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Ashley James, Glykeria Skamagki, Gwenllian Wynne-Jones, Nathan Hutting

Work related musculoskeletal disorders: Challenges and new perspectives_

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Speakers

Nathan HuttingSenior researcher, HAN University of Applied Sciences

THE INTEGRATION OF OCCUPATIONAL FACTORS AND SELF-MANAGEMENT SUPPORT

Glykeria SkamagkiAssistant Professor (Physiotherapy), Coventry University

MANAGING CHRONIC MSDs AT THE WORKPLACE: WHAT ABOUT OUR AGEING WORKFORCE?

Ashley JamesClinical Lead of Occupational Health Physiotherapy Services, IPRS Health

LOWER BACK PAIN AT WORK: TEACHING PEOPLE TO LIFT THE ‘WRONG WAY’ FOR BACK PAIN

Gwenllian Wynne-JonesSenior Research Fellow, Keele University

MANAGING THE IMPACT OF MUSCULOSKELETAL CONDITIONS ON WORKLESSONS LEARNED FROM A RANDOMISED CONTROLLED TRIAL AND AN IMPLEMENTATION INITIATIVE

Discussion & Questions

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https://www.wcpt.org/wcpt2019/programme/fs/FS-15

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Musculoskeletal disorders

PAIN & REDUCED FUNCTION MULTIFACTORIAL ORIGIN ALL AGES

OFTEN WORK-RELATED INCREASING PREVALENCE HIGH COSTS

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1. Screen for biopsychosocial factors and health comorbidities

2. Embrace patient-centredcommunication

3. What do you think you need to achieve your goals?

4. Educate beyond words using active learning approaches

5. Coach towards self-management

6. Address cormobid health factors

Lin et al., 2019; Caneiro et al., 2019; Lewis & O’Sullivan, 2018

• Focus on providing a ‘management’ plan to control the disorder and limit its impact on the person’s well-being (not on cure).

• Ongoing self-management is essential.

• Reframe the care for non-traumatic persistent and disabling musculoskeletal pain conditions:• Strong clinical alliance• Education• Exercise and lifestyle (sleep hygiene,

smoking cessation, stress management, etc)

Build the individual’s self-efficacy to take control and ultimately be responsible for their health.

Biopsychosocial

Self-managament

Education

Patient centered

Exercise

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Results: We included 94 studies. For musculoskeletal conditions, the median percentage of physical therapists who chose recommended treatments was 54% (n=23 studies; surveys completed by physical therapists) and the median percentage of patients that received recommended physical therapy-delivered treatments was 63% (n=8 studies; audits of clinical notes). For treatments not recommended, these percentages were 43% (n=37; surveys) and 27% (n=20; audits). For treatments with no recommendation, these percentages were 81% (n=37; surveys) and 45% (n=31; audits).

Conclusions: Many physical therapists seem not to follow evidence-based guidelines when managing musculoskeletal conditions. There is considerable scope to increase use of recommended treatments and reduce use of treatments that are not recommended.

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People with low back pain…

•42% of employed people had problems at work

•Struggle with the physical components of their job

•Social pressure to maintain employment and return to work

•Guilt towards other colleagues and managers

•Assistance needed to modify the workplace

•Insufficient advice or support in relation to work practices and safe transition of return to work

•Healthcare providers were more likely to advise work avoidance rather than strategies to help maintain employment

Chou et al., 2018

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Evidence Statements

•There is robust* evidence to suggest that a lack of work-focused healthcare (i.e., a failure by healthcare professionals (HCPs) to address work issues within the clinical encounter) is an obstacle to work participation.

•There is robust* evidence to suggest that a lack of communication and timely cooperation between HCPs and relevant stakeholders (e.g., employer, occupational therapist, compensatory system) is an obstacle to work participation.

*Includes good qualitative studies, evidence-based guidance, systematic reviews, reviews of multiple good studies, good original studies (e.g. cohort studies). Generally consistent findings provided by (reviews of) multiple scientific studies.

Bartys and Stochkendahl, 2019

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Relevance for physiotherapists

Among occupationally active adults, musculoskeletal disorders are the main cause of disability.

With their expertise in MSDs, PTs can play an important role in remaining at work with a health condition, facilitating rehabilitation, return to work (RTW), and prevention of absenteeism after an injury.

Several countries have specific educational programs that lead to becoming an occupational physiotherapist (OPT). However, for example in the Netherlands, less than 1% of PTs are registered as an OPT.

Therefore, it is incumbent on generalist physiotherapists (GPTs) to gain sufficient knowledge and skills to address occupational factors, and to refer patients (if needed) to other professionals.

Generalist physiotherapists may be reluctant to include work-related factors in their treatment plan if they lack occupational health training.

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Participants recognized the importance of addressing work participation.

Generalist physiotherapists take work participation insufficiently into account as a determining factor in the treatment of patients with musculoskeletal disorders.

Generalist physiotherapists often lack specific knowledge about work-related factors.

There is insufficient cooperation between generalist physiotherapists and other occupational healthcare providers.

