Workplace

April 2013

FocusWorkplace

Returning to work after an injury

Volume 42, No.4, April 2013 Pages 182-185

Peter Fenner

Background

Workplace injuries are common, cause significant morbidity for workers and have considerable economic impact. General practitioners can play an important role in facilitating early return to work, improving outcomes for all parties.

Objective/s

This article provides guiding principles for the initial assessment and early treatment phase of injury with a primary focus on the rehabilitation and return to work process.

Discussion

A case management approach to assist injured workers return to work that involves collaboration between the injured worker, medical and rehabilitation providers, the employer and work insurers, achieves better outcomes. Efficient rehabilitation involves good initial assessment, effective early treatment, early mobilisation and good communication between all parties. General practitioners have an important role to play in facilitating this process.

Work and the workplace can maintain and even improve an employee’s health and wellbeing, with benefits to both the company and the worker.1,2 A rapid but safely planned return to work is therefore of benefit to both the injured worker and the employer.

Assistance to help injured workers return to work requires collaboration between the injured worker, the treating doctor, the employer and their insurer, and the injured worker’s rehabilitation providers. A quick and safe return to work, within the restraints of personal safety, helps the injured worker to feel more useful, while enjoying comradeship and support from co-workers, thus reducing their stress. The employer benefits from the early return to work of an injured worker due to a reduction in time lost to injury and the added incentive of reduced insurance premiums.

The best return to work scenario is achieved by:

  • a good initial assessment of the injury – history, examination and diagnosis (provisional, if necessary)
  • effective early treatment of the injury
  • good rehabilitation facilitated by early communication between the employer and employee to develop suitable duties and referrals in a collaboratively developed return to work plan.

Initial assessment of a new work injury

Injury outcomes are improved by rapid assessement.1,2 While injuries such as lacerations and fractures are immediately apparent and treated accordingly, some injuries appear minor initially when the muscles are warm. However, on cooling down after work, or even the next morning, muscle spasms can greatly restrict movement, causing pain at rest that is aggravated by even the smallest of movements. This is one of the reasons that some injuries are not immediately reported and the authenticity of these types of injuries is more commonly questioned.

It is essential that at the first consultation a detailed history of the mechanism of the injury, as well as any exacerbating or contributing factors, is taken and carefully documented (Table 1). This should be followed by careful examination of the patient and formulation of a diagnosis based on the history and the physical examination (Table 2). This approach is more specific and accurate than initial imaging, unless an acute fracture or dislocation is likely.

Imaging should not be used to diagnose workplace injuries assessed in the general practice setting, due to the many variants in a ‘normal’ skeletal framework.3 Imaging is often unhelpful and can be misleading, especially imaging of the spine. Computed tomography (CT) and magnetic resonance imaging (MRI) of the general population have shown that up to 85% of people had ‘bulging discs or more serious pathology, but with no signs or symptoms’.4 An exception to this rule is an early MRI for severe unstable knee injuries, which may assist in assessing the need for early orthopaedic intervention. Workers’ compensation funds may pay for MRI in this setting to facilitate faster specialist assessment and treatment, as this speeds recovery and subsequent return to work.

The provisional diagnosis and patient circumstances can then be used to tailor injury treatment. Re-assessment and re-examination at regular intervals is important to gauge progress (or failure to improve) and to further tailor management.

Table 1. Comprehensive initial history of the injury – back to basics
  • Mechanism of injury – a full description of what occurred, movement(s) initiating pain, and the exact location of pain focus and/or tenderness to palpation is essential for a diagnosis and also for documentation
  • Previous injuries – in this area, or in other areas
  • Pain – features of the pain plus exacerbating and relieving factors
  • Radiation of pain to other areas – eg. legs or arms (as with disc injury)
  • Paresthesiae, weakness or inability to move without pain
  • Other complaints or symptoms
  • Current and previous medical problems that may impact on recovery, including mental health issues
  • Current medications and any medication or treatment  started since the injury occurred
Table 2. Principles of injury examination
  • Observation – eg. deformity, abnormal muscle activity, posture (scoliosis)
  • Palpation – detect painful localised areas over the injured area or related structures nearby
  • Active movement by the patient – is it restricted, fluid and smooth, or with muscle spasm causing jerking or catching on movement?
  • Passive movement – check for restriction or pain that limits the range of movement. (Verbal distraction can be useful during this part of the examination)
  • Specific clinical tests (eg. provocation tests) may be indicated for certain types of injury. (These vary with each injury and are beyond the scope of this article)

