset of long term disability and work loss. Soft tissue injury is a descriptive term that refers to injuries of the muscle, joint, ligament, cartilage, tendon or connective tissues (including intervertebral disc injuries). Soft tissue injuries do not include serious pathology (such as tumour and infection), fractures, nerve (neurological) damage, complex regional pain syndrome, or injuries that require or have undergone surgery. This overview document and five advice sheets have been developed to provide advice about important principles and activities which, when implemented, reduce the risk that a worker with a soft tissue injury will suffer long term disability and work loss. The advice is based on available scientific evidence and NSW workers compensation system requirements. The advice has been developed to assist workers with soft tissue injuries. However, the advice can be applied to assist any worker where it is deemed to be appropriate. In particular, the key principles are important when assisting any injured worker. Integrated, active management aims to prevent onset of long term disability and work loss, and therefore the advice is best applied during the first 12 weeks after a worker sustains a soft tissue injury, but may be applied at any time when appropriate to the worker. The specific objectives of this advice are to promote: successful early, safe and durable return to work a worker and work focused approach to injury management effective communication and common goals between key parties an evidence based, active approach cost effective, prompt and efficient interventions. 1
Key terms The following table identifies key terms and their meaning when used within the soft tissue injury management document. Key term acute intervention clinical management insurer key parties long term disability nominated treating doctor (NTD) psychosocial recovery review and transition process risk factors screening and assessment secondary intervention soft tissue injury Related terms: musculoskeletal disorder (MSD) occupational overuse syndrome (OOS) sprains and strains Description Injury management activities that occur during the early phase after injury, usually the first 4 weeks. Clinical management means evidence based assessment and treatment of the worker and their injury, usually by a medical and/or health practitioner ( treatment providers ). Insurer as referred to in this document means Scheme Agent or self insurer or specialised insurer in the NSW workers compensation scheme. All those involved in the facilitation of a worker s recovery, including the worker themselves. Key parties are listed on page 6 of this document. Limitations in a worker s ability to perform work, home or recreation activities which persist beyond expected recovery time. The worker s general practitioner is usually considered the nominated treating doctor and is responsible for coordinating all aspects of injury treatment and assisting in return to work management. The interaction of a worker s social environment (work, family, community and compensation systems) and their thoughts, beliefs, attitudes and emotions. The return to usual work, home and recreation activities. Injury management activities that occur after acute intervention when recovery is delayed and/or risk factors are identified. Comprises two key processes (1) screening and assessment; (2) transition of care. In this document, refers to psychosocial risk factors, such as those identified in FACTORWEB 1 or the FLAGS model 2, which are known to be associated with risk of long term disability and work loss. A staged process to identify the worker s barriers and needs to return to work, initially using simple methods and progressing to specific measures when necessary. Injury management activities that occur after the acute intervention has concluded, usually during the sub-acute period, between 4 and 12 weeks after injury. Soft tissue injury is a descriptive term that refers to injuries of the muscle, joint, ligament, cartilage, tendon or connective tissues (including intervertebral disc injuries). Soft tissue injuries do not include serious pathology (such as tumour and infection), fractures, nerve (neurological) damage, complex regional pain syndrome, or injuries that require or have undergone surgery. 1 FACTORWEB checklist can be found in this kit. 2 Comcare. Body Stressing Injuries. Key messages for rehabilitation providers. Comcare: Canberra 2006. 2
transition of care work loss workplace management The process of progressing physical treatment modalities from passive to active, in accordance with the best available evidence for managing soft tissue injuries. The work performed by the worker is not equivalent to pre-injury work in terms of hours worked or duties or both. Workplace management means coordinated assessment, planning and return to work activities, which are directly related to the worker s needs, duties and workplace. These activities aim to maintain the worker at, or return them to, work. Soft tissue injury: frequency, causal factors and outcomes Most workers recover following soft tissue injury and return to their usual work within four weeks of the injury. A proportion of workers does not and suffers long term disability and work loss. This initiative aims to improve health, social and financial outcomes for workers with a work related soft tissue injury by promoting recovery, and preventing onset of long term disability and work loss. Sprains and strains are the most common injury sustained by workers in New South Wales (NSW) workplaces. In 2005/06 