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ON Communicating: One size does not suit all

A one hour webinar to help all stakeholders prepare meaningful suitable duties programs for injured workers suffering from musculoskeletal disorders.

The session covers:

  • current research and developments on musculoskeletal disorders
  • managing and treating injured workers with musculoskeletal disorders
  • new rehabilitation strategies for injured workers with musculoskeletal disorders
  • the evolution of rehabilitation for musculoskeletal disorders.

Download a copy of this film (ZIP/MP4, 10 MB)

Online series ON. One size does not suit all

On series – by Office of Industrial Relations

Welcome to today's ON session entitled 'One size does not suit all'. The topic and expert speakers brought to you by the Office of Industrial Relations. We're committed to driving initiatives across the whole scheme that improve safety, wellbeing and return to work outcomes for both employers and workers. My name is Allicia Bailey and I am the Engagement Services Manager and I'll be your facilitator for today's session.

So today's session is really focused on helping all stakeholders prepare meaningful suitable duties programs for your workers suffering from musculoskeletal disorders. We intend that the session will go for approximately one hour and we'll be emailing all participants a copy of the presentation slides following today's session. We also will place a recording of the session on the Work Safe Queensland website which you're welcome to access at a later time.

So now let me introduce you to today's speakers. We have Dr Venerina Johnston and Marina Vitale who both have extensive backgrounds in injury management. Dr Johnston is an Associate Professor in the School of Health and Rehabilitation at the University of Queensland. She has qualifications in physiotherapy, occupational health and safety and work disability prevention.

Marina is the Senior Rehab Consultant for CIM Health. She is also a physiotherapist who has been working in occupational health delivering injury management services to various industry groups for workers and their employers over the past 10 years.

Both presenters are happy to take questions throughout the presentation today so don't hesitate. If you do have a question feel free to type it in the little chat box on the right hand side of your screen and we can get to those throughout the presentation. So that's enough from me. I'll hand you over to your experts who will be able to share their knowledge on the topic. So over to you.

Good afternoon everyone. Marina and I have been asked to provide an update on the latest research and developments occurring around the management of musculoskeletal disorders, the current approaches to rehabilitation for these disorders and how it has evolved, particularly when dealing with work-related compensable MSDs. While we can't address all the developments in treatment and recovery, we will provide some insight on how to translate some of these developments through a complex case scenario and hope to focus on a few key strategies that may assist your management of workers with musculoskeletal problems in your workplace.

Reviewing the Queensland Workers Compensation Regulator Report of 2014 to 2015, serious musculoskeletal injuries made up 61 per cent of all WorkCover claims in Queensland with sprain and strain claim injuries accounting for almost a third of all claims lodged in that year. Of these the back was the major bodily location accounting for 8.3 per cent of all lodgements. So just in case you're unsure of the definition of what constitutes a serious claim, it is a workers' compensation claim for an incapacity that results in a total absence from work of one working week or more.

There are some industry groups and some sectors that attract more musculoskeletal injury claims than other causes for claims such as the manufacturing industry in which musculoskeletal disorders accounted for 54 per cent of claims of all non-fatal injuries. Body stressing caused 43 per cent of these injuries and was the most prevalent causes of injuries in all industry sectors. In the transport sector almost a third of injuries affected the lower back – 31 per cent, 15 per cent affected the shoulder and 12 per cent involved the knee. A quarter of these workers with musculoskeletal disorders were heavy truck drivers. Finally the hospital and nursing home sub-sector was responsible for 84 per cent of all musculoskeletal disorder claims in the health services industry sector.

There are several issues facing industry that may impact on the number and severity of musculoskeletal claims. One of these issues is the ageing workforce. Older workers with musculoskeletal disorders tend to experience increased timeframes for recovery. There may be comorbidities to manage and they may also experience more difficulty returning to physically demanding job roles. Again the 2014-15 statistics from the Regulator reports that workers between the ages of 30 to 44 years represented the greatest reported injury rate for the back whereas workers between the ages of 45 to 59 years reported the highest rate of shoulder conditions and other body areas for sprains and strains. Interestingly workers 60 years and over only made up 7.4 per cent of all claim lodgements in 2014 to 2015. However this may change if we are expected to keep working until we're 70.

