OHP VOLUME 19.1 MARCH 2015
Occupational health physiotherapy The journal of the Association of Chartered Physiotherapists in Occupational Health and Ergonomics
in this issueâ€Ś Fit for Work service starts When stress becomes a pain Clinical reasoning in the workplace
editorial MY HEART WAS gladdened when a GP registrar phoned last week to ask if she should renew the “sick note” of one of our employees. She had not seen the patient before and was wondering if she needed to. After our planned review, I was able to report that progress was such that a return to some work was feasible and that a phased return and modified duties had already been negotiated with the manager. All she needed to do was tick the relevant boxes on the fit note and reference the occupational health report. It feels as though training of future GPs in health and work and the Fit Note is having tangible effect. This year the Fit for Work service is becoming a reality, see the guide on page 7. While employers still need to take greater ownership of absence management and avoid inappropriate medicalisation of issues, the position of
GPs in front-line healthcare means that they will remain a key source of advice and influence to most working patients for the foreseeable future. But golly, it feels good when it all joins up. This edition, my final one as editor, is also the final edition to come out in print. We have provided a digital version of the last two journals for you to get accustomed to and we hope that you will become enthusiastic users of the digital facilities. It will change from a “shades of grey” publication to a technicolour experience. The link will be emailed to you each time the e-journal is published and will also feature in the e-news. If you do not receive e-news but have not unsubscribed, check that ACPOHE has your preferred and correct email address. The journal will also continue to be available as a downloadable pdf from the ACPOHE website. Being journal editor has been an incredibly rewarding experience. ACPOHE receives great feedback about how you value the publication. I would like to
contents Chat from the chair 04 ACPOHE news 05 Fit for Work 07 News 08 ACPOHE CPD groups 11 Horizon scanning 12 SEQOHS13 The triggers of pain 14 Talking point 17 Clinical reasoning 18 Benefit of exercise 23 ACPOHE courses 24
thank Katy Burke who trained me for the role and all those people who have contributed articles, news and ideas. I owe many thanks to our publisher Jason Pelta at Pages Creative and his team who push the standards and provide continuity as well as design flair. Mark Kingston is taking over as editor and I wish him every success. Please support him by sending him copy. You do not have to wait to be invited to write; if you are doing something that you think others might be interested in, contact Mark with a proposal mark. firstname.lastname@example.org Merrin Froggett Editor
Opinions expressed by contributors are not necessarily those of the Association of Chartered Physiotherapists in Occupational Health and Ergonomics (ACPOHE). Mention of any person, product, publication or organisation in the body of the newsletter or in any advertising does not imply that it/they have been endorsed, approved, accredited or investigated by ACPOHE. While every care is taken to provide accurate information, neither the editorial team, nor the association, accepts any liability for errors or omissions. © Copyright for all material published is held by the Association of Chartered Physiotherapists in Occupational Health and Ergonomics unless specifically stated otherwise. Designed and produced by Pages Creative www.pagescreative.co.uk Printed by Severn, Gloucester.
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www.acpohe.org.uk OHP VOLUME 19.1
MARCH 2015 executive committee
ACPOHE executive committee members and responsibilities Honorary chair Mark Armour Clinical Director RehabWorks Suffolk House Angel Hill Bury St Edmunds IP33 1UZ Tel 07834 710706 email@example.com Honorary treasurer Heather O’Neill Physiotherapy Department Wansbeck Hospital Woodhorn Lane Ashington NE63 9JJ Tel 01670 564010 heather.o’firstname.lastname@example.org Honorary secretary Karin Gibberd Physio Department Royal Devon & Exeter (Wonford) NHS Foundation Trust Barrack Road Exeter EX2 5DW Tel 01392 405800 email@example.com OHP journal editor Merrin Froggett Occupational Health Department Doncaster Royal Infirmary Armthorpe Road Doncaster DN2 5LT Tel 01302 366666 ext 3750 firstname.lastname@example.org Public relations officer Josh Catlett Capital Physio The Surgery Rutherford Way Bushey Heath Bushey WD23 1NJ Tel 020 8420 4600 email@example.com PRO support Charlie Cousin 17 Velsheda Court Hythe Marina Village Hythe Southampton Hants SO45 6DW Tel 07762 142505 firstname.lastname@example.org
Membership support Tracey Atkinson Connect Physical Health 36 Apex Business Village Annitsford Cramlington NE23 7BF Tel 0191 250 4580 mobile 07921 782214 email@example.com Education officer Katharine Metters Posturite The Mill Berwick East Sussex BN26 6SZ Tel 07838 171554 firstname.lastname@example.org Conference director Simon Mesner Princess Grace Hospital 30 Devonshire Street London W1G 6PU Tel 020 7908 3660 email@example.com Research officer Heather Gray School of Health & Life Sciences Glasgow Caledonian University Cowcaddens Road Glasgow G4 0BA Tel 0141 331 8115 firstname.lastname@example.org e-news Maggi Holmes Occupational Health and Wellbeing 151 Belfast Road Carrickfergus Co Antrim BT38 8PL Tel 028 9070 0718 email@example.com Co-opted equality and diversity and education support, iCSP co-ordinator Virginia Jenkins Principal Lecturer School of Health Professions University of Brighton Rob Dodd Building 49 Darley Road Eastbourne BN20 7UR Tel 01273 643653 firstname.lastname@example.org
