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Approaches and Interventions
A simple proven return to work model

At a glance:
The review compared return to work management in an industrial situation involving the military. The following approaches produced better outcomes when managing on-the-job injuries:

1. Simple - do not over-medicalise
2. Proximate - based at the workplace
3. Immediate - care from the outset
4. Centrality - all parties work towards the common goal of return to work
5. Expectant – expectations about return to work are set appropriately; and people work towards those goals
Perspectives:
Employee
Your health outcomes depend upon the condition and treatment of that condition, however, in many situations other factors also play a significant role.

Complexity, alienation, delays, distance and unreasonable expectations can delay your recovery.

Keeping in touch with your workplace, seeking sensible medical treatment, understanding that most problems will improve and returning to work as quickly as possible will assist in your rehabilitation
rehabilitation
The process of helping a person back to their former abilities and quality of life (or as close as possible) after injury or a medical condition.
 and return to normality.
Employer
The military have the longest experience of workplace injury and returning people to work.

This review reflects experiences and learning in the American military over many decades.

The simple approach to return to work, based on a clear policy and practice model detailed below, returns people to their normal environment as soon as possible, avoids over-medicalising the condition, and keeps the person in touch with their co-workers. The model results in significantly improved outcomes.
Treater
Medical treatment is aimed at helping people. Despite positive intentions, sometimes medical treatment does not help, and can result in poorer outcomes. It is important that good advice and explanation is not replaced by a focus on over-treatment. Many people want to know how to assist themselves, to understand the nature of their condition and its likely progress, whilst having their fears and uncertainties alleviated.

Some people need to understand that treatment isn't going to solve their problem and will only alleviate some of their symptoms. Armed with that information they can choose whether to proceed or not.

Tests that label conditions can also over medicalise treatments. Following a scan, simple back pain may be labelled as a disc bulge,
disc bulge
When a disc
disc
A 'cushion' between vertebrae in the spine. Each disc helps form a joint to allow movement between the vertebrae.  Disks
disk
A 'cushion' between vertebrae in the spine. Each disc helps form a joint to allow movement between the vertebrae. Disks have a fibrous outer layer surrounding a jelly-like core, which functions to absorb impact in the spine. Alternative spelling: disc.
  have a fibrous outer layer surrounding a jelly-like core, which functions to absorb impact in the spine. Alternative spelling: disk.
 has extended out from its normal position. A disc bulge can be normal (30-80% people without back pain have some degree of disc bulge on a back scan). In other cases the disc can press on the nerve and cause sciatica
sciatica
Pain caused by pressure on a branch of the sciatic nerve, which starts in the lower back and runs through the legs. The pain is felt in the leg and foot. There may also be numbness, weakness or difficulty moving the leg.
 or leg pain. Also called a disc prolapse or disc herniation.
 or disc degeneration. These may be normal age related conditions yet this information may causes alarm for many people, who then avoid activity and work.

Using simple terms, providing appropriate reassurance and facilitating an early return to work are effective forms of management.
Insurer
One of the key features of this model is of the establishment of expectations.

Provide people with information about the workers compensation system, and help them understand their role and responsibility. Understanding what is likely to happen to their pay rates, treatment, and how they can be most effective, helps an individual meet return to work expectations.

If people understand how the system works from the outset they are more likely to work within that system.
Original Article, Authors & Publication Details:
Colledge AL, Johnson HI.

The S.P.I.C.E. model for return to work. Occupational Health & Safety 2000;69(2):64-9.
Background, Study Objectives, How It Was Done:
Delayed recovery is a recognised problem for work related injuries. A significant proportion of cases end up in delayed recovery, suggesting to the authors that the current system for managing return to work is ineffective, and may be promoting disability.

A range of studies have found that most people experience and expect some soreness as part of life. In some circumstances, particularly when there are high levels of anxiety, or reduced coping abilities, the pain and functional limitations can become more substantial, and out of proportion to the defined medical condition.

The authors of this study provide information from return to activity and work in the military. They indicate that the military has a much longer level of experience with these issues. Work disability
disability
A condition or function that leaves a person unable to do tasks that most other people can do.
 has been exponentially increasing in the industrialised world over the last 30 years. However, the military has had a much longer period of time to understand the issues.

In some battle situations there has been a rapid return to the workforce. In other circumstances simple medical problems have resulted in a low proportion of people returning to work. The authors indicate that understanding what occurs in those circumstances can help treating practitioners learn how to manage work injuries.

They indicate the similarities between military personnel and individuals employed in industrial workers compensation environments:

1. Both groups are expected to work as part of a team
2. Both groups have legally defined programmes for injuries that occur on duty
3. The number and type of disability complaints is directly related to the intensity of psychosocial
psychosocial
Refers to psychological and social factors. Examples of psychosocial factors that affect return to work area include: a person's beliefs about how they will cope with their condition, the attitude of the inured worker's family to their condition and return to work, the employer's return to work policy and the influence of the WorkCover system on a person.
 stress
4. Disability in both groups is often determined by issues other than physical condition. This includes team morale, job satisfaction, and the person's belief in their superiors.

