An award-winning approach to returning to work with musculoskeletal disorders (MSDs) is getting results. Occupational health physiotherapist Heather Watson explains the strategy behind this effective multi-disciplinary intervention.
The biopsychosocial (BPS) model of health was first suggested by psychiatrist George L Engel in 1977. He highlighted that the wider personal perspective of the patient and the socio-economic context can influence the outcome of a health condition.
This means that how the person responds to the situation can determine the outcome, as much as the health condition itself; and it can lead to many possible results.
Engel’s first paper was: “The need for a new medical model: A challenge for biomedicine”, and, almost 40 years on, it remains a challenge to biomedicine, and to clinicians managing a wide variety of health conditions.
In some circles it has become widely accepted as best practice, but in others it is still an anomaly. Nationally and internationally, healthcare professionals disagree on the use of the BPS model across all health conditions and stages of the care pathway.
In the UK, there is mounting scientific evidence (Waddell, Burton, Kendall, 2008) that employing a BPS approach can be an effective alternative to the biomedical model for a number of health conditions for functional work-related outcomes.
But its application is variable, at best used in circumstances where it is widely accepted for certain types of conditions, such as long-term health conditions and persistent pain, but at worst reserved only for those conditions, and not utilised earlier in the patient journey to reduce the likelihood of future disability.
It is worth noting in relation to the term “persistent pain”, that it has become commonplace to use the term “chronic pain” for anything other than acute pain related to damage in the body. However, often people think that chronic pain means bad or severe pain, whereas it actually refers to pain that has gone on longer than expected.
This sort of pain is often no longer associated with damage (even if it may have started with an injury) and more to do with how the central nervous system has processed the injury. It can require a slightly different approach to clinical treatment and return to work rehabilitation (Tasmanian Health Organisation South, 2014). This article explores the application of the BPS approach for MSDs in relation to the evidence about effective return-to-work strategies, and gives an example of how the model can be implemented in practice by multi-disciplinary OH teams.
MSDs continue to be a highvolume, high-impact problem in OH, being one of the leading causes of sickness absence in the UK and the leading cause of absence in the EU (The Work Foundation, 2014).
They are common health conditions, which often seem to become complex to integrate with work when they become prolonged. The goal must be to ensure early intervention, using a suitable service framework to prevent the unnecessary disabilities that can arise from MSDs that are not adequately managed.
Return-to-work principles for MSDs
This article provides an example based on existing and emerging evidence of ways in which the BPS approach can work effectively. The following is a summary of the approaches.
Psychosocial issues are known to be obstacles to recovery from injury and to return to work (Flags Think Tank, 2009). These obstacles are often referred to as “flags” and are indicated by colour – most commonly used are yellow, blue and black, which are defined as follows:
- Yellow (personal): the person’s individual thoughts, feelings, behaviours concerning their health condition. This may include believing that work will make the health condition worse, or becoming very anxious about the future.
- Blue (workplace): the employee and employer perceptions about work and health. If there is a perception that work is physically damaging, or that it is difficult to accommodate modified work to support recovery, or communication processes are poor, these can create obstacles to return to work.
- Black (context): black flags are outside of the control of the employee. They may include poor company policies that are inflexible, wider social context such as financial issues around benefits, or social isolation and negative influence from family.
The flags approach gives a framework for systematic assessment of cases. It enables an agreed platform for the identification of risk factors that may be pertinent to an individual and their condition. This allows a number of potential ways forward:
- it helps to identify what sort of intervention may be required;
- it helps to decide which stakeholders may need to be involved in the intervention; and
- it creates a plan to overcome or get round the obstacles to achieve functional recovery and return to work.
Stepped care has been found to be effective in ensuring that appropriate support is supplied at the right time, making efficient use of resources and minimising potential negative effects of over-complicating cases.
The stepped care principle is “just what’s needed when it’s needed”. The concept embraces evidence that early intervention that is simpler and more cost-effective prevents common health conditions progressing to long-term disability and is more useful than complex, costly interventions at a later stage.