So we just heard about the prevalence and location of musculoskeletal injuries in Queensland. If we were to look at the national workers' compensation data from Safe Work Australia this shows that the proportion of workers' compensation claims due to musculoskeletal injury have remained fairly constant over the last 10 years. However a few things have changed and during this time the median time lost from work for a serious claim has increased by 29 per cent from 4.2 working weeks in 2000 to 5.4 working weeks in 2011 and '12. This suggests that injured workers are taking longer to return to work than a decade ago. It's unlikely that older workers are contributing to this increase because they constitute just a small proportion of the total number of claims. Not surprisingly the cost of a serious claim has increased substantially since 2000 by 71 per cent.

So in terms of what has changed in musculoskeletal rehabilitation there are several factors that have made significant contributions to the way MSDs are managed. This includes advances in the evidence base, advances in medical technology and practice, reforms in workers' compensation legislation, the expectation of the various stakeholders in the return to work process and of course alternative models of care. So these are just the majority of things that have changed over time.

So in terms of advances in evidence base and technology there's been a significant increase in the amount of research conducted across the globe not only for the management of musculoskeletal problems but also how do we prevent the negative consequences that sometimes occur following a musculoskeletal problem? Much research has focused on identifying the right treatments for the right person at the right time because one size does not fit all.

For example some treatments are more effective in the acute than the chronic stage of recovery. There's greater knowledge of the risk factors for delayed recovery and return to work. For example we now know that depression and job dissatisfaction can negatively impact recovery and return to work. One of the greatest advances in knowledge is about the complexity of pain and how sometimes it can transition from acute to chronic pain. Chronic pain has physiological as well as psychological characteristics that may help explain why pain can continue after recovery has occurred from the original injury. We understand that education about the neurophysiology of pain can be a powerful tool in the management of chronic pain conditions. Therefore it's not unusual for health professionals to spend a fair bit of the clinical consultation time providing education and advice.

In conjunction with the research we now know that there's many interventions that can reduce the symptoms and improve return to work and recovery but also are cost effective. Our advances in medical technology and practice have resulted in faster and more accurate diagnosis so interventions are better targeted. There's a couple of websites there to help you if you want more information about pain.

In terms of the reforms and changes in the workers' compensation system, they've certainly increased over time in terms of increased employer responsibility for prevention of injury and managing the return to work of injured workers. There's also a greater focus for workers to have a work outcome by the end of their claim. Along with this ideal comes the concept of durability which provides the injured worker and employers with peace of mind that the individual has recovered and has a minimal risk of re-aggravation. In the past the first return to work was the only milestone considered and measured but now we realise the importance of ensuring that return to work is sustained.

Other changes in the workers' compensation system include the range of services that may be engaged to manage the return to work process. So these include things like a functional capacity evaluation to determine a person's current level of capacity which is particularly useful when recovery is delayed or plateaued despite treatment. We now have host placement to allow workers to build their functional tolerances in a less demanding role whilst receiving treatment for their condition before returning to their own workplace and usual work. Finally something else that's really changed and has been very important for injured workers is the increasing use of vocational assessment, host placement and job seeking services as part of the claims process. This provides a worker with the best possible chance of meaningful employment at the end of their claim particularly if it looks unlikely that they'll ever be able to return to their pre-injury role.

The expectations of stakeholders in terms of the insurers and regulators has also changed. The regulators and insurers require health professionals to be more accountable as evidenced the Provider Management Plan. Health professionals are required to demonstrate the effectiveness of the intervention that they're using, functional outcome measures to identify barriers to return to work and recommend strategies to overcome these barriers. The barriers may be physical, psychological or workplace. Hence it's not unusual today for a physiotherapist or a psychologist to assess an injured person's psychological and social status. This information helps identify potential risk factors for delayed recovery.

Health care professionals are also expected to adhere to the principles of the Clinical Framework which we'll be discussing later on. As part of the implementation of these principles it's expected that health care professionals will communicate with other health care professionals to assist in the rehabilitation of injured persons. To facilitate this communication it's now included as a billable service in the table of costs as is case conferencing.