more than 61 per cent of workplace injuries in NSW resulted in sprains and strains, at a cost of $348 million. In 2005/06 sprains and strains were the most common type of injury (53 per cent) resulting in permanent impairment of workers and these cost $109 million in permanent impairment payments. A significant proportion of sprains and strains are likely to fall under the term soft tissue injuries as defined in this document. Sprains and strains were also the most common type of injury arising in workers undertaking other work related activities while not on duty (such as commuting and when on recess) in 2005/06. During this same period, vehicle related incidents (55 per cent) and slips trips and falls (26 per cent) were the most common means of sustaining injury while not on duty. Manual handling was the most common cause of injury (31 per cent) sustained by workers in NSW workplaces in 2005/06. 3 Manual handling is when a person uses his or her musculoskeletal system to perform a physical activity, at work. The musculoskeletal system is made up of bone, muscle, joint, ligament, cartilage, tendon, and connective tissues. Soft tissues therefore comprise a large proportion of the musculoskeletal system and as a consequence are at risk of injury during manual handling. The back was the most common body location (26 per cent) of work place injury and permanent disability (13 per cent) in NSW workers during 2005/06. Ninety-five per cent of workers with back injuries resulting in permanent disability had sustained the injury via a sprain or strain. It is therefore reasonable to conclude that soft tissue injuries, generally, and back injuries, specifically, are prevalent in NSW workers and may result in permanent disability. Soft tissue injuries in NSW workers are likely to arise in the workplace or during other work related activities such as commuting. Manual handling is likely to be a significant factor in the onset of a worker s soft tissue injury. WorkCover NSW is currently undertaking a five year manual handling program to facilitate improved management of manual handling risk. Refer to www.smartmove.com.au for information. 3 WorkCover Statistical Bulletin 2005/06. 3
Key principles: Integrated, active management of workers with soft tissue injury Five key principles for management of workers with soft tissue injury ( key principles ) have been identified. The key principles are best applied immediately from the time of injury. The key principles are: 1. Early, safe and durable return to work. 2. Focus on activity and independence. 3. Work toward common goals. 4. Regular review of progress and risk factors. 5. Targeted education. The key principles are to be applied with the worker central to the process of injury management. This concept is illustrated in the diagram below. Key principles: Integrated, active management of workers with soft tissue injury 4
The key principles align with the main findings of a recent review commissioned by the South Australian WorkCover Corporation 4 entitled Facilitators and Barriers to Return to Work: A Literature Review. The key findings of the review were: advise the worker to stay active ensure communication, cooperation and common goals between key parties ensure early return to work change from clinical treatment to work focus in the sub acute period address psychosocial factors. The key principles align with the biopsychosocial approach to management of a worker s injury. This approach is widely accepted as vital to improving outcomes when managing injured workers 5 6. The biopsychosocial approach recognises that pain is not felt in accordance with the amount of injury to the tissues. Rather, pain perception is influenced by a worker s social environment (work, family, community and compensation systems) and their thoughts, beliefs, attitudes and emotions. These other influences are often grouped together and referred to as psychosocial factors. Therefore, application of a biopsychosocial approach that considers the physical, social, psychosocial & emotional needs of the worker, underpins effective management. The key principles and supporting fundamentals for each are described in the table below. Key principle 1. Early, safe and durable return to work 2. Focus on activity and independence 3. Work toward common goals Supporting statements Early reporting and return to work promotes the worker s recovery and prevents long term disability and work loss. Early return to work maintains the worker s activity and links with the workplace. Safe return to work with guidance can occur despite the worker s symptoms. Keeping active promotes recovery. The worker s activity ideally is work related, functional and graded. Activity (including work) can occur despite the worker s symptoms. The design of activity promotes transition to independence and self management. Self management skills are integrated into clinical management to improve the worker s confidence and independence. Key parties discuss expectations with the worker and others soon after the injury. The worker and other key parties are informed of expectations, recovery and matters relevant to return to work. The worker and key parties work together to set and achieve goals. A biopsychosocial approach ensures the worker s needs are identified and addressed holistically. Communication issues/difficulties are promptly addressed. 4 Foreman P, Murphy G and Swerissen H. Barriers and facilitators to return to work. A literature review. Australian Institute for Primary Care, La Trobe University: Melbourne 2006. 5 Accident Compensation Corporation. New Zealand Acute Low Back Pain Guide October 2004 edition. 6 Burton AK, Kendall NAS, Pearce BG, Birrell LN, Bainbridge LC. Management of upper limb disorders and the biopsychosocial model. Health and Safety Executive RR 596: Norwich 2008. 5
