Case history:

Ms DJ is a 59 year old machine operator who has worked for her employer for 6 years. Her pre-injury role was on day shift, rotating duties through various machines. Her duties required her to use her upper arms regularly to insert goods into machines, perform packing, trimming and assembling.

DJ has had soreness at her low back for several years and has worked on restricted duties for the past few years, avoiding tasks which require lifting over six kgs.

DJ was working on her regular duties, when a colleague pushed a large trolley into her body. She was caught between the trolley and a machine, with the force being taken by her upper arms.

At the time of the injury DJ sustained some bruising but no specific major injury. She has since reported ongoing heaviness and pain in her arms, upper back, shoulders and neck, which has been constant over the past six months. During each conversation with the return to work coordinator she reports how much her pain is bothering her, and how worried she is about it getting better.

Her treatment has consisted of anti-inflammatory tablets and Panadeine Forte.

She has had relief with physiotherapy treatment, undertaken twice weekly initially, then reduced to weekly. Her treatment consists of hands on treatment, specifically massage. She is also undertaking a home program of stretching, strengthening and exercises.

Return to Work Interventions:

After the incident occurred DJ continued to work for the following few days, until she reported her arms being continually sore and she was placed off work by her doctor. She was off work for most of the following month.

After the month DJ returned to work on three hours per day, three days per week. At this time her employer recommended she return to work on packing duties, but her doctor recommended a return to machining duties. After a week of machine operator duties, DJ was experiencing ongoing pain in her arms, upper back and neck and requested to be moved to packing duties.

Since this time, she has continued to remain on various alternative duties, predominantly packing, for the nine hours per week – taking rest breaks as required.

The packing duties are self paced and light, without significant lifting, but DJ still reports experiencing some soreness.

She reports generalised tenderness in her back, neck, shoulders and arms, and indicates her condition is not improving.

Key Messages:

Distressed people don't do as well with return to work

The describe incident resulted in distress. Distress impacts how a person reports their problems and in turn how they are managed. People who are distressed have more investigations, more treatment, have poorer return to work outcomes, and may remain off work.

Pain is a subjective experience. That is, pain cannot be measured. A doctor or other treating practitioner relies on the patient's reports about their pain to assess the problem. Distressed people use more emotive terms, describe greater levels of pain, and greater difficulty in coping with the pain.

Treaters hear the patient's plea for help and respond accordingly. With good intentions more tests are done. A person in their fifties will often have so called abnormalities on XRs or scans. For example, 50% of people aged 50 have a partial tear on their shoulder ultrasound, even without any shoulder symptoms.

Test abnormalities are not well understood by many treaters, and the results can be conveyed to the patient as though they are important. This results in the person becoming increasingly concerned about the problem and their future. And if the tests are normal some people worry even more – why doesn't the problem show on the test? Maybe there is something more serious.

Continued reports of pain result in more treatment. Despite minimal benefit the treatment often continues. A cycle that focuses on the problem rather than return to normal function develops.

Hurt does not mean harm

57% of the population has a long term musculoskeletal condition: a sore back, neck, elbow or knee. People live with the problem most of the time, but seek treatment if the condition plays up, interferes with what they need / want to do, or the pain gets too bad.

Musculoskeletal conditions often take time to settle. Expectations that the problem will settle in days or weeks are often unrealistic. Many conditions take months to settle, but return to good function generally occurs quickly. For example, following an uncomplicated ankle sprain many people report some ongoing level of soreness for six months. But they are back walking and doing normal activities and work within days. It is a common problem and people don't worry too much about ankle sprains. But when the same thing happens with back pain there can be much greater concern about return to activity.

The soreness may take months to resolve but return to function should occur more rapidly.

Return to function is best achieved though:

Ensuring the person feels heard and understood. This is the basis for the person trusting the treater or employer's recommendations.

• Appropriate investigations where needed
• A thorough explanation about the nature of the condition, and any investigation results (the investigations need to be interpreted in conjunction with the medical condition)
• Reassurance that hurt does not mean harm. Helping the person understand this can take considerable time and effort. Ordering further test or medication is often quicker and easier!

While DJ may believe that rest and a passive return to work are her best options, there is a wealth of evidence to suggest that the longer workers stay on reduced hours or alternative duties, the less likely they are to make a full return to work.

Extended rest is unlikely to improve her soreness symptoms and a better form of management would be to refocus the treatment, include a strengthening program and put a graduated return to pre-injury duties in place. Short stretch breaks and a rotation of duties can help a person get back to their normal tasks.

In summary, DJ's case is best managed by

1. Ensuring the episode at work is acknowledged, and the cause of the incident is understood and fixed so it does not happen again.
2. Support with early medical care, with any relevant investigations performed early
3. Proactive advice about the result of any tests, and information about the diagnosis
4. A planned return to normal duties, involving the employee in the development of the plan
5. Regular communication and support for the employee, from her supervisor and coworkers, encouraging return to normal hours and work
6. Use of a treater experienced and proactive in the management of musculoskeletal conditions, who provides advice about return to normal activities
7. Advice about ways DJ can lessen any soreness, such as regular use of simple analgesics like Panadol, use of heat packs, stretches, changing posture
8. Congratulations and encouragement of progress.