This presentation provides advice to general practitioners and practice managers about applying the relevant principles and considerations in assessing a patient with a work-related musculoskeletal injury.
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Doctor Education Series
Office of Industrial Relations
Advice to GPs on patients with musculoskeletaltal injuries
Recorded on: 15 December 2016
Presented by: Mr Dalton Langenhoven, Education Engagement Officer, Moderator
Presenter: Dr Matthew Brandt, Consultant Occupational Physician
Welcome to today's presentation specifically designed for general practitioners that will assist them in making an occupational health assessment of a patient presenting with a work related musculoskeletal injury.
The topic and speaker is brought to you by the Office of Industrial Relations. As a Department we are committed to driving initiatives across the whole scheme that improves safety, wellbeing and return to work outcomes for both businesses and workers. We recognise the valued contribution that medical practitioners make towards supporting workers return to the workplace as safe and early as possible.
My name is Dalton Langenhoven. I am the Education Engagement Officer within the Office of Industrial Relations.
We are pleased to introduce our presenter today, Dr Matt Brandt. Dr Brandt is a consultant occupational physician who has worked for several years in numerous treatment and consultancy roles assisting injured workers, employers and insurers. He has experience in medical risk assessment, analysis of causation of illness and injury, evidence based fitness for duty, rehabilitation and organisational management.
I will now hand over to Matthew to present today's topic.
Dr Matthew Brandt:
Well thank you very much. This webinar focuses on some key principles involved in the occupational health of a patient who's presenting with a musculoskeletal injury in the context of assessing work capacity.
So there are number of learning objectives for this webinar as listed on the slide there. So there will be a little bit of discussion around the role of the treating GP, the principles underlying the occupational health assessment, the assessment of the patient, the job and functional ability, and also some guidance on work capacity decision making. And this will be followed by a case study to illustrate the learning objectives.
So the primary role of the treating GP is to assess, diagnose and provide clinical intervention for the patient. But in the workers' compensation context, there are additional roles and responsibilities which involve supporting a return to work as early as is medically feasible, collaborating with other key stakeholders, including the injured worker, the employer and the insurer, to contribute to return to work planning, and regularly reviewing the progress against treatment and rehabilitation goals. And the last bullet point is work capacity certification which is also a requirement of this process.
So a few considerations. There are proven benefits for a successful recovery and return to work from an approach that involves a proactive, early evidence-based intervention. It's now very well known that an undue delay in return to work reduces the likelihood of recovery, increases the risk of prolonged disability and increases the risk of morbidity.
It's also important to acknowledge that the patient's acute injury could initially be worsened by the demands of the normal pre-injury duties by potential hazards in the work environment, and also the acute effects of the patient's injury could potentially present a risk to the patient but also others in the workplace, and certain work environments may initially be unsafe.
So now let's move on to the principles of the occupational health assessment which involve an assessment of the presenting situation, the job and the workplace, the patient's functional abilities and determining work capacity by matching the functional abilities with job requirements.
So the first slide involves an approach to assessment of the patient. Clearly obviously the priority here is to obviously provide an initial assessment with view to diagnosis and treatment, but it's also important to obtain the patient's history of the incident and the mechanism of injury. This information is recommended for medico legal purposes, and it's also required for work capacity certification.
During the initial assessment it's also advisable to gain an understanding of the patient's premorbid functioning in regards activities of daily living and recreation, but I've also mentioned the advice to assess whether any currently prescribed medications could result in any potential adverse effects that could impact on a safe return to work and travel.
In the initial assessment it's also beneficial to gain an understanding of comorbidities, including relevant underlying conditions or prior injury or pathology that may have actually been aggravated by the subject incident, or could potentially impede recovery from the current injury. There may also be other medical conditions and comorbidities which combined with the current injury could worsen the functional effects arising out of the current injury.
I would also recommend initial exploration of any potential psychosocial factors which may affect recovery at this stage.
During the initial assessment I would also routinely obtain information about the baseline level of physical tolerances. And you can see on that particular slide there's a number of physical and postural tolerances listed there based on mobility and use of the upper limbs and so forth. And for each of those sorts of tolerances it's useful to estimate from discussion with the patient the duration of which an activity can be performed, whether an activity can be performed or not, distance, particularly for mobility tolerances, and safe load capacity, particularly for upper limb activities.
Now whilst this information can initially be obtained from history and observation, further down the track during the course of rehabilitation, on occasion it is necessary to recommend a formal functional capacity valuation, which is typically performed by an occupational therapist or an occupational physiotherapist.