Health practitioners have also changed in their expectations in that they expect their time to complete forms such as the medical certificate and to communicate with the other stakeholders to be reimbursed. There is also a greater emphasis on the patient contribution to the recovery and rehabilitation journey. So the health practitioner may actually spend more time now engaging the worker in the rehab process.

In addition to all these expectations the worker themselves has changed in what they expect from the health professional and the insurer. They expect a holistic and comprehensive health service a bit like a one-stop-shop where they can attend the medical professional, the physiotherapist, exercise physiologist, psychologist etc. Something else that's changed over time is the increased health literacy of the individual which means that they're more interested and engaged in the rehabilitation process. Expectations of the employer have changed and many actually take overall control and responsibility for managing the return to work of injured workers especially if the organisation is self-insured. Many large organisations employ health professionals to provide in-house injury management services but sometimes may subcontract this work to an external rehab provider for complex cases.

Another advance in the way health care is being delivered is an alternative model of care. So with increases in technology and costs of delivering health care, we as a society are exploring alternative models of care such as telehealth and telerehab, multidisciplinary and transdisciplinary care, telephone delivered care and extended scope of practice. Telemedicine for example is being delivered for people in remote communities but I'm not aware of it being used to deliver occupational rehab services in Queensland. Well not yet. Maybe it is.

There's also an increasing number of health professionals involved in the return to work process such as the psychologist, locational counsellor and exercise physiologist compared to 30 years ago and now an integral part of the team. While the multidisciplinary approach to health care is common in other areas for health, the need for someone to coordinate the rehab process is of far greater importance now than ever. It's extremely easy for each member of the team to work under isolated silos which increases the need for each professional to be aware of what everyone else does, when to refer to another health professional and how they can work best to achieve an optimal outcome for the worker. That's a key role for the return to work coordinator.

The workers' compensation regulators in conjunction with health professional bodies developed the Clinical Framework for the management of an injured person to support health care professionals in their treatment of an injury through five principles. These principles are consistent with best practice and the evidence base for recovery following workplace injury. We will summarise the principles here and demonstrate how they are utilised through a case study.

These five principles are measurement and demonstration of the effectiveness of treatment, empowering the injured person to manage their injury, adoption of a biopsychosocial approach, implementing goals focused on optimising function, participation and return to work, and base treatment on best practice available through research evidence.

Before we start the case study we thought we should elaborate on the biopsychosocial framework to understanding and managing musculoskeletal problems. This models expands on the traditional biomedical model as we now realise that there are many factors contributing to and recovery from a musculoskeletal problem other than the actual soft tissue injury. This model considers the physical, psychological and social factors. The 'bio' refers to the physical or mental health condition. The 'psychological' aspects recognises that the individual psychological factors also influence function and that the person themselves must take some measure of personal responsibility for his or her behaviour. The 'social' component recognises the importance of the social context such as the work and family environment and the various pressures and constraints on their behaviour and functioning. By adopting the biopsychosocial model we recognise the critical domains that need to be considered in injury management approaches.

Okay. So we're just going to move onto the case study now. We sent you this prior to the webinar and hopefully you've had a chance to read it. This is a real case I was involved with as the occupational rehabilitation provider. It has been embellished and modified somewhat to protect the identity of the worker. I will talk through the case and Venerina will intervene at several points to discuss the evidence for the intervention.

So John's a 49 year old labourer reporting high levels of pain the lower back radiating down his right leg from an incident at work involving the use of a manual hand tool. He was upset that it was the third time his back was sore from this task over a short period of time, that his employer had not supplied the pneumatic tool that he had been promised and it was his perception that clearly no one was listening or caring about his situation. So he went to his doctor and then to his lawyer.

John was initially given the diagnosis of non-specific low back pain. This is actually the most common type of acute low back pain. It's called 'non-specific' because no specific problem or disease can be identified as the cause of the pain. Most likely it's soft tissue, for example muscular. In the past when a patient heard this diagnosis it was sometimes interpreted as 'Well if there's no cause for the pain it must be in my head.' Fortunately our understanding of pain has increased enormously and we now know that the lack of visible evidence on X-Ray or MRI does not indicate that the pain is real.