Co-opted CPD Lead Katherine Roberts Working Health Consulting Ltd 7 Gatley Drive Guildford GU4 7JJ Tel 07718 541554 email@example.com Website officer Miles Atkinson Fit for Work (UK) Jubilee Stand Ledrington Road London SE19 2BB Tel 020 8768 4838 firstname.lastname@example.org Journal support Mark Kingston Rhondda Cynon Taf CBC Occupational Health Unit Municipal Buildings Gelliwastad Road Pontypridd CF37 1BF Tel 01443 494003 email@example.com Horizon scanning Jonathan Hill Rhondda Cynon Taf CBC Occupational Health Unit Municipal Buildings Gelliwastad Road Pontypridd CF37 1BF Tel 07595 046641 firstname.lastname@example.org ACPOHE administration support Tracy Long ACPOHE c/o Bury Physio Maynewater Lane Bury St Edmunds Suffolk IP33 2AB Tel 01284 748202 email@example.com
MEMBER ENQUIRIES Many of our processes at ACPOHE are now online or easy to deal with by email, but occasionally you may need to speak to our administration support, Tracy Long. Tracy is in the office regularly on Monday and Friday mornings and Wednesday evenings on: 01284 748202 or email firstname.lastname@example.org OHP VOLUME 19.1
4 executive news
chat from the chair THIS CHAT FROM THE CHAIR comes along as I reflect on the Health and Wellbeing at Work conference 2015. One of the main speakers was Alasdair Emslie, Chief Medical Officer of Maximus (Health Management Limited) which has been awarded the contract to deliver the new Fit for Work service. It is one of the largest providers of occupational health services in the UK and took over the contract for work capability assessments for the DWP in March when Atos left the contract early. Dr Emslie conveyed a view that much of current OH provision is not fit for purpose and that employers are getting a poor service. Many ACPOHE physiotherapists work in a subcontracted manner to occupational health companies and are at risk of being tarred with the same brush as the collective OH service. It may pay to be mindful of this and make sure you maintain evidence of good practice, including statistics of your own performance against service levels, and case studies demonstrating the great work you do. Hot on the heels of the Health and Wellbeing at Work conference was an event at the CSP entitled “Call to Action: Supporting a healthy workforce – the role of education and training in Occupational Health”. It discussed the National School of Occupational Health (NSOH) and the requirements for training across all the disciplines which contribute to occupational health. I am pleased to report that there was broad acknowledgement, recognition and genuine appreciation of the value of OH physiotherapy and of our structured approach to postgraduate education and development despite a lack of formal programmes and resources. Glyn Smyth provided a synopsis of our current education provision, challenges and opportunities. He articulated the next step of needing to develop an advanced CPD programme for our registered members and the establishment of a OHP VOLUME 19.1
multidisciplinary mentorship scheme. The consensus of the attendees was that we should all share the same core knowledge of key principles such as legislation, ethics and confidentiality and that the introduction of multidisciplinary OH training for common elements would be extremely valuable. Watch this space for further outputs from the NSOH. ACPOHE would like to congratulate and thank Leonie Dawson who has been seconded from the CSP to work with NSOH on research and development of future training requirements. With SEQOHS for physiotherapy going live in April, the committee is preparing for the assessment process. We are training six assessors and providing representation on the SEQOHS board. Thank you to those who responded to our survey about your views and intentions on SEQOHS accreditation. More work in hand for the ACPOHE Executive committee includes reviewing our existing guidance documents and the commissioning of new guidance documents on DSE assessment and on understanding and negotiating commercial arrangements in OH. Membership numbers have risen to almost 100 more than at this time last year. We are, however, behind on our goal to have 250 registered members by now, though there are still a large number of people in the process. If you committed to routes 2 or 3 but have not submitted your evidence yet, you can expect a reminder in the post soon. Another interesting area I have stumbled into recently is the British Standards Association. I represented the ACPOHE membership in meetings about developing two new standards: ISO 45001 Occupational health and safety and HCS/001 Human capital management. The world of international standards is a new and unexpected experience for me. The challenge of agreeing common language and phrases that are internationally recognised may
take me some time to acclimatise to. Draft standards for 45001 and HCS/001 will be found in the consultations section of our website as they are released for your comment. Due to our decision to join in Physiotherapy UK 2015 and expose the wider profession to some occupational health content, our AGM will be later in the year than normal. We have some vacancies appearing on the committee (as is usual) in the meantime. With so much going on, we would appreciate filling vacancies as soon as possible. If you are curious about getting involved, please approach any of the committee to discuss what’s involved. Being on the Executive committee is one of the best learning and growth opportunities around and you’ll make good friends, too. You don’t have to bring a special skill or sign up to a particular role straight away, we know it takes time to develop. Finally, don’t forget to start thinking about Work out at Work Day 2015 on June 12. It’s an excellent arena to showcase your role, knowledge and skills to employers and the public. Mark Armour Chair