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of the respondents indicated that occupational factors should be addressed to a greater extent within physiotherapy.

of the respondents indicated that they communicate with or consult a physiotherapist specialized in occupational health.

of the respondents who do not have a specialized physiotherapist within their practice sometimes/regularly refer patients to a specialized physiotherapist.

64%

15%

13%

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Questionnaires about patients´ work participation

Screening lists to assess to what extent the patient´s complaint is work-related

Knowledge about work tasks/work activities, work methods/techniques, working hours, workload

Practical tools to integrate work within physiotherapist practice

More practical skills to carry out basic workplace assessments

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Aim:To determine whether a coaching intervention which was focussed on enabling better strategies for coping with work stressors is superior to physiotherapy alone in the reduction of musculoskeletal complaints.

Results:In respect of musculoskeletal complaints, the IG compared to the CG showed a significant improvement in the pain severity of everyday movements.

The IG exhibited a significant improvement of work ability in reference to the physical working demands, and work-related wellbeing.

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Work-Up Trial

PHYSIOTHERAPY WORK PLACE DIALOGUE

Patient interview(PT and patient)

Employer interview(PT and employer)

CDM*(PT, patient and employer)

*Convergence Dialogue Meeting

Need for work place adjustments?

Who is responsible?When and how?

Follow-up?

• Caused by work

conditions?

• Caused by conditions

outside work?

• Has the employer made

any work place

adjustments?

• Has the patient made any

lifestyle changes or other

relevant changes?

• What is needed to maintain

or increase work ability?

Sennehed et al, 2018

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Musculoskeletal disorders are often

work related and almost always

work relevant.

Generalist physiotherapists

(GPTs) find it difficult to integrate

work participation in their care.

There are no existing interventions for

physiotherapists aimed at increasing

knowledge and improving cooperation

with regard to work participation.

Background

Funding

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Aim of the project is to improve the effectiveness

and efficiency of physiotherapy (in primary health

care) with respect to work participation of

employees with a musculoskeletal disorder by

increasing the knowledge and skills of generalist

physiotherapists and by improving the

collaboration between generalist physiotherapists

and occupational health physiotherapists.

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DEVELOPMENT

PRODUCTS

TOOLKIT E-LEARNING PROTOCOL DECISION TOOL COOPERATION

CONSULT

PROTOCOLDECISION TOOL

SEPTEMBER 2019

START DEVELOPMENT

PRODUCTS

FEBRUARY 2019

START RECRUITMENT

PHYSIOTHERAPISTS

AUGUST 2019

DEVELOPMENT

PRODUCTS FINISHED

SEPTEMBER 2019 – AUGUST 2020

RANDOMIZED CONTROLLED

TRIAL

SEPTEMBER 2020 – FEBRUARY

2021

DATA ANALYSIS

MARCH 2021

PUBLICATION AND

IMPLEMENTATION

PROJECT START PROJECT END

Time line

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History takingBasic knowledge / skills

Awareness patient

Examination Treatment

Cooperation Measurement

• Workload• Psychosocial factors• Work related / work

relevant• Work load, workplace,

methods, work pressure• Work - privat life balance• Load and loadability• Work content• Positive health • Work tasks analysis

• Laws and regulations• Responsibilities• Financial aspects• Role of employer• Advice about work• Coaching/ behaviour

change• Communication• Motivational interviewing• Shared decision making

• Assessment of work-related risks

• Load and loadability• Analysis of work tasks• Functional asssessment• Using photo / video

• Work(place) adaptations• Load and loadability advise• Workplace visit• Specific exercises• Manual handling / posture /

lift advise• RTW advise

• Information materials• Communication• Importance of work• Responsibilities• Self-management• Questionnaires

• Expertise occupational health providers

• Unknownness with occupationalhealth PT

• Network• Guidelines• Communictation

• Screening tools• Questionnaires

Guidelines

• Guidelines PT• Guidelines work• Guidelines other

professions (occupationalhealth)

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Definition self-management

“The ability to manage the symptoms, treatment, physical and psychosocial consequences, and lifestyle changes inherent in living with

a chronic condition”.

Barlow et al., 2010

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1. Screen for biopsychosocial factors and health comorbidities

2. Embrace patient-centred communication

3. What do you think you need to achieve your goals?

4. Educate beyond words using active learning approaches

5. Coach towards self-management

6. Address cormobid health factors

• Focus on providing a ‘management’ plan to control the disorder and limit its impact on the person’s well-being (not on cure).

• Ongoing self-management is essential.• Reframe the care for non-traumatic persistent and

disabling musculoskeletal pain conditions:• Strong clinical alliance• Education• Exercise and lifestyle (sleep hygiene, smoking

cessation, stress management, etc)

Build the individual’s self-efficacy to take control and ultimately be responsible for their health.

Lin et al., 2019; Caneiro et al., 2019; Lewis & O’Sullivan, 2018; Foster et al., 2018; Zadro at al., 2019

Guidelines recommend self-management, physical and psychological therapies, and some forms of complementary medicine, and place less emphasis on pharmacological and surgical treatments; routine use of imaging and investigations is not recommended

Only 12 out of the 48 studies on low back pain reported that physical therapists provide advice to stay active, while even less reported reassurance (n=2) or advice and education to support self-management (n=2).