So having assessed the patient in regards to the acute injury and the physical tolerances arising out of the effects of the injury, the next phase of the assessment is to assess the job and the workplace. Now typically this can be done in any number of ways. Often the employer will be able to provide a task analysis which provides information about the nature of the duties and the environments the duties are performed in and the physical demands. That may not always be available however, and information can also be obtained discussing with the patient and also potentially the rehabilitation coordinator if they're available at the time.
The next few slides list some important attributes of the work and the work environment that do need to be considered in helping to plan a safe return to work. And you'll note on the first slide travel to and from work is important, as is the work environment, and in particular any requirement for example to climb stairs or mobilise to amenities or any requirement for wheelchair accessibility.
And this slide illustrates the range of potential physical job demands that might be relevant to the job, and it's important to obtain that information either from a discussion with the patient and potentially with the employer, but also the employer may be able to provide a job task analysis around these physical job demands.
Now in assessing the job itself and the workplace, there are a number of other considerations, and these can include hazards, so for example if the job involves ambulating over uneven or potentially slippery surfaces, personal protective equipment such as the requirement to wear safety boots, and emergency and evacuation procedures.
Part of the initial assessment is also to gauge the psychosocial characteristics of the workplace and the work relationships, including the supervisory relationship and the job satisfaction of the patient. It's also useful at this point to have a discussion with the patient in regards their perceived ability and any potential difficulties or barriers in regards return to work.
So this next slide outlines some of the considerations when assessing the patient's functional ability. And I guess the most important questions are first of all is the patient's functional ability affected by the injury at this stage? Are any particular activities at work likely to aggravate the injury or hinder recovery? And what are the patient's capabilities and constraints, so for example in regards use of the upper limbs or ambulating and climbing or operating machinery, particularly if hand or foot controls are required?
And the purpose of this particular part of the assessment is to evaluate the match between the patient's functional ability and the job requirements in order to be able to facilitate a safe return to work.
So once the assessment has reached this stage, we're getting to the point where we're able to now make some decisions with the patient about the return to work. And generally speaking there are going to be three decision nodes. Firstly, the patient currently has the capacity to safely return to normal pre-injury duties. Secondly, the patient has the capacity to safely return to work if suitable duties are available, and these could include modified tasks, alternative duties or a temporary placement at a different job. Or thirdly, the patient doesn't currently have the functional capacity to safely return to any form of work.
Now this third decision node is generally going to be unlikely, because most of the time, albeit depending on the nature of the injury and the workplace, the patient will have a capacity to resume some form of work, and this may involve suitable duties and reduced hours for a period of time.
So a couple of important principles in the decision making in regards temporary unfitness for work. First of all this would generally be pending further treatment and review. One would expect that the capacity will change over time with recovery. And secondly, it's important at this point if we're making that decision with the patient and the employer, that we do communicate very clearly a predicted timeframe for a return to some form of work and then eventually full duties.
So we'll move on to a case study. So this patient is fictitious. It's not been taken from real practice.
Alex MacDonald is a 24 year old construction labourer and supervisor employed in the building industry. Now Alex on the previous day sustained a left ankle inversion/plantar flexion injury whilst stepping down from scaffolding at a building site. Alex was taken to a private hospital emergency department and was diagnosed with a partial tear of the anterior talofibular ligament and treatment was commenced.
Now Alex has now presented to your practice on the following day accompanied by the employer's rehabilitation coordinator. Alex is mobilising with crutches and Alex's left ankle is in a compression wrap.
So presuming that your role is involved in treatment and rehabilitation, including physical therapy, but also in assisting and planning the return to work process, maybe pause the presentation briefly and have a bit of a think about further information that you want to obtain at this point to assist in assessing Alex's work capacity.
So in regards additional history, Alex is reporting pain and tenderness around the left lateral ankle. The pain is at a visual analogue score of 3/10. There is considerable bruising around the left lateral ankle. Alex is unable to weight bear on the left foot and would be unable to wear a safety boot at this stage, but he's able to mobilise safely using crutches. Now Alex's current treatment is simple analgesia and non-steroidal anti-inflammatory medication, as well as regular elevation of the left foot and the application of an ice pack three times per day. Now we wouldn't be anticipating any adverse functional effects from current use of analgesia.
Alex prior to the injury was very physically active, participating in full activities of daily living, regular social touch football, swimming and bush walking. Now in regards comorbidities, Alex does not have any prior history of a relevant lower limb condition. Alex has a prior history of asthma which is controlled with inhaled preventative medication and is not currently symptomatic, and Alex is taking a prescribed SSRI medication for a depressive disorder and is currently not experiencing any significant mood or neuro vegetative symptoms.