While stepped care is the provision of a series of services of increasing intensity and complexity, stratified care is the process by which we decide what service a person requires at what time.
This means that it is not necessarily a case of applying the steps sequentially based on time since injury or absence, or that one step must be completed before another is begun.
Stratified care suggests allocating a person to a service based on their prognosis (risk of long-term disability) at the time of assessment. Hill et al (2011) developed the Keele University STarT Back Tool for the clinical management of back pain using this approach. This tool is based on using screening to allocate patients to matched care pathways.
Although stratified care is a clinical treatment model (ensuring that patients receive the care that they are most likely to benefit from), the concept is relevant to OH management as it identifies early on the sort of support that a person needs. This means that OH practitioners can allocate individuals to the correct level of care (step) immediately, thus reducing the time frame to get effective support, and avoiding wasting money on interventions that are likely to be ineffective. The trial of the STarT Back Tool demonstrated significant improvements in disability and days off work (and other outcomes) at four-month and 12-month follow-ups.
Active case management
In the past decade, there has been a rise in the interest and application of case management approaches. Case management has been defined as “a goal-orientated approach to keeping employees at work and facilitating an early return to work” in a research report published for the Health and Safety Executive (Hanson et al, 2006). The research found good scientific evidence that active case management approaches are “cost-effective through reducing time off work and lost productivity, and reducing healthcare costs”.
The practice involves having a case manager allocated to an employee, who becomes the key point of contact for others involved in the case – often they are the person who develops a plan for return to work, collects information, coordinates communications, arranges referrals, and keeps the case moving towards the agreed goals, by recognising and addressing some of the key obstacles to return to work.
The evidence suggests that case management is moderately effective when used in this way. It is also a principle that must sit within the selection of interventions that may be available within a stepped and stratified care model. It is important to note the word “active” when describing an approach that proactively works towards a resolution of the situation. Maintaining progress is much more effective than a “passive” approach that allocates a case manager who oversees a case but does not provide the momentum for progress.
In the same research report (Hanson et al, 2006), there was found to be even stronger evidence that “best practice rehabilitation methods have the potential to significantly reduce the burden of long-term sickness absence due to MSDs”. The authors found that rehabilitation programmes were effective in sub-acute and persistent (chronic) groups for reducing pain, increasing productive activity, and highly cost effective when delivered to individuals who were screened (using flags-based tools) as having a high risk of a poor outcome. There was strong evidence that applying rehabilitation in the sub-acute phase could prevent development of long-term problems and reduce time off work.
Key components of best practice were found to be:
- use of a screening process to identify which cases would benefit from rehabilitation (flags);
- correct timing of the intervention (stepped and stratified care);
- targeting individual obstacles to recovery and return to work;
- integrated case management through an agreed plan; and
- successful programmes focused on return to work, cognitive behavioural and a problem-solving approach that was activity based, integrated within the workplace and based on evidence-based clinical approaches.
Bringing principles together in practice
The challenge is how to integrate these principles into OH practice, when companies include a number of professionals from different backgrounds and interests. Teams will vary from setting to setting, but often include physicians, nurses, nurse advisers, technicians, physiotherapists, psychologists, counsellors, occupational therapists, occupational hygienists and health and safety professionals.
When developing a departmental strategy, all the elements need to be in place throughout the team, with all clinical staff understanding their role within the process. These principles were applied to develop an “award-winning” in-house OH specialist musculoskeletal (MSK) fitness for work service within an NHS trust.
It should be noted that, throughout the process outlined below, two types of physiotherapy are referred to: standard outpatient (OPD) MSK physiotherapy; and specialist OH physiotherapy. It is important to recognise that the different types of physiotherapist deliver different levels of service within the stepped care/stratified care concept. Standard physiotherapy is that which is commonly available via the NHS and private providers for clinical management of common MSDs, without any specialist OH knowledge.
Specialist OH physiotherapy refers to work services provided by physiotherapists with additional training (similar to that of OH nurse advisers) to extend their scope and expertise to include specific fitness for work assessment skills, fitness for work rehabilitation provision, ergonomics and workplace assessment skills.