John had been off work for eight weeks when the rehabilitation provider was called to do an initial needs assessment which was agreed to occur at his home. A simple functional capacity screening was conducted and his psychological status was discussed openly. He reported constant high levels of pain, nine out of 10 on a visual analogue scale. He'd had a lumbar epidural injection three weeks earlier into his lumbar facet joints and physiotherapy which had had little effect. He was referred to a spinal specialist who was unable to recommend any other intervention except pain management. John had been prescribed Endep but found this spaced him out and he didn't like the feeling. He also noticed that his mood was becoming more irritable.

John reported that he had OCD type behaviour with his home duties. He enjoyed a drink usually and he had a passion for lawn bowls which he played competitively. He was a single parent of two daughters who were now at university and he felt he had to continue to support them financially. He believed that he was good at his job for which he'd been employed for more than 20 years.

So based on the information that you've heard do you think John's at risk of a poor work outcome? The evidence suggests that the following features are associated with a greater risk of poor work outcome.

Heavy physical work is a known risk factor for poor return to work. A history of low back pain is actually one of the strongest predictors of future low back pain. Pain referred down the leg which we call radiating pain is another predictor of poor recovery and the time since initial injury. So we know that John's symptoms may be actually transitioning to the chronic phase of disability. We know that the longer a person is away from work the harder it is to return to work. Finally the poor relationship with the workplace, so that tension is associated or may be associated with a delayed return to work. So therefore John's irritability is understandable given the negative impact of the injury on his financial and social situation where he wasn't able to play lawn bowls.

So just for your information John's diagnosis was revised to Gluteus Medius Tendinopathy. This condition is characterised by pain at the side of the hip and is very common in people with lower back pain. In conjunction with John a plan was then developed to move him forward. This included identifying his goals as A) return to work and B) return to lawn bowls. John recognised that to achieve both goals he needed to improve his general fitness and his back strength and endurance. Once these goals were identified strategies to achieve these goals were established. It was explained that in contrast to his younger football playing days his body would take a little longer to recover.

The agreed on strategies included first of all attending hydrotherapy three times a week – Monday, Wednesday, Friday from 10:00 'til 11:00 for the first two weeks increasing to daily for the next two weeks as per his doctor's recommendations. This was the potential to improve his general fitness and back strength. John decided these times would be more beneficial as he found it difficult to get going in the mornings and the hydrotherapy would help him with this.

The next strategy was developing a return to work plan. This involved discussion on the benefits of a graduated return to work for him physically and psychologically. John was asked what he felt was a reasonable number of hours of work, timing of work hours with his hydrotherapy sessions and what suitable duties he could identify at the workplace. However the suitable duties plan did end up in another work area due to the heavy physical demands of his usual work. Whilst John was initially unhappy with this decision it was explained that this was a temporary measure until his medical restrictions had allowed him to attend his hydrotherapy sessions.

So there were several barriers to achieving the planned hydrotherapy sessions and the return to work were identified. The first was John reported that driving for more than 15 minutes made his glute burn and walking was also restricted. So it was negotiated with the workplace we could use taxi vouchers provided by them to attend hydrotherapy and work until his sitting and walking tolerances improved. The second barrier – John was concerned about the impact of the medications on his cognitive levels but was reluctant to reduce the medication in fear that his pain levels would increase. This is a normal fear and using motivational interviewing, he was empowered to discuss with the pain specialist reducing and even ceasing the medications. A letter outlining the agreed plan was provided for John to give to the specialist at his next appointment.

The third barrier – John was reluctant to attend the work site to establish the return to work plan. He felt let down by his employer. Again through motivational interviewing and pointing out that I, as the independent third party, would be there to facilitate the discussions and keep them positive, John agreed to attend. A work site visit with his supervisor, manager, return to work coordinator and myself was organised. The purpose of the visit was to ensure that the duties identified were suitable and that any other ergonomic considerations could be arranged to assist John with pacing of duties.