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Self-managementPatients are stimulated to be engaged in:

• Activities that protect and promote health

• Monitoring and managing the symptoms and signs of illness

• Managing the impact of illness on functioning, emotions and interpersonal relationships

• Adhering to treatment regimes

Self-management enables patients:

• To make informed choices

• To adopt new perspectives and generic skills that can be applied to new problems as they arise

• To practice new health behaviours

Hutting, 2015

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Self-management attributesPerson-oriented attributes

1.The person must actively take part in the care

process.

2. The person must take responsibility for the care

process.

3. The person must have a positive way of coping with

adversity.

Person-environment-oriented attributes

4. The person must be correctly informed about the

condition, disease and treatment.

5. Self-management is individually defined and entails

expressing needs, values and priorities.

6. Self-management entails openness to ensure a

reciprocal partnership with healthcare providers.

7. Self-management entails openness to social

support.

Summarising attributes

8. Self-management is a lifetime task.

9. Self-management assumes personal skills:

9.1Problem-solving;

9.2 Decision-making;

9.3 Using resources;

9.4 Forming a patient-healthcare provider

partnership;

9.5 Goal setting and evaluating the attainment of

the goals.

10.Self-management encompasses medical, role and

emotional domains:

10.1 Medical management;

10.2 Role-management;

10.3 Emotional management.

Van der Velde et al., 2019

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Exercise and physical activity are effective in treating musculoskeletal pain and improving health.

An active lifestyle and exercise should be the cornerstone of a self-management approach.

National Institute for Health Research Dissemination Centre, 2018; Hutting et al., 2019

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Self-management vs education

•Self-management support is not simply patient education

•Patient education usually involves clinicians providing disease-specific information, teaching specific disease-related information, and contingency planning

•Self-management support focuses on teaching skills that can be generalized and that patients can use to manage their own health conditions independently

McGowan, 2012; Hutting et al., 2019

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Self-management vs education

Patient education Self-management

Provides information and teaches technical disease-

related skills

Teaches skills on how to act on problems

Problems covered are widespread common

problems related to a specific disease

Problems covered are identified by the patient

Disease specific and offers information and

technical skills related to the disease

Provides problem-solving skills that are relevant to

the consequences of chronic conditions in general

Based on the underlying theory that disease-specific

knowledge creates behavior change, which in turn

produces better outcomes

Based on the theory that greater patient confidence

in their capacity to make life-improving changes

yields better clinical outcomes

Goal is compliance Goal is increased self-efficacy and improved clinical

outcomes

Health professional is the educator Educators may be health professionals, peer leaders,

or other patients

McGowan, 2012

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Way of delivery

LOW PARTICIPATION

LEVELS

PROACTIVE

INTERMEDIARY MODEL

TO SUPPORT SELF-

CARE

GAP BETWEEN ONE-ON-

ONE PROVIDERS AND

INDEPENDENCE IN LONG-

TERM MANAGEMENT

LENGTHY INITIAL

PERIODS IN GROUP

CONTINUE WITHOUT

CONSULTATION

1

2 MEANINGFUL

THERAPEUTIC ALLIANCE

ONE SIZE DOES NOT FIT

ALL

Hoon et al., 2015; Beattie, 2018; Devan et al., 2018; Wahl et al., 2018; Hutting et al., 2019

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Providing self-management support• The most effective actions to support self-management include:

• Self-management support integrated into routine health care• Interactive online self-management programs

• Programs with individual sessions or in a clinical setting might improve adherence

• In an individualized self-management approach, health care providers focus on developing a ‘management’ plan to limit the impact of the condition on the person’s well-being, in close collaboration and partnership with the patient

• In this way, patients will feel empowered and have the skills and knowledge to actively manage their condition, even after the initial treatment period has ended

Evidence Centre for National Voices, 2014; Bal et al., 2014; Hutting et al., 2019

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OPEN ACCES

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Physical therapists should use a self-management approach to individualized (physical therapy) treatment for patients with persistent musculoskeletal disorders

whenever possible.

Physical therapists should use customized self-management support, targeting biomechanical, psychosocial, and individual characteristics in their treatment of people with

persistent musculoskeletal disorders.

Hutting et al., 2019

Https://www.Vectorstock.Com/royalty-free-vector/color-silhouette-with-multicolor-support-hands-vector-13589755

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What ‘good’ self-management support should look like• To facilitate effective self-management:

1. Help the patient to identify his or her barriers and goals2. Assist in identifying optimal strategies to reduce or avoid symptom

exacerbation through problem solving3. Support the patient to identify ways to measure the effectiveness of

self-management

• Within a self-management approach, health care providers can apply principles of cognitive behavioral therapy, shared decision making, acceptance and commitment therapy, mindfulness, motivational interviewing, and pain education

Hutting et al., 2019

@NathanHuttingHutting et al., 2019

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Take Home Messages

DISCUSS WORK WORK TOGETHER

PT CENTERED APPROACH SM SUPPORT

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Nathan.Hutting@han.nl