Effective early treatment

Control of pain is the first step to success in rehabilitation, allowing early mobilisation of the injured area. This can be achieved through both physical and pharmacological measures. Table 3 provides a guide to immediate injury management.

Traditional medical training suggested that injuries needed rest to allow healing,5 and that manual work be avoided to prevent wound infection if sutures were in-situ. The evidence now suggests that rapid and aggressive mobilisation of the injured area is a more effective treatment for most injuries. The emphasis is therefore on returning the employee to work as quickly and safely as possible.6 This involves protecting the injured area from further aggravation while working the uninjured areas to prevent ‘disuse regression’.7 This approach facilitates return to full activity or work tasks in a quick, effective and safe manner.6 Immobilisation is only indicated for specific injuries such as broken bones or joint sprains. Most injured areas must be mobilised quickly; treatment includes stretching and mobilising tight muscles (eg. physiotherapy) to reduce pain and symptoms.

Further investigations may be necessary if the injury fails to improve, especially if the reported cause and effect do not seem to correlate. This includes investigation of ‘red flags’ – symptoms that do not follow a typical pattern in response to injury treatment, suggesting further, more sinister causes of pain and treatment failure.8

Table 3. Immediate injury management
  • Cold packs for joint pain – reduces swelling and inflammation (excessive swelling slows healing). Usually 20 minutes on, 20 minutes off. Use cold packs until acute pain has settled, then as necessary until acute swelling settles. Cold packs can also be used in recovery phases after exacerbation of the injury
  • Heat packs for muscle spasms
  • Analgesia 
    • regular, slow-release paracetamol: 665 mg two tablets regularly, 2–3 times per day
    • stronger analgesics: only if needed to control more severe pain
  • Anti-inflammatory medication: when and if appropriate
  • Benzodiazepines to reduce anxiety and/or possible muscle tightening: with caution and for a short duration for appropriate injuries in selected patients

Good rehabilitation

After appropriate first aid is given and active medical treatment provided, the treating doctor (who can be nominated by the injured worker) is responsible for the medical management of the injury, working in conjunction with other healthcare professionals and the employer (or their representative). Most commonly this is the worker’s general practitioner, but may be an occupational physician, particularly in complex cases that are slow to resolve. Table 4 illustrates the important role of the GP in the management of the patient with a workplace injury.

Table 4. Management of workplace injuries
  • Initial assessment and acute management (this may also be undertaken at an emergency department)
  • WorkCover notification and associated paperwork
  • Facilitate rehabilitation with appropriate referral
  • Communication and coordination between the worker, employer, rehabilitation providers and the employer’s insurers
  • Monitor the worker’s progress and re-assess at regular intervals
  • Investigate, alter management or refer to a specialist if the patient fails to improve
  • Support and advocate for the patient as required
  • Provide ongoing support and similar care (ie. not becoming too injury focused)

The ‘paperwork’

In all Australian states and territories, companies have governing workers’ compensation protocols to follow if an injury occurs at work. Although these protocols vary, each state and territory requires notification of an injured worker to the relevant workers’ compensation authority or company insurer within 48 hours of the injury occurring, using their specific standard paperwork.9 For tips on completing workers’ compensation forms, refer to the article by Dodgshun and Malios10 (see Resources).

The return to work plan

Successful, efficient rehabilitation involves knowing the employee’s job description and associated tasks. The employer can supply this information. A return to work plan that enables the injured worker to perform most of their usual tasks keeps them ‘work hardened’ while protecting the injury by specifying appropriate restrictions on tasks, or parts of a task that may aggravate the injury.

