If I’m in pain, should I train? Interpreting musculoskeletal pain.

Whether you work at a desk or a construction site, walking to the bus or playing rugby, coping with some level of pain or discomfort is common. This blog explores the meaning of pain symptoms, to help you interpret when that coping is good or bad.

Does pain severity or duration measure the severity of injury that is occurring?

It might surprise you that pain severity and injury severity are not as hand-in-hand as you might expect. To give a stimulus that causes musculoskeletal pain (as opposed to psychological causes), the stimulus can be:

• Mechanical: pressure/shear/tension;
• Chemical: inflammation/capsaicin/acid etc; or
• Thermal (cold/heat).

The easiest stimulus to control is thermal. We all know that touching something around 50deg C doesn’t hurt as much as something 100deg. So, the nervous system is doing its job to give us a meaningful warning, telling us to protect from exposure to those temperatures, but it is often not as simple as that.

In research labs, thermodes can precisely control temperature of an electrode the size of a matchbox, which is rested on the skin to test the thresholds and severity of people’s pain perception. With sustained heat, approximately 45deg or more can cause a burn injury. To test the relationship between severity of stimulus and severity of pain, Robert Coghill and colleagues (2013, PNAS) applied a thermode at 49deg C. More than enough to provoke pain in most people. If we rate pain on a 0-10 scale, from 0 = no pain to 10 = worst imaginable pain, with 49deg you might expect most people to rate the pain a perhaps 4-7/10.

When Robert tested 17 people, the pain that they experienced ranged from 1-9/10. Pain is an individual experience. Sometimes the pain that you feel will give far too little or far too much warning relative to the severity of stimulus or injury.

Figure 1: adapted from Wong DL, Baker CM. 1988. Pain in children: comparison of assessment scales. Pediatric Nursing 14(1):9–17

How can pain be so variable compared to the stimulus or injury? Two words sum up an enormous about pain. Pain is predictive and protective. There are three steps that occur with most things that we feel with any of our senses (touch, taste, smell, hear, see):

1. Transduction of the stimulus, so that nerves change the input stimulus to an electrical signal, much like a microphone converts sound.
2. Transmission of the stimulus along the nervous system towards the spinal cord and brain, like a microphone cable.
3. Perception of the stimulus, like a music editing app on a computer.

At each step of transduction, transmission and perception, signals from the body can be amplified or diminished. Then with perception, our brain and mind mix the incoming signal as well as our expectations, memories of past experiences, our social and environmental context, our emotions, even our immune and hormonal stress response systems, to make sense of what you feel. If the brain feels threatened enough by the signal, it creates a feeling of pain.

Claus and MacDonald, JDMS  https://doi.org/10.12678/1089-313X.21.1.5  Adapted from Melzack Journal of Dental Education 2001, 65(12) p.1378-82.

Each of us brings our own experiences, expectations, emotions and nervous system into the equation to determine what we feel. For example, if you had previously experienced pain at your kneecap when climbing stairs, even before you take much weight on your foot to climb a step, your nervous system could produce a lot of pain to warn you. Like an alarm bell ringing, even if there is little or no new injury occurring from doing an activity as simple as stepping up.

If I’m in pain, should I train (or work)?

How do I know when pain is a meaningful warning or something I can ignore and carry on? Good question. First, a warning. It is important to check for serious pathology. Persistent pain, whether severe or not, can occur with a wide range of diseases and injuries. These require health professional diagnosis and management. Depending on the cause, serious disease / injury processes may prevent training or working as normal.

If serious pathology has been excluded and pain is not severe/unremitting, think about the activities that you regularly do that cause some pain. If your ability to do the task is declining over days, weeks or months, or if doing the task flares your pain badly and limits what you can do the next day, then it may also be important to reduce training or working to limit the flare-ups.

If your ability to do the task is maintaining from month to month, despite experiencing some pain, that is a clue that the pain may represent little or no new injury occurring, like the example of some discomfort at the kneecap when climbing stairs. Continuing to train despite some pain may be a reasonable option.

