The military has immense experience dealing with injuries. A steady development in the quality of medical treatment has, perhaps ironically, accompanied our past century of warfare. Military medicos have witnessed an evolution in various treatment approaches and a range of vastly different outcomes.

In WWI, one such approach to dealing with trauma involved removing injured British soldiers to England rather than treating and supporting them in the field. As it turned out, the soldier’s rate of rejoining the active workforce was significantly reduced, to the point where almost none of these soldiers returned to active duty. The military soon learned that this approach was more likely to lead to permanent disability in patients.

This led to the military devising a different approach, named the SPICE model. They also call this the “forward treatment” model. It produces sounder rehabilitation outcomes and minimises the risk of long-term disability.

SPICE is:

• Simplicity - avoidance of over-medicalised terms and treatment;
• Proximity – treatment based in the workplace environment;
• Immediacy - care from the outset;
• Centrality - all parties work towards the common goal of return to work; and
• Expectations – the patient’s medical and return to work expectations are set appropriately.

The elements and benefits of SPICE were explained by Dr Alan Colledge, MD of the Utah State Labor Commission, when he presented on workers’ compensation to the Montana Department of Labor in 2007. We’ll look at a few of his points now.

Forward thinking

Colledge explains that during the Yom Kippur War in 1973, forward treatment models were not yet being used. Physicians noted that despite “state of the art” medical treatment being given to patients, even minor physical impairments caused soldiers to “behave as if they were disabled.” Most became “permanently disabled” with “few ever returning to active duty.”

In contrast, by the time the 1982 Lebanon war took place, Israel had adopted the forward treatment model. 60 per cent of soldiers with injuries comparable to those in the Yom Kippur War returned to full active duty in 72 hours. Disability rates were substantially lower.

While these are both examples of the military experience with SPICE, when we expand the acronym we see how SPICE relates to all rehab and return to work scenarios.

Simplicity

The military recommended medical terminology be kept simple, rather than using complicated diagnostic labelling for mental or physical health problems. Patients are already anxious about their conditions and they mostly don’t understand medical jargon. This only induces fear in patients and helps them rationalise that their condition is more severe than they previously realised.

Colledge gives a simple explanation. “The more a patient is convinced that their symptoms are serious and pathologic, the more intense, prolonged and disabling their symptoms become.” He cites numerous studies that all point to the worsening of patient disability when minor problems are over-diagnosed and treated.

Proximity

As mentioned before, the military discovered that removing the soldier from their colleagues and sources of stress didn't actually help them recover in the longer term.

After WWII, physicians saw a correlation between simple, close-by treatment and faster soldier recovery. In the case of the Lebanon war, treatments that took place within 2 to 5 kilometres from the combat front enjoyed a 60% return to combat rate within 72 hours. Those treated at the rear of a division had a return rate of 40%.

When soldiers were rehabilitated within their normal environments, they kept in touch with colleagues and didn't have to face reintegrating to a difficult situation from which they had been removed. Ongoing contact with their colleagues kept up the soldier's morale, while keeping return to work the goal prevented disability.

Immediacy

When people within the military were treated early and helped, they responded in a like fashion. They were more likely to respond to early care with early return to their job. One of the main factors leading to widespread “shell-shock” disability after WWI was leaving simple stress conditions improperly or un-treated.

Colledge stated, “Delay of treatment can significantly increase psychosocial issues and delayed recovery.”

Centrality

When the soldier was the centre of care, they did better. That meant that all people working on their rehab, including the soldier themselves, needed to have the goal of return to work front and centre in their minds. The team could not become fragmented in approach.

According to Colledge, “A multitude of different diagnosis, treatment and social expectations given to the soldier strengthened his subconscious resolve that something indeed must be seriously wrong with me because no one can find of fix it.”

Expectations

In WWI, shell-shock was the second leading cause of disability in Great Britain after the war. The military found that when people were diagnosed with terms such as “shell-shock” versus “nervousness”, the outcomes were worse. The psychosocial expectations attached to the outdated term shell-shock caused soldiers’ treatment progress to be limited. Colledge said the term “battle fatigue” better portrays the common stress reaction to combat as a normal human function, which with reassurance and rest sees 70 per cent of soldiers returned to duty within 72 hours.

Setting positive but realistic expectations, with goals that supported those expectations, provided remarkably better outcomes.

SPICE up your RTW:

While the army is at the extreme end of workplace injury and stress, the issues remain the same for all return to work situations. When people are removed from their everyday situation, labelled with worrying problems and have expectations of a poor outcome, not surprisingly they're likely to do worse.

Season your rehab with some SPICE and you’ll get tastier return to work results.