During the work site visit the supervisor walked him through the suitable duties so that there would be no misunderstanding of the expectations of the worker whilst on site. John performed some of the key tasks to show that he was able to perform them. All assistive handling equipment was organised and trialled. A suitable chair was identified for his seated breaks and a safety induction was performed that John had to sign off on.

With John's written consent I discussed his return to work plan further with his employer. During these discussions I pointed out that John was concerned about reinjury on his return to work, that no one was listening to him and that he was taking positive steps to rehabilitate from his injury. I also suggested to the employer that maintaining John's connection with his work teammates such as inviting them to a toolbox meeting or smoko would also show that his employer is interested in his wellbeing and recovery from his injury. The agreed plan was detailed in writing and submitted to John's doctor for approval. All parties signed the plan.

Let's have a look at how the clinical framework for the delivery of health services was applied in John's case. The first principal is that a health professional should measure and demonstrate the effectiveness of treatment. In this case the rehab provider used the Orebro Acute Low Back Scale. I don't think Marina actually mentioned it, but she did say she did.

Other scales that could have been used are the Oswestry Back Disability Questionnaire, the Return to Work Self-Efficacy Scale or the Patient-Specific Functional Outcome Measure. Any measure that's taken at baseline should be reassessed at regular intervals and be relevant to the functional goals and the person's injury. Some of these scales like the Orebro and the Return to Work Self-Efficacy Scale are particularly useful as they include questions to identify psychosocial concerns.

The second principle recommends that the health provider adopt a biopsychosocial approach. In John's case this approach was adopted to understand the biological concerns, that means the excess pain, the radiating pain and the problems sitting for more than 15 minutes, the psychological issues which was the fear of reinjury and the social barriers which was the tension at the workplace. All of these concerns need to be addressed to ensure a successful outcome. There's no specific order or hierarchy in which they should be addressed, but usually occur simultaneously.

The research tells us that the psychosocial predictors for work outcomes that for people like John with subacute back pain, there's strong evidence for recovery expectations but not depression or job satisfaction, or psychological strain. In fact a systematic review found that the odds of remaining absent from work at a given time point beyond 12 weeks after the onset of pain were two times higher among those with negative expectations about their recovery. This highlights the importance of staying positive with the worker throughout the return to work process.

To empower the injured person to manage their injury the rehab provider in this case used motivational interviewing to engage and help John identify his goals, develop strategies and solve problems in a collaborative, client-focused relationship. There is actually evidence that adding problem solving to usual care for workers with low back pain can significantly reduce the number of days of sick leave and increase the likelihood of return to work.

The advantage of problem solving with the worker is that it teaches strategies to help them feel confident and in control of stressful situations, for example to solve work-related problems when pain reoccurs. Recently researchers in Sweden developed an early intervention program for injured workers and their supervisors to improve problem solving and communication skills. They showed that this early intervention reduced the number of days absent from work and the number of health care visits compared with usual care. Interestingly the communication training was based on empathetic, person-centred techniques.

The fourth principle states that the health provider should implement goals focused on optimising function, participation and return to work. In John's case the SMART goals were set.

The acronym 'SMART' stands for specific, measureable, achievable, relevant and timed. You'll recognise the goals set for John. They were specific in terms of he had to attend hydrotherapy to build strength and endurance for return to work and lawn bowls. It was measurable such that he was going three times a week - Monday, Wednesday, Friday 10:00 'til 11:00 for the first two weeks. The intervention was achievable in that the activity selected was discussed with John and it was relevant because walking was problematic. So hydrotherapy was a good compromise to increase fitness and strength. It was timed in that hydrotherapy was to start tomorrow and after two weeks he would increase to daily sessions.

So now I'd like to walk you through a sample of the four weeks' suitable duties program that was compiled for John. So for weeks one and two John commenced the return to work using a two week plan initially starting with three hours for three days for the first week and then four hours for three days per week so as not to overwhelm him, allow him to attend hydrotherapy and make him feel he was succeeding with the goals set for his return to work.

