Background
Soft tissue or musculoskeletal injuries are the most common work-related injuries. For primary care providers the main goals with this group are promoting recovery (especially successful return to work [RTW]), minimising pain, and preventing secondary disability. It is not known if we can prevent the development of chronic pain, but for some time we have had good evidence from systematic reviews and meta-analyses of prospective studies that psychological and social/environmental factors are strong predictors of delayed recovery and disability associated with chronic pain (Chou & Shekelle, 2010; Mallen, Peat, Thomas, Dunn, & Croft, 2007). The good news is that these factors (e.g. anxiety, depression, poor coping skills, catastrophising, etc.) should be modifiable and, if successful, the likelihood of disabling chronic pain should be reduced. Nevertheless, many studies have demonstrated little benefit when psychologically informed approaches were added to standard physical therapies and medical advice for patients presenting with acute back pain – the most common pain site (e.g. Hay et al., 2005; Jellema et al., 2005a).
However, a review of controlled trials by (Nicholas, Linton, Watson, & Main, 2011) noted that the ‘no difference’ studies typically applied the psychologically informed treatment for all presenting patients, regardless of whether they displayed psychological risk factors. Also, the psychological aspects of the interventions were provided by either general practitioners or physiotherapists (all of whom had some brief training in the methods used). In contrast, those studies which employed psychologically-informed approaches for only those patients identified (by screening instruments) as having psychological risk factors achieved superior benefits in terms of reduced disability and return to work, relative to usual care. Interestingly, in many of these successful interventions psychologists were employed to deliver the targeted psychological interventions, usually alongside physical therapies (e.g. Gatchel et al., 2003; Linton et al., 2005).
Nicholas et al. (2011) and others (e.g. Jellema et al., 2005b; Pincus & McCracken, 2013; Sullivan, Feuerstein, Gatchel, Linton, & Pransky, 2005) have concluded that targeted psychologically-informed interventions for patients with persisting pain should be reserved for those cases where psychological risk factors have been identified.
Identifying psychological risk factors
Relative to patients with chronic pain, identifying psychological risk factors in the acute phase (one to four weeks after injury) is challenging. The approach endorsed by WorkCover NSW (2008) specifies that psychological risk factors should be considered if recovery appeared slower than expected. In general, the primary healthcare providers were expected to use their clinical judgment to identify these psychological risk factors. But, as we know, this is an extremely unreliable metric.
Administration of psychometrically sound instruments for identifying psychological risk factors has been left to the discretion of the GP and physiotherapist. WorkCover NSW (2008) provided the 24-item Orebro Musculoskeletal Pain Screening Questionnaire (OMPSQ) (Linton & Boersma, 2003) in their guidance material, but it seems that physiotherapists are the main group to have used it. Unfortunately, many say they don’t know what to do with the information revealed by the tool. In part, this may explained by recent findings (Alexanders, Anderson, & Henderson, 2015) that, as a group, physiotherapists have not been confident in their ability to employ psychological interventions (and many don’t see that as their role anyway).
The net effect is that workers with soft-tissue injuries who are at risk of developing chronic pain and disability are frequently not identified until they are already chronic. In the experience of psychologists treating injured workers it is uncommon to see a case within three to six months of injury. But as injured workers who have been off work for six months can be sacked (at least in NSW), this practice means that psychologists are often placed in the invidious position of chasing the horse after it has bolted.
Thus, despite the strong evidence that psychological risk factors are predictive of delayed recovery and future disability following injury, this information has not been reflected in routine practice.
The WISE study
In 2012, a group of researchers led by the author obtained funding from a consortium comprising NSW Health, EML Insurance, and SI-Corp (now iCare, NSW) to conduct a controlled trial of an early identification and intervention protocol vs usual care in the NSW workers compensation environment, using injured public health workers as the target population. The project, known as the Work Injury Screening and Early intervention (WISE) study, employed a protocol that is consistent with the WorkCover (2008) guidelines, but more prescriptive in requiring psychological screening (of all those having a week off work) using the 10-item OMPSQ (Linton, Nicholas, & MacDonald, 2011) within seven days of their injury, followed by early assessment (two to three weeks after injury) by a psychologist who was approved to conduct up to six sessions of (weekly) treatment for identified obstacles for RTW.
The form of treatment was not specified, but it had to be brief and based on the psychologist’s assessment of the obstacles for RTW (rather than long-term problems). The psychologists were expected to liaise closely with the workers’ workplace via the RTW coordinator who, in turn, was expected to address any workplace obstacles for RTW. Regular liaison with the patient’s nominated treating doctor (NTD) and insurance company was also expected, and no-one was denied access to treatments recommended by the NTD. A research manager was employed to oversee all these activities and try to ensure that all parties adhered to the protocol that had been agreed to by the employer and insurer.
Outcomes to date
The preliminary results have been very encouraging. In fact, the costs saved already have repaid the costs of the grant to run the study. Overall, 24 per cent of the 580 injured workers who agreed to participate scored in the high-risk range on the OMPSQ-10. NSW Health (the employer for the workers in the study) has been so pleased with the results (almost a halving of lost time from work and reduced costs overall, which have been sustained) that they have begun implementing the WISE protocol as standard practice for all publically employed health workers injured in NSW. Also, analyses of the changes achieved by the psychologists (after an average of only five sessions) were all highly statistically and clinically significant. These included improvements on measures of depression severity (DASS), disability, pain catastrophising, and pain self-efficacy. Take a bow, psychologists!
A graph of the cumulative wage replacement costs over the time since injury shows that the Intervention group reached a plateau by around nine months, while those of the Control group have continued to rise. This indicates the Intervention group has a sustained RTW, while the Control group is still having time off one year after injury notification.
Cautions
While the WISE results provide support for the early engagement of psychologists in the assessment and treatment of injured workers, it is strongly recommended that those psychologists who would like to contribute to the more general implementation of this protocol should undergo brief competency-based training to ensure a common (high) standard is achieved and maintained. It should also be emphasised, this is not a magic pill – it reflects hard work and engagement with the workplace and the insurer, in addition to the willingness of healthcare providers (including psychologists) to adhere to the protocol. This is really a system-based intervention and success is dependent on all stakeholders to play their part. The rollout to other sectors will take time and thorough negotiation with all main stakeholders and the details may well vary from employer to employer. But at least we have demonstrated that psychologists can make a significant contribution to helping the injured workers return to work and we can reveal that the workers seen by the psychologists in the study have been consistently appreciative of this help, even though many thought initially it was odd to see a psychologist so soon after a physical injury.
The first author can be contacted at [email protected]