4. Regular review of progress and risk factors Risk factors are of universal importance; they are not usually specific to site of injury. Review the worker regularly to identify and address risk factors and progress of recovery. Select outcome tools/methods which provide a measure of the impact of the intervention. Initiate action promptly when a review identifies a need. The worker s progress is always under review. 5. Targeted education Provide education to assist with beliefs, expectations, early return to work and activity, safe work practices and understanding of the biopsychosocial nature of pain. Education is targeted to the specific needs of each worker. Education is aligned with current evidence and provided consistently by all key parties. Education promotes learning and self management. Intergrated management working together Outcomes are improved when key parties work together effectively. Working together facilitates implementation of the key principles during injury management. Working together is the best way to ensure a worker with a soft tissue injury successfully returns to work. Key parties include: injured worker and his/her family employers (including managers, supervisors, return to work coordinators) insurers nominated treating doctors and other medical practitioners rehabilitation providers treatment providers for example clinical counsellors, chiropractors, exercise physiologists, occupational therapists, osteopaths, physiotherapists, psychologists and remedial massage therapists. Injury management is the process that comprises activities and procedures that are undertaken for the purpose of achieving a timely, safe and durable return to work for workers following workplace injuries. The worker s needs in order to return to work are central to effective injury management. For the purpose of this document, three main focus areas within injury management are identified: 1. clinical management 2. workplace management 3. insurer case management. The insurer ensures interventions are integrated through effective injury management. A strong, single focus on clinical management, even in the early phase following injury is not advisable. 6
Most key parties are involved to some degree across these three areas. When key parties work towards return to work as the common goal, then all injury management activities are linked and have a clear focus. The worker is central in planning for return to work and setting work and treatment goals. Key parties regularly review progress toward goals, which ensures that problems are promptly reported and actioned by the appropriate person. Clinical management Clinical management means evidence based assessment and treatment of the worker and their injury, by a medical or other health practitioners ( treatment providers ). Assessment and treatment may include but is not limited to clinical musculoskeletal assessment; screening for risk factors; hands on therapy; exercise therapy; medication and reassurance/advice for workers with soft tissue injuries. Published guidelines about specific treatment regimens for soft tissue injuries, based on best available scientific evidence, are widely available. Treatment providers use these and other appropriate guidelines to inform their clinical decision making. This document provides advice specifically about preventing long term disability and work loss. In particular, the change in treatment approach indicated when workers with soft tissue injuries do not recover as expected. Lack of progress usually becomes evident within four weeks of a worker s injury. It is important that treatment providers thoroughly assess and review the worker s needs in order to apply prompt and appropriate treatment. The worker s needs also need to be assessed in accordance with a biopsychosocial approach to management. Refer to advice sheets in this document for detailed information about clinical management during the intervention phases. Advice Sheet 1 Information for workers Advice Sheet 2 Acute intervention Advice Sheet 3 Review and transition process Advice Sheet 4 Secondary intervention Advice Sheet 5 Treatment using work related activity. Workplace management Workplace management means coordinated planning, assessment and return to work activities which are directly related to the worker s needs, duties and workplace. These activities aim to maintain the worker at, or return them to, work. Early return to work facilitates a successful return to work outcome. Early return to work can be facilitated by interventions to match worker capacity, the workplace and the duties performed. In a review 7 of modified work programs (workplace management including suitable duties; task modification; equipment; work trial; supported employment; participatory ergonomics) the authors concluded that such programs facilitate return to work. Specifically, workers on a program of modified work returned to work twice as often and in half the time, compared to others. A review about workers with back and neck pain concluded that ensuring that the worker has an expectation of return to work (pre injury duties and hours with the same employer) was also critical to a successful work outcome 8. Accordingly, it is advisable that key parties promote a consistent expectation of early return to work. 7 Krause N, Dasinger LK & Nehauser F. Modified work and return to work: A review of the literature. Journal of Occupational Rehabilitation 8:2, 1998. 8 Schonstein E, Kenny DT, Keating J & Koes BW. Work conditioning, work hardening and funcional restoration for workers with back and neck pain. Cochrane Database of Systematic Reviews 2003, Issue 3. 7