Return to work certificates, available from state WorkCover offices, can provide a template that can assist in assessing the tasks that the person can or cannot perform. Following most injuries, the vast majority of workers can return to work immediately, unless they are in too much pain or totally incapacitated.

Early return to work depends on factors including work practice, workplace culture and good injury management programs. This helps the worker feel valued and supported in their work roles and assists their health and wellbeing. Return to work also reduces the employer’s insurance premiums, so most companies will arrange modified work and vary hours or days when necessary, aware that good rehabilitation returns their worker to full productivity as quickly as possible without aggravating the injury. When planned carefully, the return to work plan can utilise the worker’s knowledge to be beneficial to both the injured person and their employer.11

To facilitate the rehabilitation process, communication is essential between the GP and the employer regarding the condition, expected investigation and treatment processes, a suitable duties plan and the likely timeframe for a return to full duties. Completion of the medical certificate provides some information, but is usually insufficient. Additional communication and documentation, particularly in regards to treatments needed and predicted timeframes, prevents frustration later in the process and may assist early funding approval of key rehabilitation referrals.

Tasks the worker can do at home – sitting, standing, walking, writing, thinking – can also be achieved at work, but may require coaching of both employee and employer to ensure that the rehabilitation plan is safe. Duties should be consistent with medical advice but productive, appropriate and as meaningful as possible, assisting the injured worker’s physical and psychological condition, making them feel useful and improving their self-image.

Rather than suggesting specific work tasks, the GP should advise on weight or lifting restrictions, movements to avoid, and time restrictions for particular tasks, including how they can slowly be increased within pain and/or mobility restrictions.

As well as modified duties, work hours and/or days per week may also need reducing. For example, work hours may be reduced to 2–4 hours per day with working days alternating with a rest day between. The hours can then be gradually increased to 6, 8 and then 12 hours if this is the normal working day, as the worker improves. This approach maintains work fitness and increases work hardening. When a worker can cope with a full days work, then the number of days per week (or shifts) is increased, although the work tasks may still be restricted during this time.

Active treatment during rehabilitation

To assist the patient’s progress, the injured area should be mobilised and strengthened back to a pre-injury state. In addition to physiotherapy, WorkCover may fund other specific rehabilitation activities to enable a quicker and safer return to work without re-injury, such as hydrotherapy to reduce weight on lower limb and back injuries, allowing faster mobilisation of the injured area to assist progress to normal duties.12 If the injury is caused by specific weakness in a muscle, or muscle groups, strengthening may be needed to prevent further or ongoing injury (eg. low back injuries can benefit from deep abdominal muscle exercises, ie. ‘core strengthening’). Exercises commence with simple floor exercises and progress to light weights, gym work or rehabilitation pilates.13

Many physiotherapists can assist in this process, and those with an interest in occupational health can be found on the Australian Physiotherapy Association’s website (see Resources).

Similarly, many occupational therapists can prepare a return to work plan, assist with follow up and provide advice on increasing the patient’s duties during the rehabilitation process.

The role of the rehabilitation coordinator

In most Australian states and territories, employers are required to have a rehabilitation coordinator. If the patient agrees, the rehabilitation coordinator may attend the consultation, after the patient has been examined and advice given on injury restrictions. The rehabilitation coordinator then works within the limitations set by the GP, and the worker’s proposed plan, to devise a shared return to work plan that avoids any tasks and movements that could irritate the injured area, but one that allows all other areas to maintain general fitness.

The return to work plan prepared by the employer’s rehabilitation coordinator must be seen and approved by the GP to ensure that the listed tasks comply with their imposed restrictions. The GP, the injured worker and the rehabilitation coordinator then ‘sign off’ an agreement on those restrictions. A conference may be required between all parties to fully appreciate the scope of work or required restrictions required for rehabilitation. This conference is fully funded by work insurers at a higher rate than a standard consultation.

