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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
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Take Home Messages
DISCUSS WORK WORK TOGETHER
PT CENTERED APPROACH SM SUPPORT
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