A clinical trial about managing workers with back pain concluded that a close link between the clinical and workplace based interventions is important in improving outcomes in workers 9. Key parties working together toward the goal of return to work improves worker outcomes. Early and safe return to work can be facilitated in the workplace by: ensuring the worker is central to the process and decision making ensuring effective OHS management systems are in place identifying and providing suitable duties as early as possible providing graded suitable duties/ work modification if indicated ensuring there is good support from those at the workplace during return to work clearly communicating the return to work goal to all parties organising workplace rehabilitation if indicated providing support within the workplace when the worker is returning to work with symptoms, which may fluctuate during work clearly linking clinical and occupational interventions through effective coordination. Refer to the advice sheets in this document for detailed information about workplace management during the intervention phases. Advice Sheet 2 Acute intervention Advice Sheet 3 Review and transition process Advice Sheet 4 Secondary intervention. Insurer case management Case management means a coordinated and managed approach that integrates all aspects of injury and claims management. WorkCover NSW s case management framework provides a set of clearly defined practices, underpinned by quality assurance and continuous improvement, to ensure effective management of a claim from notification through to finalisation. Refer to Case Management Principles (WorkCover 2005) for advice on effective case management. The case manager facilitates the recovery and successful return to work of the worker. This is done by working in partnership with key parties, resolving issues promptly and effectively promoting the common goal of return to work. Effective case management is directed at preventing long term disability and work loss. Case managers ensure that progress towards agreed goals is regularly reviewed. Regular case conferencing with key parties may be appropriate. It is important that decision making occurs promptly to facilitate the interventions essential for recovery. Refer to the advice sheets in this document for detailed information about case management during the intervention phases. Advice Sheet 2 Acute intervention Advice Sheet 3 Review and transition process Advice Sheet 4 Secondary intervention Advice Sheet 5 Treatment using work related activity. 9 Loisel P, Aenhaim L, Durand P, Esdaile JM Suisse S, Gosselin, Simard R Turcotte J & Lemaire J. A population-based, randomised clinical trial on back pain management. Spine 22:24 1997. 8
Decision making tool: Management of workers with soft tissue injury The soft tissue injury management decision making tool ( decision making tool ) is designed to guide key parties to: decide when the recommendations of this document will be applied take appropriate action when recovery is delayed and/or there are risk factors progress from acute to secondary intervention promptly when indicated progress management to achieve return to work. Decision Making Tool: Management of Workers with Soft Tissue Injury Is this a soft tissue injury? YES NO Implement soft tissue injury management Implement alternate appropriate injury management Acute intervention (0 4 Weeks) Recovery delayed and/or risk factors identified? Review and transition process (3 6 Weeks) YES NO Management and review Return to work Secondary intervention (4 12 Weeks) Recovery delayed and/or risk factors identified? YES NO Further intervention Detailed review and assessment of need The ideal timeframe to implement the advice contained in this document is during the first 12 weeks after a worker sustains a soft tissue injury. Prompt application of this advice is necessary to reduce the risk that a worker will suffer long term disability and work loss. When a worker does not return to work within 12 weeks of injury, the process becomes more difficult and is less likely to result in return to work. However, the principles in this document can be applied later when it is appropriate for the worker. 9
Decision: Is this a soft tissue injury? Soft tissue injury is a descriptive term that refers to injuries of the muscle, joint, ligament, cartilage, tendon or connective tissues and include intervertebral disc injuries. Soft tissue injuries do not include serious pathology (such as tumour or infection), fractures, nerve (neurological) damage, complex regional pain syndrome, or injuries that require or have undergone surgery. In many cases, the general term of soft tissue injury is used because a number of different tissues are responsible for pain and other symptoms or the specific tissue responsible cannot be identified with certainty. Identifying the specific tissue which is causing symptoms (for example through scans or x-rays) is not always necessary to effectively treat the injury. It is important that the NTD and/ or treatment provider rules out potentially serious causes such as nerve damage, tumour, infection, or significant structural injury such as a fracture or tendon rupture. Once these serious causes have