Weeks three and four – once John had demonstrated his capacity over the initial two week plan a new plan was drawn up and of course approved by his treating doctor graduating hours and days to five hours per day, five days per week.

You may also notice on the plan that during this time the lifting tolerances were gradually increased and the level from where he was lifting to and from was also graduated. This approach provided John the opportunity to increase his overall function and confidence to work below waist level again which he needed to do when he returned to his usual work area.

At the end of week four John's self-efficacy was increased to the point that he believed that the suitable duties plan was no longer necessary. So he sought a clearance to return to his usual job role. As you can imagine this freaked out his employer because they were not ready for this. So it was decided that I would perform a functional capacity evaluation of his usual job requirements on site along with the supervisor to ensure that he was able to work unrestricted. This process provided confidence to the employer and co-workers that he was capable of returning to his usual job role. His supervisor presented him with a new pneumatic power tool to replace the hand tool and the claim ended with John returning to his usual job the following day. His solicitor was not mentioned again.

It's obvious that principle five of the clinical framework is at work here which is base treatment on the best available research evidence. The evidence supports involving the worker, supervisor and case manager from the workplace in developing a return to work plan. The evidence also supports that the plan should include suitable duties that are agreed to by all parties, a strength and conditioning program that included hydrotherapy, improved symptoms and durability, the offer of modified duties by the employer suitable to the individual's functional capacity and consistent with medical restrictions is also supported by the evidence, the importance of having someone to coordinate the return to work, in this case the external rehab provider and that the employer and health care providers communicate with each other about the workplace demands as needed with the worker's consent. In John's case the rehabilitation provider communicated with the treating doctor.

So to summarise we can see that in John's case he had actually a positive outcome but there were a few obstacles along the way. For example some of the risk factors for delayed recovery and return to work should have been identified earlier than eight weeks post injury. However once the rehab provider was introduced together with John, goals were identified, strategies determined and problems solved in a collaborative relationship. The relationship between John and the health professional and rehab provider is crucial and must be centred on mutual trust. John was engaged with the process by openly discussing his recovery. This was only possible through the client-focused relationship established. For example the rehab provider met John at his home rather than the workplace. This action demonstrated to John that she was able to meet him in an environment where he felt safe.

The lack of success with physiotherapy and a lumbar epidural injection was another obstacle. This lack of success should not be interpreted as health provider ineffectiveness. There are several possible explanations. Firstly the intervention may not have been appropriate for John and as we saw, the final diagnosis was actually gluteal tendinopathy which wouldn't have responded to the lumbar injection. Back pain is not a homogenous condition. By this I mean that not all back pain is the same and differentiating this from gluteal tendinopathy can be challenging. It's important to identify which treatments work for the presenting problem and as the title of this presentation says, one treatment or a treatment, one size or treatment does not fit all.

There were some elements of success and these included effective communication throughout the return to work process and addressing psychosocial concerns early.

So maintaining open and honest communication from the initial reporting of the incident to the return to work program is crucial. Using communication styles such as effective questioning or open-ended questions allows the injured worker to feel that they have been heard in a non-judgemental way. I'm often amazed how much you can find out in a short period of time what injured workers are really thinking and feeling about their injury. You can start to formulate an understanding of what other factors may be impacting on them if you just give them their five minutes to debrief.

Effective communication also means getting the worker involved in the process. They should be kept up to date through regular agreed communications such as phone, text or face to face by their employer representative. Providing this support can prevent them feeling isolated from their workplace and team especially when delayed return to work can occur due to the nature of their injury. Focus on what they can do rather than what they can't do. Everyone responds well to positive feedback, so acknowledge injured workers on suitable duties when they are doing well and provide encouragement to meet their goals. Showing empathy by trying to put yourself in the worker's shoes to understand why they may be reluctant to report an injury or why they don't see meaning in the proposed suitable duties you have suggested. You can also get them to buy in the injured workers when formulating suitable duties.

Marina, can I just interrupt and ask a question at this point? I know from their lead up into the case study it was really clear that John had this disconnect with his workplace and there was a bit of mistrust or the relationship was strained to some extent and you guys have really enforced the importance of communication. Are those strategies that you've just listed, do they form part of this motivational interviewing technique which you touched on? Or is it a different concept that people need to know about?

