Management of musculoskeletal pain in a compensable environment: Implementation of helpful and unhelpful Models of Care in supporting recovery and return to work

Abstract

Models of Care (MoCs) for injured workers in the compensation environment recommend adoption of biopsychosocial management approaches. Still, widespread dominance of biomedical constructs at the system, organisational and individual levels of the compensation system prevails, contributing to suboptimal management practices and outcomes for injured workers. Efforts to implement contemporary MoCs in the compensation environment show some promise in improving outcomes. Areas of promise at the organisational level, particularly in the workplace, and at the system level are discussed. Implementation of a contemporary understanding of pain biology as part of the biopsychosocial approach in the management of the person with pain and associated disability has been effective in the non-compensable environment. The implications of this for the compensable environment are explored. Resultant helpful and unhelpful perspectives and behaviours are presented as a blueprint for areas of potential change in development and implementation of MoCs in a compensable environment.

Introduction

Models of Care (MoCs) represent evidence-informed frameworks or policy for optimal delivery of health services . There are contemporary MoCs for the management of musculoskeletal pain in the compensable environment and to address work disability . The overarching principles that bind these MoCs are well established. One is that these MoCs align to the multidimensional, biopsychosocial nature of pain and some include a contemporary understanding of pain biology , comparable to MoCs for musculoskeletal conditions more generally . Another key overarching principle is that work is good for your health and well-being , and that work itself is therapeutic. In general though, uptake of these principles into healthcare practitioners’ education, clinical practice and clinical trials has been limited resulting in suboptimal outcomes for injured workers. That the compensation environment in itself may increase vulnerabilities to suboptimal outcomes compounds the problem. In most cases, clinical management strategies based on pathoanatomical/biomedical constructs prevail in the compensation environment . Pathoanatomical/biomedical approaches pervade injured workers’ expectations and beliefs, organisational management of compensation claims, and drive the structural and legal basis of compensation systems (see also ).

Here we provide guidance on strategies for the implementation of appropriate MoCs in the compensation environment. To optimise an individual’s journey through a compensation claim, the MoCs need to facilitate integration of care and services across different levels of the compensation environment ( Fig. 1 ). This integration needs to occur across the system (macro) level (compensation systems, legalisation and policy), to the organisational (meso) level (the workplace/employer, insurer and clinical panels), to the individual (micro) level (the injured worker and their family, their healthcare practitioners and other individual stakeholders) ( Fig. 1 ). Sound communication and maximal consensus based on the optimal MoCs across all levels facilitate horizontal integration between the three levels of the compensation environment .

The most influential factors contributing to a positive/helpful journey for an injured worker may change during the time of a compensation claim ( Fig. 2 ). A potential link between multiple levels ( Fig. 1 ), multiple stakeholders , and temporality ( Fig. 2 ) is the influence these factors have on ‘context’ for the injured worker. In this paper, context refers to the individual biopsychosocial factors and circumstances forming the injured worker’s reality. This is the essence of the biopsychosocial model of pain aetiology and care . In each interaction a person has during their compensation journey, what is said, what is done and how this is interpreted have significant influence on ‘context’ and may be helpful or unhelpful.