Expert physiotherapists at AXIS are well placed to help identify whether persistent musculoskeletal pain is caused by a serious disease/injury, whether you can train or work in a modified way, or continue as normal. They can design a rehabilitation program to suit individual needs, training a paced progression of loads for the body and the nervous system, to progress ability and reduce symptoms.

Expert psychologists at AXIS are also well placed to help when low mood, thoughts, memories or other feelings are contributing to what the brain does to create pain. Where the amplitude of what you feel is turned up, pain is being over-protective and limiting ability to do the activities that matter for you. Dealing with chronic pain is hard, so the advice and skills from a psychologist who has helped a lot of other people with their pain experiences can be just the right support to make progress.

What is effective early intervention?

In working with many of our partners in industry, it’s intriguing how often we lose sight of what effective early intervention looks like, when managing injury. I’m going to outline some broad philosophies that will assist in guiding an early intervention program for your workplace.

Whilst my ‘sandpit’ is work-related musculoskeletal injury, I think it’s important to note that these same approaches work well with many non work related and psychological injuries in the workplace.

It might be easier to start with what is not early intervention. Early intervention is not:

• Reporting the injury in the workplace injury database and handing them a workers compensation claim pack.
• Sending a person with a non-traumatic musculoskeletal complaint to an emergency department for follow up care.
• Sending a person with a non-traumatic musculoskeletal complaint immediately to a GP.

Whilst these strategies may help many businesses ‘tick a box’, they will often lead to greater fear and anxiety for the injured worker. The long term effect is a greater likelihood of chronicity developing and a failed return to work outcome.

Effective early intervention for musculoskeletal injury applies several concepts.

Worry about the person and their injury, not whether it ‘really’ happened at work.

We know that people who feel supported both at home and at work, tend to get better quicker. The primary focus of the safety team is on ensuring the injured worker feels supported following their injury. Feeling supported means feeling safe, and improves the likelihood that the worker will work with the workplace to recover from their injury. Strategies that help enhance this support include:

• Regular phone calls or touchpoints with the team member
• Offering to support them by meeting with healthcare providers (with permission and where appropriate).

Use healthcare that encourages a ‘remain at work’ approach.

Navigating how best to manage an injury and communicate with a workplace can be challenging for an injured worker. It can often lead to added stress and anxiety that hampers their recovery, or the prescription of duties that are beyond their physical capacity. A healthcare practitioner should be supporting the injured worker through written or verbal correspondence with your workplace (with the worker’s permission) to help explain the support that the injured worker will need. Further encourage these channels of communication through:

• Offering to attend with the worker at their appointment (if they feel comfortable)
• Invite the healthcare provider for a site tour.

Develop relationships with local physiotherapy and medical providers that understand these core concepts. If you’re looking for a provider, consider reviewing the signatories to the Health Benefits of Good Work.

In providing onsite healthcare and AXIS One Call telehealth services for acute injuries, AXIS deliver information return to work plans to the workplace rapidly following consultations. The same should be expected of any healthcare service you might refer to, and is reasonable for you to ask of an injured worker’s healthcare provider.

Use healthcare that includes effective communication with both the injured person and your workplace.

Navigating how best to manage an injury and communicate with a workplace can be challenging for an injured worker. It can often lead to added stress and anxiety that hampers their recovery, or the prescription of duties that are beyond their physical capacity. A healthcare practitioner should be supporting the injured worker through written or verbal correspondence with your workplace (with the worker’s permission) to help explain the support that the injured worker will need. Further encourage these channels of communication through:

• Offering to attend with the worker at their appointment (if they feel comfortable)
• Invite the healthcare provider for a site tour.

Early Intervention doesn’t end after two days.

Many businesses believe that early intervention begins with an injury, and ends once you’ve booked an initial consultation with the doctor. Whilst this is clean-cut for businesses to track their KPIs, it manifestly underestimates the needs of workers following an injury. In reality, an early intervention system needs to be applied over more realistic periods of time (such as 1-2 weeks following the onset of symptoms). By changing your early intervention mindset to a more extended timeframe, you’re more likely to:

• Arrange appropriate follow up healthcare for the worker through a course of physiotherapy or referring for medical care.
• Arrange regular touchpoints with the worker and their supervisors to track their recovery and return to work.
• Set realistic expectations regarding recovery with the worker.