The authors note that the military now use a treatment regime known as “Forward treatment." This is based on the discovery that some individual's conditions such as combat anxiety and stress are defence mechanisms. Others may adopt a similar approach, but this may overprotect the individual. A relatively simple disorder such as fatigue can be turned into an illness resulting in a long-term problem, and disability. This can happen if the condition is technicalised or over treated, and case management is distanced from their normal work area.

Research within the military has led to the use of a simplified and proactive approach towards treating staff. This is known as the S.P.I.C.E. model.
Study Findings:
Within the military the following approach has been found to reduce disability and improve outcomes:

1. Simplicity
2. Proximity
3. Immediacy
4. Centrality
5. Expectancy

Further information on each of these areas is as follows.

1. Simplicity

The idea of this approach came from the observation that ominous sounding diagnostic
diagnostic
Used to identify a medical condition or disease by its symptoms, the findings from a medical examination, and from the results of X-rays, scans, or other tests.
 terminology, combined with sophisticated tests and treatments for fairly minor problems, strengthened the belief of serious illness. Problems occur when simple uncomplicated conditions are treated in a complicated manner.

When patients with back pain are treated intensively, such as the use of CT
CT
Computed tomography (CT), originally known as computed axial tomography (CAT or CT scan) is a medical imaging method. The images can show soft tissues such as lumbar discs.
 and MRI
MRI
Magnetic resonance imaging (MRI) is used in medical imaging and works by applying a magnetic field to the body and observing how the atoms behave in the field in order to create an image. Whilst an X-ray shows bones, MRI scans can show soft tissues and are used to examine tissues such as discs in the back, cartilage lining a joint, muscles and tendons.
 scans, their condition may be labelled as a disc degeneration, making them believe they are suffering from a serious ailment.

To help prevent these “system induced' complications, the military focused on using simple and uncomplicated terms, and avoided diagnostic labelling.

The authors went on to indicate that reassurance and advice were often more effective in the longer term; and banned the use of MRI. They point out that on many occasions the MRI findings are incidental and should not be used as an explanation for the person's pain or soreness. Degenerative changes on MRI are normal with aging.

2. Proximity

The military discovered that if they removed the individual from their colleagues and any source of stress, such as a battle the outcomes were worse. When they treated their staff in their normal environment with a supportive approach and uncomplicated treatment, results were improved.

The authors of this paper suggest that removing people from their normal environment, such as the workplace, carries the risk of alienating the person from everyday activities, workplace relations, and increases uncertainty.

Immediate contact with staff, and assistance with improving morale, safety, and the general level of fitness of those in the workforce, is recommended.

3. Immediacy

This reflects the need to deal with issues in a timely manner. The military deal with battle fatigue with immediate treatment, improving a soldier's outcome.

Application of this principle includes:

Early treatment
Helping people avoid delays in obtaining treatment
Recognising that returning people to meaningful modified duty, and then full duty as quickly as possible, reduces disability

4. Centrality

This means that all of the people involved with the injured worker should share a common goal for successful return to work. This includes the individual, their family, the employer, co-workers, treaters, and those managing the claim.

Unfortunately, this is often not the case, and the system can become fragmented. Working with providers in a positive relationship improves outcomes.

Applying this principle would mean that:

Communication is coordinated, with goals and expectations the same for all of those involved
All parties demonstrate good faith in returning the person to employment
The person with the injury has a good understanding of the industrial and compensation system
The person with the injury demonstrates appropriate motivation for rehabilitation and return to work
The treating practitioner
treating practitioner
A health professional that treats patients. In return to work this may include doctors, physiotherapists, chiropractors, osteopaths, psychologists, masseurs, etc.
 co-ordinates treatment, and sets up appropriate expectations and goals within suitable timeframes.

5. Expectancy

This term represents the idea that people with an injury often fulfil the clinical and labelling expectations placed on them.

In the military when people have been diagnosed using terms such as “Shell Shock', as opposed to “Nervousness", their outcomes were worse. There was an expectation that the first term would provide a long-term problem.

The work injury scenario application of this area includes:

Reinforcement of the proactive return to gainful employment
Establishing appropriate short term goals
Establishing timelines for return to employment
Being sensitive to factors that help motivate the person, and actively manage these issues
Ongoing regular updates of return to work goals
Conclusions:
The authors conclude by quoting Aristotle:

“Treatment of the part should never be attempted without treatment of the whole. That is the error of our day, separation of the body from the soul.'

We need to look at the whole person, rather than a medical diagnosis
diagnosis
The process of identifying a medical condition or disease by its symptoms, the findings from a medical examination, and from the results of various diagnostic procedures.
 or label. Harm can be done by not dealing with the overall situation and the individual as a whole.
References:
PubMed Abstract
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