More information can be found on OH physiotherapy competencies developed with the Council for Health and Work via the Association of Chartered Physiotherapists in Occupational Health & Ergonomics website.
Six tips for creating a model for multi-disciplinary team provision of OH services for MSDs
1. Create easy, early access referral for standard OPD physiotherapy via the OH department. This should include the option for self-referral so that staff can proactively manage their own situation.
2. Set up processes for early screening for psychosocial flags to identify staff who may be at risk of developing long-term absence and disability, and a corresponding guide to allocate an employee to the most suitable service. Consider that:
- all clinical OH staff need to be able to carry out appropriate “triage” of MSD referrals at the point of first contact (usually over the phone) with the OH department; and
- all clinical OH staff need to be able to carry out a basic assessment of risk of long-term absence and disability at a face-to-face appointment.
This ensures that every referral that comes via OH is screened and that the screening can be incorporated by using a few key questions in the referral form, which are also asked in other types of appointments, for example management referrals, so that no matter how the employee came to the department, issues can be picked up early.
3. Provide training to the whole department so that they understand the process, are familiar with the BPS model, and know what the key screening questions are, why they are important, and what to do with the results – in the context of the services available in the organisation. This also creates consistency of advice and messages across the team and reduces the possibility of conflicting advice being given to employees and managers from professionals within the same department. The approach has a positive impact on the organisational culture of management of MSDs over time.
4. Provide stepped services and stratified care. Agree criteria for how referrals are dealt with, depending on the outcome of the screening process and what pathways are available, for example: standard OPD physiotherapy; OH physiotherapy; case management; and psychological support.
Examples of services available to refer into within a stepped care framework include:
- advice only, with opportunity to follow up if needed (if at work and no problems);
- referral to OPD physiotherapy with opportunity to follow up if needed (case managed by nurse if having any work difficulties);
- referral to OPD physiotherapy and OH physiotherapy for fitness for work, alongside standard physiotherapy care locally if off work or taking recurrent absence (case managed by OH physiotherapist);
- option to refer for medical opinion/investigations if necessary to rehabilitation process (such as orthopaedic diagnosis, scans, or pain management);
- OH physiotherapy for fitness for work assessment and occupational rehabilitation programme, which could include a combination of physical rehabilitation and conditioning, workplace ergonomics and addressing psychosocial obstacles identified in screening and in-depth assessment, case managed by OH physiotherapist, usually where OPD physiotherapy has ended or failed;
- case management – ability to add other clinical support if needed, eg psychology, to any of the above while case managed;
- case management – ability to use workplace support and modification of duties/hours to facilitate return to work with the aim of returning employee to their original job (eg work outcome – position in staff hierarchy) or liaise with managers and HR to find a permanent alternative; and
- referral to OH physician for consideration if rehab plan fails, or ill-health retirement as a last resort.
5. Incorporate active case management. Once a staff member has been referred to the OH team, if they are experiencing any workrelated issues they would be allocated a case manager depending on the severity of the situation.
Case management may range from a monitoring call to ensure that they have commenced OPD physiotherapy treatment and review of screening questions, through to more involved coordination of reports, communication with all providers and leading of case meetings (eg with management and HR) for more complex cases. This incorporates stepped care and allows “just what is needed when it’s needed”.
The case manager becomes the key person and link for the individual employee, manager, HR and therapist for all updates and communications – they ensure that all parties that need to be involved are kept up to date.
6. Provide access to specialist rehabilitation. Where a person is identified as needing more than standard care, active steps are needed to move towards a return to work.
If nothing is done, the person is unlikely to suddenly return to work without help. It may be as simple as discussing a plan and helping to facilitate a phased return to work or may require a more in-depth personalised rehabilitation plan.
In these cases, specialist OH physiotherapists can carry out a fitness for work assessment using the BPS framework. This enables the physiotherapist to integrate many sources of information, including a clinical examination, and allows a more thorough investigation of individual obstacles to return to work. This then enables development of a bespoke, person-centred rehabilitation plan to address these issues.