Early Intervention has a place even when a claim is likely

Ultimately, the goal of any injury management approach should be to reduce the burden of injury to the worker. This will inevitably lead to improvements in claim costs and recovery timeframes. Accessing early intervention, before any claims determination and with a ‘no fault’ approach, ensures that you set the injured worker up with the best chance of speedy recovery, even within a claim process.

When applied, the concepts discussed demonstrate that you are using an evidence-based approach to injury management in your workplace. Feel free to reach out to AXIS for more information.

Change is a process.

Change is hard. Helping people to change is hard. This is the challenge we face as clinicians working with those who are engaging in maladaptive or harmful health behaviors knows. People learn powerful habits and coping skills in response to stimuli and life events. One conversation is not sufficient for meaningful change. Change that does occur under the guidance of a clinician is rarely linear or consistent. There is always the temptation to assume that the client “is not ready or not motivated” or that their noncompliance is an indication of a clinical failure, however its not that simple.

The science moves away from a deficit model and towards a process of precontemplation, contemplation, preparation, action, and maintenance. A deficit model puts the responsibility on the flaws of the client, the stages of change model aims to meet a client where they are. Crucially, when working with vulnerable populations, validating and acknowledging external barriers (such as socioeconomic factors) is often required. This supports for rapport and accurate formulation. Notably the research has found that repeated education around the uptake of a health behaviour, leads to poor rapport, disengagement, and feelings of disempowerment. Information does not create behaviour change. In contrast, reviewing points of decision making can enhance the patients innate ability for change. Each stage requires different approaches for long term success. The process of change often includes periods of recycling stages or regression, which does not indicate a failure.

During precontemplation the client is unaware or under evaluates their problems (i.e smoking, problem drinking, avoidance of activity post injury). These clients often present to allied health practitioners (such a physiotherapists or psychologists) due to pressure from loved ones, well meaning doctors or the workplace. These clients may be resigned or report feelings of no control, or experience denial. They often struggle believe any poor outcomes could happen to them. While this can come across argumentative it is crucial to explore the behavior requiring change with open questioning:

1. “What would have to happen for you to know that this is a problem?”
2. “What warming signs would let you know that this is a problem?”
3. “Have you tried to change in the past?”

Fig 1: Less than ideal clinical care.

A client in the contemplation of change stage will experience feelings of ambivalence and will start to assess barriers and benefits of change. There is also an acknowledgment of the future loss when cessation of the behavior does occur (e.g missing the positive factors of smoking like feeling “calmer”). The role of the clinician to explore the benefits and barriers of change equally, while not attempting to sway the client’s decision making, allowing the client to make the choice to change on their own. Open questioning must continue:

1. “Why do you want to change at this time?’
2. “What were the reasons for not changing?”

More active work occurs during the preparation stage, where both the client and the clinician explore specific behavioral change and engage in experimentation. This may look like a trial of certain feared movement for persistent pain clients, which is feared the least. In those who are attempting to quit smoking, cutting out one or two cigarettes a day. The preparation stage aims to build confidence and some psychological safety for the following action stage

The action stage is where the obvious changes can be seen, a smoker stops smoking and a patient with chronic pain begins an exercise program to regain function. This is the stage all clinicians aim for in the rehabilitation sector. The action stage is where we see change in key performance indicators, such as mobility and lower pain or distress. Going into the action stage without the prior stages can lead to premature recycling backwards. This can happen if the client made the changes abruptly and potentially without their own reasons to do so. Compliance in rehabilitation is rarely built by advice only, more often it comes from the clients own meaning making and values.

Maintenance and relapse prevention focuses in on incorporating the new behavior into the client’s lifestyle. However, relapse awareness crucial to empower people to recycle through steps again. Recycling or regressing through steps is common and normal, building anticipation for this can help facilitate ongoing rehabilitation. Life happens. A key point for clients is that even though they have relapsed, it has taught them something about themselves and what triggers they may need to avoid. The cyclic nature of the stages of change model helps patients to adopt a more flexible cognitive appraisal of their health behaviour. Rather than a black and white approach e.g. smoking or not smoking.