Barriers to an early return to work

The return to work will ultimately be more successful, particularly after an absence, if the worker understands the health benefits of work and is willing to assist the process. Any barriers to a quick and safe return should be identified early and addressed. Sometimes psychological counselling may be needed to facilitate ‘adjustment to injury’. Work injury can provoke fears of possible redundancy or a period of financial hardship due to the absence of overtime work and pay for the duration of the supervised return to work plan.

With time, even workers with severe injuries can be safely and progressively returned to most or all of their usual duties. However, there may be residual difficulties in some tasks where complete resolution of the injury cannot be achieved.

If the company cannot provide prescribed acceptable tasks, the injured worker can be referred to another ‘host’ company that is willing to accept the worker’s specific restrictions. This host company is fully protected by law from any injury claims relating to setbacks or a claim from the original injury.

Follow up

Regular follow up is essential. Insurance companies accept and expect a more frequent review rate of workers recovering from injury. Any setbacks may need to be managed by a reduction in hours, days per week, and/or the physical demands by reducing the weight lifted, reducing repetition or frequency of the aggravating duties.

It must be strictly reinforced at each follow up visit that the suitable duties in the return to work plans are also applicable at home, not just at the workplace. It is pointless if someone is restricted to lifting 10 kg at work but at home carries their 20 kg child around or even digs the garden when bending and twisting are forbidden.

Summary

Effective and early injury treatment together with good rehabilitation in a shared plan for early return to work is beneficial to both the worker and employer. General practitioners have an important role to play in this process including providing initial assessment, effective early treatment, facilitating good communication between all involved parties and providing ongoing monitoring.

Resources

Competing interests: None.
Provenance and peer review: Commissioned; externally peer reviewed.

References

  1. Black C. Working for a healthier tomorrow. COMCARE Work 4 Health Forum. Canberra 26 October 2010.
  2. Australasian Faculty of Occupational and Environmental Medicine, Royal Australasian College of Physicians. Australian and New Zealand Consensus Statements on the Health Benefits of Work. Available at www.racp.edu.au [Accessed 4 March 2013].
  3. Takatalo J, Karppinen J, Niinimäki J, et al. Does lumbar disc degeneration on magnetic resonance imaging associate with low back symptom severity in young Finnish adults? Spine 2011;36:2180–9.
  4. Boos N, Semmer N, Elfering A, et al. Natural history of individuals with asymptomatic disc abnormalities in MRI: Predictors of low back pain-related medical consultation and work incapacity. Spine 2000;25:1484.
  5. Gellhorn AC, Katz JN, Suri P. Osteoarthritis of the spine: the facet joints. Nat Rev Rheumatol 2012 doi: 10.1038/nrrheum.2012.199. [Epub ahead of print].
  6. Waddell G. Simple low back pain: rest or active exercise? Ann Rheum Dis 1993;52:317–9.
  7. Belavý DL, Bock O, Börst H, et al. The 2nd Berlin BedRest Study: protocol and implementation. J Musculoskelet Neuronal Interact 2010;10:207–19.
  8. Henschke N, Maher CG, Refshauge KM, et al. Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis Rheum 2009;60:3072–80.
  9. WorkCover Authority of NSW. Available at www.workcover.nsw.gov.au/injuriesclaims/Reportinganincidentinjury/Pages/default.aspx [Accessed 6 February 2013].
  10. Dodgshun C, Malios J. Workers’ compensation forms: a guide for GPs. Aust Fam Physician 2011;40:730–3.
  11. MacEachen E, Clarke J, Franche RL, Irvin E. Systematic review of the qualitative literature on return to work after injury. Scand J Work Environ Health 2006;32:257–69.
  12. Waller B, Lambeck J, Daly D. Therapeutic aquatic exercise in the treatment of low back pain: a systematic review. Clin Rehabil 2009;23:3–14.
  13. Akuthota V, Ferreiro A, Moore T, Fredericson M. Core stability exercise principles. Curr Sports Med Rep 2008;7:39–44.

Correspondence afp@racgp.org.au

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