Effective communication, all those points that I mentioned is all part of motivational interviewing. So being client focused, having that empathy, keeping it client centred and goal orientated and getting them to help as part of the problem solving of how to move forward.

So as we saw in John's case there was some psychosocial risk factors. Whilst I'm not an organisation psychologist employers and health professionals can be vigilant to identify psychosocial risk factors that are relevant to musculoskeletal injuries and return to work outcomes. We know that it is essential to identify yellow or the psychological flags and blue occupational flags within the first 12 weeks of an injury occurring. This timeframe is recognised as being the crucial time during which to intervene. Treatment can include cognitive and behavioural management and/or workplace liaison and intervention.

Employee assistance programs or EAPs can be used for critical incident debriefing to address any catastrophising behaviours or adjustment to injury counselling to assist with pain management. Workplaces can also look at addressing the work demands, the environment and other workplace influences such as interactions with co-workers, EBA or job security. Mediation at the workplace, case conferences or on-site meetings including HR and insurer representatives can also assist with addressing some of these workplace stresses.

If the supervisor is one of the barriers for return to work, an alternative person for the worker to report to within the workplace can be organised or an external provider may be required.

We're coming to the end of our presentation, so in summary best practice in managing musculoskeletal disorders and return to work include things like the rehabilitation provider following the clinical framework for injured workers by adopting a biopsychosocial approach. In this approach the workers are empowered to manage their injury. Treatment effectiveness is measured and is based on best available research evidence. There should be clear goals determined and tailored to the individual with graduated exposure to tasks and/or hours of work to build their confidence and fitness for work. When these goals are focused on optimising function a return to work that is timely and durable has a better chance of success.

Best practice also includes identifying any issues or flags as Marina mentioned that may be potential barriers to return to work as soon as possible. It's important to agree on the best methods to communicate with all stakeholders on a regular basis so that potential barriers to a timely return to work can be problem solved. We know that recovery at work is best, however sometimes the nature of work will be the greatest barrier for a timely return to work. Employers and rehabilitation providers may need to be more creative to find meaningful and staged exposure to tasks that are considered more demanding or high risk. Use of a host employer at times can be the most appropriate way to ensure work hardening for return to work and reduce the risk of psychological issues for delayed return to work.

Best practice also includes knowing the legislation and the services that are available through the insurer. For example when recovery has plateaued a functional capacity assessment or an independent medical assessment can be very useful. Good intentions for return to work can easily go off track. So adhering to the process whilst tailoring your approach to the individual can make a big difference in the outcome of complex claims.

When consulting the insurer another service that may be useful is to engage an external provider. Someone with experience and training in best practice injury management can assist the insurer, employer and injured worker when complex situations or conditions arise. It's also worthwhile remembering that it's not always the injury that's the issue. Addressing workplace stresses for the injured worker can go a long way to give worker confidence and durable outcomes.

So that's all we have in terms of content for the webinar. So we're happy to take – I think we have time for a few questions.

Yeah. We've just got one from one of the participants. They've said that they've experienced resistance from union bodies when looking to get functional capacity evaluations done. It's their perceptions that the unions view this as a negative and not really a positive step to return to work. Do you have any particular suggestions for I guess, convincing the unions that this is a good step in terms of getting a successful return to work outcome?

In my experience the thing about FCEs, as long as it's done in the actual rehabilitation space, you're less likely to get unions not supporting it. The times I have noticed that is when it's become a periodical assessment tool or another way of screening their workers outside of a WorkCover claim. Of course you will notice unions not particularly interested in that strategy. But if it's directed by a doctor, it's suggested through an IME if you've got that support I don't think the unions have got a lot that they should be able to say influencing that claim.

It's good to know because as the Office of Industrial Relations and we are introducing this new work capacity certificate which is completely focused on the promotion of functional capacity, in terms of making it more understandable for the participants, can you give some idea as to who are the professionals that actually do these assessments or how they can actually request a particular functional capacity evaluation if they feel it's needed to get their worker back into the workplace?