At all stages active listening and empathy is key. The sciences also support a person-centered approach. Studies have found clinician empathy to correlate with a reduction of problem drinking. In contrast confrontational styles have been found to predict ongoing issues. The stages of change model conceptualises change at an active, ongoing and non linear process. Change can be hard, yet crucial in the rehabilitation sector when delivering healthcare.

References

McPhail, S., & Schippers, M. (2012). An evolving perspective on physical activity counselling by medical professionals. BMC Family Practice, 13(1), 1-8.

Prochaska, J. O., DiClemente, C. C., Velicer, W. F., Ginpil, S., & Norcross, J. C. (1985). Predicting change in smoking status for self-changers. Addictive behaviors, 10(4), 395-406.

Prochaska, J. O., Norcross, J. C., & DiClemente, C. C. (2013). Applying the stages of change. Psychotherapy in Australia, 19(2), 10-15.

Zimmerman, G. L., Olsen, C. G., & Bosworth, M. F. (2000). A’stages of change’approach to helping patients change behavior. American family physician, 61(5), 1409-1416.

OREBRO Plus is here…

OREBRO Plus: One click delivery of the world class Orebro risk questionnaire to your people.

The Orebro Musculoskeletal Screening Questionnaire is widely used to help identify individuals who may have delayed recovery and return to work following MSDs.

However, dispensing, scoring and collecting Orebro’s is a challenge, let alone keeping track, especially if you have a large amount of cases.

To solve this problem, the AXIS Rehabilitation at Work team have been busy developing a free and easy to use digital tool to send, receive, track and dashboard Orebro results all in one place – OREBRO Plus.

For free access to this tool visit: www.orebroplus.com.au

Orebro: Predictions are difficult, especially about the future

Musculoskeletal pain disorders can significantly impact the lives of individuals.  This group represent the most common type of work-related injury.

A small portion of work-related injuries have delayed recovery and delayed return to work (RTW).   For this group, length of time off is associated with difficulty ever returning to work and negative physical and psychological health outcomes.  The impact on these individuals and their families is significant and can result in loss of employment.  There are also significant adverse impacts on their employers and at times their co-workers.

It is these negative life impacts and broader impacts on organizations and the community that creates an interest in identifying those injured workers at risk of delayed RTW as early as possible.  It is hoped that then adverse outcomes can be avoided.

Reliably identifying these individuals at risk among large case numbers has proved difficult and focusing on injury severity does not seem to be a reliable predictor of ongoing disability and time off work.

However, there is increasing understanding that musculoskeletal pain disorders need to be viewed as a multidimensional, biopsychosocial interaction and that psychosocial factors (yellow flags) can have a major impact on developing persistent pain, disability, and time off work.

The complex interaction of psychosocial factors can mean that it is difficult for clinicians to prioritize the relative importance of different dimensions and at times there is a focus on physical factors alone.

One widely used psychosocial self-report scale is the Orebro Musculoskeletal Pain Screening Questionnaire (Orebro).  The Orebro is not limited to back pain like some other screening tools and in its short form it relatively simple to administer.

The short form Orebro has only 10 questions and the cut-off of 50/100 was found to provide direction for detecting those likely to have more lost time.  A prospective study by Nicholas et al used a workers compensation insurer to administer the Orebro and found that a score of over 50, high risk score, was associated with a median time off work of 26.6 days compared to a below 50, low risk score, being associated with 10.1 days.

The physicist Niels Bohr is credited with saying: Predictions are difficult, especially about the future.

While we cannot predict the future, the Orebro is a ‘yellow flag’ screening tool that provides valuable information about psychosocial contributors to an injured workers presentation.  It has utility in helping understand risk of ongoing pain, disability, and difficulty with RTW.

Screening injured workers with tools like the Orebro hopefully will help identify individual workers that need support in their recovery journey, and that this will make a positive difference in their lives, their family and their community.

Is Hazardous Manual Handling the only Enemy?

