Musculoskeletal conditions: Part one - a primer.

It can be frustrating to deal with a musculoskeletal problem.

There are many factors that increase the frustration experienced by someone being treated for a musculoskeletal problem. Here’s a description from the Preventing Needless Work Disability SAW/RTW White Paper (2006) :

”People who have been injured or become ill have had their life disrupted. Even a minor injury may seem like a big event to the person who is injured because it is out of the ordinary. People may suddenly find themselves in pain, upset, worried, and dependent on strangers.

"They may suddenly feel uncertain or uneasy because they don’t know where to turn for help, or what doctor to go to. They may be angry at the person who caused the injury, or embarrassed and mad at themselves for being careless or breaking a safety rule. They may be afraid that they will get into trouble, may need surgery, may never be able to walk again or that this will mean the end of their career...Most of the time, they also have to figure out how to deal with an unfamiliar bureaucracy and set of rules.

"Other parties often contribute to the uncertainty involved. Employers and insurers often neglect to tell or intentionally choose not to tell injured or ill employees very much about how their disability benefit programs work, what to expect, and what they can do to make the process run smoothly.

"Doctors often do not tell patients much about their condition – how it will affect their daily life and work, what the eventual outcome and options are likely to be, the expected timeline for treatment and recovery, and what they can do to achieve the best possible result.

"These issues and predicaments can be a lot to cope with, and many workers with a significant injury or illness experience it as a stressful predicament.”  

Some of the problems people with an injury face include:

• Medical investigations and treatments may only provide limited benefits;  
• Investigations often show normal age related changes. But this may be reported to the patient as the cause of their condition, e.g.:
  • 50% of people WITHOUT shoulder symptoms at the age of 50 have a partial thickness tear in their shoulder rotator cuff muscle;
  • 50% of people aged 50 WITHOUT back pain have disc degeneration seen in an MRI of the back.  
• Treatment may not assist;  
• Explanations given by their treating practitioners may not answer all of patients’ relevant questions;  
• Trials of one treatment after another without success often leave the employee frustrated and bewildered by lack of improvement; and  
• Delays in accessing treatment, particularly delays in approval being given for recommended procedures, can compound the sense of frustration.  

Compounding issues

Uncertainty and worry cause worse outcomes. Research tells us that people remaining off work for long periods are fearful about damaging the affected body part. This stops them from returning to activity. The affected body part then becomes stiffer; the person less active and more protective, and this vicious cycle makes the problems worse.

Some doctors are experienced and good at managing musculoskeletal problems. Others, however, are less experienced. People with musculoskeletal problems are often sent for investigations that are unhelpful, and a series of treatments that don’t help.

When the problem doesn’t improve, their frustration and concern worsens. If treatment isn’t helping, they can wonder whether this means they have something even more worrying. Patients may have seen three or four different treating practitioners, e.g. a physio, masseur etc., with each providing a different label or diagnosis. 

Further, the usual checks and balances of an individual assessing the benefit of the treatment and whether they are getting ‘value’ for their dollar, does not occur in the compensation situation. The system pays, and the person with the condition will typically do as they are told with little in the way of questioning the approach.

At the same time those around them, particularly their fellow workers, don’t see a visible injury. Verbal and non-verbal communication will often reflect these co-worker’s suspicions, causing further distress. This is often enough to make it uncomfortable for the person with the condition to be at work.  

In summary:

• For some musculoskeletal conditions, we have well recognised treatments that help the problem quickly. However, for many musculoskeletal conditions treatment is of limited effectiveness.  
• The label or diagnosis given to the patient can worry them, and cause them to over restrict what they do, e.g. disc degeneration, or a tear in the rotator cuff at the shoulder.  
• The advice given to patients is often limited and can be confusing. Much of the advice given is NOT evidence based.  
• X-rays and scans are often unhelpful.  
• For some treatment e.g. back pain, the treatment is often trial and error, causing frustration as the injured worker hopes that with each treatment they will recover.  
• Musculoskeletal conditions are typically ‘non-visible,’ and over time co-workers and managers may start to ‘disbelieve’ the extent and duration of the condition.  
• In compensable cases where the invoices are sent to the company or insurer, the usual system of the patient judging the ‘value’ of treatment is missing.  
• Treatment outcomes in compensable cases are worse. This includes the results of surgery and non-surgical treatments. This could be due to the focus of the employee moving towards compensation rather than returning to work.  
• Treating practitioners often use different words or diagnoses for the condition e.g. the physiotherapist says that it is a disc bulge, while the doctor says it is a ligament strain.