been ruled out then it is likely that the condition falls into the category soft tissue injury. Workers with other types of work related injuries may benefit from the application of this advice. The focus of this document on soft tissue injuries does not preclude application to other injuries when necessary to prevent long term disability and work loss. The decision making tool for management of workers with soft tissue injury describes three overlapping stages of activity in the early period (usually the first 12 weeks) after soft tissue injury: 1. acute intervention 2. review and transition process 3. secondary intervention. Refer to the coloured boxes in the diagram. Each stage requires different approaches and interventions, which are discussed in detail within the relevant advice sheet. The activities and timeframes for each stage are provided as advice to guide practice. The needs and circumstances of each individual case are considered when implementing the advice. The review and transition process is initiated only when recovery is delayed and/or risk factors are identified. Secondary intervention only occurs when the review and transition process identifies a need. Acute intervention Acute intervention usually occurs during the first four weeks after injury for the purposes of this advice. Within 4 6 weeks of injury, the soft tissues are expected to be predominantly healed and at minimal risk of further damage. The expected healing time will vary according to the nature of the injury and the worker s individual factors, such as co-existing conditions. Acute intervention which integrates clinical and workplace management and emphasises an active approach is vital to the worker s recovery. Acute intervention incorporates a biopsychosocial approach to managing the worker from day 1. This contributes to the prevention of long term disability and work loss in workers after soft tissue injury. 10
Acute interventions and the parties responsible are outlined in the table below. Intervention Injury notification Medical assessment and certification (includes formulating recovery expectation) Early contact and assessment (includes simple screening for risk factors; gather information about expected recovery) Evidence based treatment (includes education/ advice; simple screening for risk factors; formulating recovery expectation) Return to work (includes simple screening for risk factors) Risk management (includes reducing the risk of injury re-occurring to any worker) Monitor recovery Responsibility Worker; employer NTD Insurer, in consultation with key parties NTD; treatment provider Worker; employer; NTD; rehabilitation provider Employer; workers A suitably qualified professional may advise All key parties Refer to Advice Sheet 2: Acute intervention for detailed information about important activities during this phase of management. Decision: Is recovery delayed and/ or risk factors identified? A recovery expectation is formulated as soon as possible after injury. The recovery expectation takes into account: expected recovery time for the injured tissues expected return to work expected return to function, such as activities outside work worker s other conditions (for example diabetes, cardiovascular disease, osteoporosis, mental health conditions). The recovery expectation is usually formulated by the NTD and/or treatment provider, with the worker. Key parties monitor recovery during acute intervention. When recovery is not delayed then injury management continues until the worker returns to their pre injury work (duties and hours) within the expected recovery timeframe. Simple screening is done by key parties to identify risk factors. When recovery is delayed and/or risk factors are identified, the review and transition process commences. Formal screening and assessment forms the basis for determining the worker s barriers and needs in order to return to work. Secondary intervention implements strategies to address the identified needs. Key parties monitor recovery during secondary intervention. When secondary intervention has not resulted in the worker recovering as expected, a detailed re-assessment of need may be required. Further intervention may be needed to return to work. 11
Review and transition process The process usually begins 3 6 weeks after a worker sustains a soft tissue injury. However, the process can be initiated as soon as indicated, which may be very early in some cases, such as when the worker has a history of recurrent episodes of injury. The review and transition process is initiated when: recovery is delayed, and/or passive therapy is not resulting in substantial progress toward return to work, and/or psychosocial risk factors have been identified, through simple screening. This stage in the framework emphasises: formal screening and assessment of workers to identify those at risk of long term disability and work loss transition of care (treatment approach) for example from hands on manual therapy to prescribed work related activity incorporating a cognitive behavioural approach prompt initiation of these activities in order to prevent long term disability and work loss. Review and transition interventions and the parties responsible are outlined in the table below. Intervention Formal screening Additional assessment (includes clinical review by current treatment provider/s; workplace assessment; others as indicated) Transition of treatment Injury management planning Responsibility Insurer to facilitate; key parties to conduct Insurer to facilitate; suitably qualified parties to