The consequence of workplace musculoskeletal disorders (MSD’s) is well documented, with significant social and economic burdens for the injured worker, employer and health care system.

The gold standard approach for preventing MSDs should focus on the effective implementation of a risk management approach which considers all possible contributing hazards that may contribute to the development of MSDs.

In many instances though, the risk management approach is often only directed toward eliminating or reducing physical hazards directly related to the inherent characteristics of manual tasks.  For most people, targeting control measures towards physical task characteristics seems intuitive.  Reducing a worker’s exposure to force, awkward posturing and repetitive or sustained movements will help reduce physical stress on the body and help curtail injury.

Research, however, suggests that workplace psychosocial and organisational factors also present as significant risk factors for work related MSDs.  Considering this, effective risk management for the prevention of MSD’s should not just focus on physical hazards but should also consider, identify, assess and control workplace psychosocial and organisation hazards that are known to contribute to the onset of MSD’s [1].

By definition, work-related psychosocial risks concern aspects of the design and management of work and its social and organisational contexts that have the potential for causing psychological or physical harm.

When it comes to understanding MSDs, these risk factors are often less tangible, less obvious, and are often not considered or easily accepted by workplaces as potential hazards for MSDs.  Despite this, research highlights workplace psychosocial, organisational and cultural factors are independent risk factors for the development of MSD’s [2].

Examples of workplace psychosocial hazards that can contribute to MSDs include: time pressures; cognitive demands; hours of work; poorly defined work roles; poorly managed change; poor conflict management, lack of job control; lack of supervisor and/or co-worker support; organisational injustice; and inadequate reward and recognition.

Such workplace psychosocial risk factors may not only lead to occupational stress, but can promote a wide variety of mental and behavioural responses within a worker. A growing body of evidence now exists, highlighting how occupational stress can increase a workers risk of tissue damage and pain.

In the case of work related low back injuries, evidence highlights that poor supervisor and manager support, lack of social support from colleagues, low job control and poor job satisfaction are all independent risk factors for low back pain.  These have also been shown to be causative to work related upper limb MSDs, as has a lack of task variation, job insecurity and working under time pressure and deadlines.

Similar to managing physical risk factors, a risk management approach to psychosocial hazards should be employed.  The People at Work Project, a collaboration between the University of Queensland, The Australian National University, Workplace Health and Safety Queensland, WorkCover NSW, WorkSafe Victoria, Comcare, Safe Work Australia, and BeyondBlue, has developed People at Work, a psychosocial risk assessment tool which helps business understand and manage their psychosocial risks.

It promotes appropriate prioritisation of risks and provides direction for the implementation of appropriate prevention strategies to help create psychologically healthy and safe workplaces.  Such strategies may need to be tailored at the job design, organisational or individual level.

Job design strategies might focus on changes to rostering, shift patterns, job rotation etc.   Effective controls at this level may not only help reduce psychosocial hazards related to performing tasks but may also have a direct effect on reducing exposure to hazardous manual tasks.

At the organisational level, strategies to foster an improved WHS culture should be considered.  This may include greater worker consultation in health and safety issues or ensuring supervisors and managers set the standard by modelling correct processes and procedures, whilst also employing transparent honest communication.

Regardless of where the intervention is directed, the success of controlling psychosocial risk is contingent on several variables:

Overt and visible senior management involvement is required.  This can signal the importance of the process and can impart a sense of ‘support’ for the work force.   This may include senior management being active in WHS committees or attending toolbox meetings.  Direct and consistent organisational communication is also required to ensure that management commitment to addressing psychosocial issues is conveyed, and to help promote worker engagement. This may be achieved through focus groups, noticeboards, broadcast emails and management participation in WHS committees.

Furthermore, supervisor commitment and engagement is needed.  Supervisors are often the direct link between workers and senior management. Supervisors who commit to a risk management process, role model correct processes and procedures, and who are approachable, supportive and non-judgemental, not only instil a positive health and safety culture, but will often be the first person to identify psychosocial risks for individual workers, or for the workplace as a whole.