Employers are able to talk to their customer advisor through WorkCover and usually they have a list of providers that are able to perform that function. Occupational therapists, physiotherapists, exercise physiologists perhaps are all health professionals that do or are capable of doing a functional capacity evaluation. So functional capacity, yeah, it's a specialised training that's required. It's not something that even a physiotherapist in a clinic can perform. It's usually something that is done through specialised training occupational health providers.

The other thing that makes it valuable is if it's specific as well. So FCEs, if you can be specific, if workplaces have their job task analysis of the job roles that are required for the worker to go back to, that is usually the gold standard if you'd like to say, in helping with goal setting. That may also help the unions as well if they know that you are not just going out on a witch hunt, but you're actually looking at specifically the job role, their safety to return to that role.

You mentioned earlier and I think it was really evident in the case study that without that regular and engaging communication you really have quite a big barrier in terms of getting this person back to work successfully. In your experience are there any really other strong key barriers that you've had to overcome in terms of getting them back?

…in this particular case but yeah, there's so many different barriers particularly in industrial settings we have cultural barriers now. I work in one workplace where we have 40 different languages and cultural backgrounds going on. So understanding their needs, it's – you know. Whether you're male, female, the different cultural barriers such as how they like to communicate, finding out whether you have got interpreters on site that can actually help you to really get to understand what their needs are. In some cultures saying 'yes' - they'll say 'yes' to everything even if they're not particularly engaged or interested in what you have to say because they're not truly understanding what you're saying to them.

Yeah. So it sounds like you need to invest in terms of working and understanding your people working for you so that like holistically even though if an injury does or doesn't happen you actually know those strategies to help engage with them. In your experience when you have needed to use host employment is that something you organise through your insurer, whether that be WorkCover or a self-insurer?

Usually that's worked through with the customer advisor. So in my experience if we've gone out to a work site visit and the employer really is genuinely struggling to find suitable duties that are meaningful for the worker to be engaged in, a host employment situation will be considered and there are providers out there that can provide that service for WorkCover. Or WorkCover I understand also have their own host list of employers that they can call upon.

In your experience as a rehab provider do you see it part of your role to educate the employers as the worker is on their graduated return to work program?

Absolutely. Absolutely, yes. Employers have a limited understanding sometimes on all of the multi facets of return to work, what they are able to say and what they're not able to do. I find that some employers are really quite nervous about how to manage somebody particularly like in John's case, where he was quite angry. He was threatening lawyers on them all the time. He only wanted to communicate via email. Those kind of situations do make it difficult for employers to know what their rights are as part of the return to work process.

Excellent and I think we had someone who's probably [inaudible] which is good to know. I think in terms of time though we might have to wrap it up. If there are any questions that weren't answered we'll ensure that we work with Dr Johnston and Marina to get those back out to you so you have a response.

Just to remind you while I do have you still on the line, I will take the opportunity to let you know that the Safe Work and Return to Work Awards for 2016 are now open. So this is a really great opportunity if you know someone who's made an improvement or an identified solution to health, safety and rehab in your workplace or another workplace, it may be something that maybe someone that you know of, please make sure that you enter them and nominate them for one of the categories in our awards this year. You can access the award nominations on the Safe Work and Return to Work Awards website. So make sure you go on there to check it out.

Thanks to everyone who has participated.

We do have another sessions in our ON series which will be on the 15th of June. We've got Craig and Natalie from All Trades Queensland providing their session which will focus on understanding the importance of communicating with younger workers to help them prevent and recover from workplace incidents. So join us for this ON series titled 'Communicating young and injured, seriously'. It's quite an interesting case study. It's a real life case study. It's a bit tragic but I guess it highlights that these are real life events and it gives you some practical strategies for how to manage young workers when injuries occur within your workplace.

So we've reached the end of this session. Again, thank you Dr Johnston. Thank you Marina for your time today.

Your feedback is really important to us guys, so please take the couple of minutes to complete the survey and tell us what you think, and particularly tell us what you want for future sessions.

So see you next time.

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