The rehabilitation plan may include aspects of usual physiotherapy practice such as strengthening and fitness, but also: specific education to address unhelpful beliefs about pain and work; specific movement training to address fear about performing certain work tasks; visits to the workplace to assess ergonomics and advise on modifications of work practices that may help day-to-day management of condition at work; and coordination of a phased return-to-work plan to build physical capacity and tolerance to activity, as well as confidence.
Rehabilitation therefore follows a work-focused plan through to resolution. The employee is an active part of the process, and the manager and workplace are involved and informed throughout.
In conclusion, this model demonstrates one way in which the BPS approach can be applied within a multi-disciplinary OH team. Key messages include:
- Ensure that all staff understand the reasons for having a suitable pathway for the management of MSDs within the organisation and the importance of early, appropriately targeted active management to promote return to work for the benefit of the long-term health of the employee, and the organisation.
- Ensure that the staff are adequately trained in the clinical evidence-based management principles of MSDs, and the roles that each member of the team can play to deliver the service. Understanding the contributions of the different allied health professionals is of vital importance in achieving the best outcome for the employees using the service.
- Have a clear structure and processes for the implementation of the pathways and clinical delivery of service, including communication strategies for working with professionals outside the OH team, for example physiotherapy services, GPs, hospital specialists and podiatry.
- The range of services available within any OH department should have consistent, positive, joined-up messages about work and health that debunk unhelpful myths that can perpetuate absence from work, and actually contribute to future disability. Discrepancies can lead to confusion for managers and employers, and loss of confidence in OH to give meaningful advice. All OH team members should support each other in reinforcing the pathways and correct clinical management of MSDs to ensure that they are not undermining each other.
- Management of MSDs within the workplace must keep up to date with developments on clinical management and reflect this in their services. Emphasis needs to be on rehabilitation for function for return to work, and move away from a pathology-based, medical management approach that fails to address psychosocial components and reinforces passive coping strategies on the part of the employee. Work needs to be constantly reframed as a positive contribution to wellbeing and recovery from injury, and be included as a fundamental part of the rehabilitation process. This means employees can return to work while having medical treatment or therapy or waiting for investigations, as long as suitable duties can be agreed. Vocational and clinical management must run in parallel, rather than waiting for someone to get better.
- Lastly, one of the most compelling pieces of evidence is that the return-to-work rehabilitation of MSDs must be a collaborative process, with the patient/employee at the centre of the plans and actively engaged in the process. The healthcare and OH teams and organisation manager need to be facilitators in a journey owned by the employee.
Association of Chartered Physiotherapists in Occupational Health & Ergonomics available at: www.acpohe.org.uk/about-us
Engel GL (1977). “The need for a new medical model: A challenge for biomedicine”. Science 196; pp.129–136.
Hanson MA, Burton K, Kendall NAS, Lancaster RJ, Pilkington A (2006). “The costs and benefits of active case management and rehabilitation for musculoskeletal disorders”. HSE Research Report, p.493.
Hill JC, Whitehurst DGT, Lewis M, Bryan S, Dunn KM, Foster NE, Konstantinou K, Main CJ, Mason E, Somerville S, Sowden G, Vohora K, Hay EM (2011). “Comparison of stratified primary care management for low back pain with current best practice (STArT Back): A randomised controlled trial”. Lancet; 378(9802), pp.1560-1571.
Summers K, Bajorek Z, Bevan S (2014). Self Management of chronic musculoskeletal disorders and employment. The Work Foundation.
Tasmanian Health Organisation South (2014). “Understanding persistent pain – how to turn down the volume on persistent pain”.
The Flags Think Tank (2009). “Tackling musculoskeletal problems flags – a guide for workplace and clinic: Identifying obstacles using the biopsychosocial framework”. TSO Bookshop.
Waddell G, Burton K, Kendall NAS (2008). “Vocational rehabilitation: what works, for whom, and when”. TSO Bookshop.