conduct; treatment provider; rehabilitation provider Treatment provider; NTD; worker Insurer Screening and assessment Screening and assessment forms the basis for determining the worker s barriers and needs to return to work. Screening and assessment is a staged process. Simple screening is undertaken during acute intervention. If neccessary, formal screening is then undertaken during the review and transition process, using formal screening tools such as the Orebro Musculoskeletal Pain Questionnaire (OMPQ). When formal screening indicates a need, a suitably qualified person then conducts the necessary assessment to further investigate the identified area of need. Refer to Advice Sheet 3 Review and Transition Process for detailed information about undertaking formal screening and additional assessment. Transition of treatment Transition from passive care to increased activity to manage workers with soft tissue injuries in the sub acute period (4 12 weeks) is supported by the evidence. 12
Transition of Care Amount of treatment Passive Care Activity Education 0 4 6 12 Time (weeks) This diagram illustrates the concept of transition of care. Let the worker know from day 1 about the type of treatment that they can expect for their soft tissue injury. This requires education including advice that it is normal for treatment to be progressed from passive care to increased activity in the sub acute period. Providing early and consistent education and advice helps prevent the worker feeling that something is wrong when management is changed. This is likely to occur if the worker does not understand the reason for the change. Dr Rob Boland, Independent Physiotherapy Consultant Refer to Advice Sheet 3: Review and transition process for detailed information about important activities during this phase of management. 13
Secondary intervention Secondary intervention usually occurs during the sub acute injury period, approximately 4 12 weeks after a worker s injury. This is a crucial period for workers who are assessed as at risk of long term disability and work loss. A targeted intervention process is initiated promptly when the worker s recovery is delayed and/or risk factors are identified. Intervention may occur less than 4 weeks after injury where the need is identified, for example when the worker has a history of recurring episodes. Secondary interventions: focus on early, safe and durable return to work address the individual need/s identified through screening and assessment in a cost effective manner encourage activity and self management by the worker deliver measurable progress toward identified work and functional goals occur as a clear, collaborative and open process between key parties incorporate a biopsychosocial approach; encompassing all needs of the individual worker to return to work. Secondary intervention activities and the parties responsible are outlined in the table below. Activities Case management Return to work Active treatment (includes education, work related activity and self management strategies) Maintenance and flare up strategies Monitor recovery Responsibility Insurer Worker; employer; NTD; rehabilitation provider Treatment provider; NTD Worker; NTD; treatment provider; employer All key parties Refer to Advice Sheet 4: Secondary intervention for detailed information about important activities during this phase of management. 14
Development and administration of this document WorkCover has developed this document to highlight and bring together the best currently available information for key parties to use. The information includes a blend of advice that is: specific to the New South Wales workers compensation system based on scientific research designed to help key parties understand the process, roles and responsibilities general guidance that requires individual application to each worker. This document supersedes three earlier WorkCover guides: Management of Soft Tissue Injuries General Guide Management of Soft Tissue Injuries Treatment Providers Management of Soft Tissue Injuries Insurer Guide (February 2006). Technical information is kept to a minimum. The material will direct you to further sources which may be useful. Key parties are advised to keep up to date with available research outcomes and publications. This document comes into effect in July 2008 and will be reviewed by WorkCover within two years of publication. WorkCover will measure outcomes of this initiative. Evaluation of outcomes will be used during the review process. The document should be cited as Overview. Improving outcomes: Integrated, active management of workers with soft tissue injury. 15
Disclaimer This publication may contain occupational health and safety and workers compensation information. It may include some of your obligations under the various legislations that WorkCover NSW administers. To ensure you comply with your legal obligations you must refer to the appropriate legislation. Information on the latest laws can be checked by visiting the NSW legislation website www.legislation.nsw.gov.au. This publication does not represent a comprehensive statement of the law as it applies to particular problems or to individuals or as a substitute for legal advice. You should seek independent legal advice if you need assistance on the application of the law to your situation. Catalogue No. WC05364 WorkCover Publications Hotline 1300 799 003 WorkCover NSW 92-100 Donnison St Gosford NSW 2250 Locked Bag 2906 Lisarow NSW 2252 WorkCover Assistance Service 13 10 50 Website www.workcover.nsw.gov.au Copyright WorkCover NSW 0710