So the next slide will look at some of the current physical tolerances, but before we move on to that slide, again it might be worth your while pausing briefly to reflect on some of the impacts of Alex's left ankle injury at day one on functional abilities and tolerances.
So this slide shows a table of Alex's current physical tolerances. Under the left column are a number of different postural and mobility and upper limb tolerances, and on the right column is the impact of Alex's left ankle injury at this stage. So the table illustrates that presently Alex has an unrestricted sitting tolerance, but has a very limited standing tolerance and requires crutches and is only able to walk over short distances with crutches, and would not be able to safely mobilise over any uneven or slippery surface. At the present time, because of the requirement to use crutches, Alex is not able to mobilise up a gradient, stairs or ladders.
We haven't assessed Alex's balance formally, but it's likely to be impaired at the present time. And again because of the limitation through the left lower limb, Alex would not be currently capable of safely crouching or kneeling.
Because of the requirement to use crutches Alex is unable to lift and carry things, but would be able to push or pull objects and manipulate objects in the seated position. And at the bottom of the table you'll note the comment on driving, and I've mentioned that Alex would not be currently capable of driving any vehicle requiring use of the left foot for control.
So now that we've evaluated the nature of Alex's injury and current physical tolerances, let's move on to the job requirements itself, so an assessment of the job. Alex drives a manual ute between home and various work sites, and it takes about one hour each way. Alex performs a range of building construction tasks and supervision of other labourers on a full time basis between Monday and Friday. The work environment is primarily outdoors and it does involve working on uneven and potentially slippery surfaces.
In consultation with Alex and in viewing the task analysis document that's been provided by Alex's employer, you note that the physical demands include constant standing and extensive walking, occasional climbing of steps or ladders, occasional crouching and kneeling, and quite a significant degree of lifting between floor and chest height.
You'll also note that there is some occasional repetitive upper limb motion and occasional impact activities such as use of a hammer.
In regards hazards, it's clear from discussion with Alex and review of the documentation that the workplace is characterised by uneven and potentially slippery terrain and moving machinery. It is mandatory for all workers on the construction site to wear safety boots, and it's important to understand now I think that Alex has a very supportive supervisor and company manager. Alex enjoys the job and wants to progress into a managerial role in the industry.
During discussion it becomes apparent that office based seated duties are available away from the construction site. And during discussion with Alex it's apparent that Alex understands that it's not currently possible to return to full duties on the building site, but Alex wants to resume some form of work as soon as possible.
So this slide summarises the assessment findings in regards Alex's functional ability which will lead into decision making in regards work capacity. So first of all it's very clear from the preceding slides that Alex currently has a diminished capability for weight bearing, crouching, climbing and driving. And at day one of an acute left ankle soft tissue injury, any sort of activities involving unsupported weight bearing, crouching and climbing are currently likely to potentially aggravate the injury but also hinder recovery.
Due to the limited weight bearing capability and an inability to wear a safety boot and requirement to use crutches, Alex is not currently able to safely resume normal duties at the construction site. Furthermore, it's clear that Alex would not be able to presently drive a manual vehicle to and from work or to a work site.
Having said all that, Alex does have the capability to perform seated office tasks at a workstation which facilitates foot elevation as required, but would need to be able to use crutches to mobilise in the workplace, so for example from the vehicle to the office and within the office, and to access and use workplace amenities, but obviously would not be able to climb stairs or steps in the workplace.
So in terms of assessment of work capacity, these are the conclusions I've reached. First of all Alex does not presently have the capacity to safely return to normal pre-injury duties, but does have the capacity to safely return to some form of work if suitable duties and assistance with transport are available within current constraints. And it's clear that Alex has expressed the motivation to resume work and has an employer who is supporting his rehabilitation.
At this point I would also conclude that the assessment prognosis in Alex's case is pending further treatment and functional rehabilitation, but it's reasonable to predict that recovery and gradual return to full work is likely to occur within about four to six weeks.
So in summary, this webinar has focused on some of the key principles of occupational health assessment for a patient presenting with a musculoskeletal injury in the context of assessing work capacity.
Thank you very much, and I'll now hand you back to Dalton.
Thank you Matt for sharing your experience on today's topic.
The Office of Industrial Relations is committed to sharing knowledge with its stakeholders on the latest topics related to effective rehabilitation and early return to work for injured workers. We hope the information provided has been of value.
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