Finally, worker participation and engagement are crucial.  This can foster a greater sense of ‘work control’ and ‘support’ and may in fact assist in reducing the very stressors that contribute to psychosocial hazards.  Furthermore, worker input ensures any interventions are specifically tailored to workers concerns.

Although these variables have been discussed in the context of effective management of psychosocial risk, they are equally important in the risk management process for hazardous manual tasks. The two are not mutually exclusive.

In summary, effective risk management of MSDs in the workplace is complex and requires more than just consideration of hazardous manual tasks.  Understanding the nature and effect of psychosocial risk factors is critical. Furthermore, implementation of an effective risk management program that considers all possible risk factors requires strong leadership and workforce engagement – from front line workers through to senior management.

Source

[1] Marras, W.S., Cutlip, R.G., Burt, S.E., Waters, T.R.  Epidemilogical evidence on relative influence of workplace psychosocial versus physical factors on contribution of MSDS.  Applied Ergonomics. 2009 Jan;40(1): pp. 15-22

[2] Johnston, J.M., Landsittel, D.P., Nelson, N., Garnder, L,I., Wassell, J.T. Stressful psychosocial work environment increases risk for back pain among retail material handlers.   American Journal of Industrial Medicine.  2003 Feb;43(2):179-87

National Pain Week

This week is National Pain Week. Chronic pain is a really big problem, affecting up to 40% of people at some point during their life. [1]

Chronic pain carries a large financial burden in Australia. A 2019 report from Deloitte estimated that the average cost for an Australian person living with chronic pain is AU$22,588-$42,979 per year when indirect costs were considered. [2]

The theme of Chronic Pain Australia’s National Pain Week this year is – CONNECTION.

And one thing we know at AXIS is that patients with chronic pain often lose connection with their workplace. This is one part of the big picture problem of the impact of chronic pain, and it is why at AXIS our pain management and rehabilitation programs have a laser focus on return to work.

Our expert clinicians work very hard to help our patient re-establish their meaningful life connections – including family, social and critically work connections. We know that being able to engage in good work is enormously beneficial for our patients physical and mental health.

At AXIS, 1 in 3 patients who start our program off work are able to return to work whilst completing their rehabilitation. We achieve this in five key ways:

1.  Allied health led by Highly experienced and qualified team

We provide an allied health led program. This means that our patients are active participants in their rehabilitation. It also means that they are able to maintain their CONNECTION with their existing care providers such as their GP or specialist.

2.  Run part-time fostering the goal of ‘return to work’

Our programs are run part-time and this allows our patients to remain at work OR return to work whilst engaging in rehabilitation. This allows them to remain CONNECTED with their employer and helps them discover that work IS rehabilitation.

3.  Comprehensive communication with all stakeholders to facilitate a positive RTW outcome

We don’t provide our rehabilitation in a silo. Coming to AXIS isn’t a holiday from the usual pressures and challenges that are present in day-to-day life. We work hard to CONNECT with our patients’ usual care team and communicate a rehabilitation plan that helps them stay on track with their recovery long after they have completed our program.

4.  Individual sessions (1:1) and tailored to the individual needs of client

We understand that every one of our patients is an individual and therefore needs an individualized recovery plan. We don’t believe in recipe approaches or that one size fits all and all of our sessions are run one on one. This ensures a strong CONNECTION between us and our patients.

5.  Flexible locations, hours and start dates

Finally, we know that having chronic pain doesn’t mean that all of the other demands on our time stops. That’s why we have positioned our clinics conveniently around South East Queensland, so that patients don’t have to commute for hours just to attend specialist care. And because we are part-time, patients can find a time that suits their schedule. That way, they stay CONNECTED with their usual life whilst they recover.

For more information on National Pain Week, visit https://www.nationalpainweek.org.au/

Source

[1] Cohen, S. P., Vase, L., & Hooten, W. M. (2021). Chronic pain: an update on burden, best practices, and new advances. The Lancet, 397(10289), 2082-2097.

[2] Deloitte Access Economics. The cost of pain in Australia. March, 2019. https://www2.deloitte.com/au/en/pages/economics/articles/cost-pain-australia.html (accessed 7 July, 2021).