MARCH 2015 acpohe news
Fitness for Work Assessment Guidance Group seeks conference input update In the November issue of OHP, members were told about the formation of a new group within ACPOHE with a specific interest in functional capacity evaluation. The group convened again in December via phone conference and agreed to be known as the ACPOHE Fitness for Work Assessment Group. A core team of members has been trawling though the evidence for various functional tests and updating a database on upper limb, lower limb and spinal tests. The long-term plan is to identify suitable cost-effective but valid and reliable tools which will form the basis
of the ACPOHE Functional Work Assessment toolkit. As the toolkit takes form, the Assessing Fitness for Work and Function course will be updated to reflect the new group’s recommendations. On behalf of the group, a proposal has been submitted to the CSP to present a workshop at the Physio UK conference in October and we await confirmation as to whether this has been selected for the programme. In the meantime, the Fitness for Work Assessment Group will hold its next phone conference meeting in March. Katy Burke
Website better than ever Miles Atkinson continues to develop the website into an invaluable resource. He has added a job opportunities tab to the homepage so that it is accessible to non-members. If you have an occupational health job to advertise, send it to both Miles (email@example.com) and Maggi for e-news (magsjj@gmail. com). There is now a list of registered members on the “physio near you” tab and this will be regularly updated as more registered members come on stream. Miles is keeping the ACPOHE regional network page up to date, so don’t forget to send him notice of events and reports of your activities in case someone you don’t know is looking to join your local group. Google Analytics data is helping Miles to understand traffic to the site; for example, 56.5% of the site views are from new visitors, 20% are from the London area and Google is the most common source of referral to the site.
Job ads push e-news ratings E-news opening rate is up to 50% which is high for comparable e-bulletins. The regular job adverts have got members hitting the site regularly. Remember that job adverts are free to members on e-news for 15 words plus contact details and e-news goes out once or twice a month. Contact the e-news officer Maggi Holmes on firstname.lastname@example.org
Business is booming There is now an extensive resource on making the business case for OH physiotherapy on the news section of the ACPOHE website. This includes workshop presentations from previous ACPOHE conferences on “Making a case for physiotherapy” by Mark Armour, and “Setting up an on-site physiotherapy service” by Stuart Paterson.
There is a new addition to the ACPOHE guidance documents on “Carrying out work-based assessments for blind and partially sighted people”. This effective practice guide has been produced by RNIB to assist employment and access technology professionals with carrying out work-based assessments for blind and partially sighted people. As well as providing guidance for evaluating the potential for workplace adjustments that allow a blind or partially sighted person to fulfil their role better, it also details ground rules for any work-based assessment.
On your marks The small team of markers have nearly completed all the registered membership applications submitted last year during the introductory period of reduced fees. Membership support Tracey Atkinson would like members to know that their patience throughout the process has been appreciated. There are still a number of members who signed up to registered membership application but have not submitted their evidence yet. Tracey is going to contact these people individually about getting their application back on track.
Please note that three Executive committee members have changed contact details: Josh Catlett, Miles Atkinson, Simon Mesner. See their new details on page three. OHP VOLUME 19.1
6 acpohe news
Workout at Work Day seeks a record number of volunteers taking part
22% rise in membership as corporate offer starts
The CSP’s popular Workout at Work Day campaign is back for a fifth year and will be held on Friday 12 June. The campaign had a fantastic turnout last year, with almost 300 members holding 230 events across the UK, from lunchtime walks and cycling sessions to workplace exercise classes and outdoor gym circuits – our chief executive Professor Karen Middleton was even put through her paces in an energetic outdoor gym session to mark the day in London. W@WD continues to offer members a great opportunity to promote the role physiotherapists play in keeping people “fit for work” and the PR team hopes to see a record number sign up for the 2015 campaign. This year we’re taking a bit of a different approach and will include a scale of involvement to show how any member can join in spreading the W@WD message – from small asks like hanging a W@WD poster with posture
Since September 2014, ACPOHE has seen a 22% increase in general membership, now having 405 members. This has been helped by the committee’s decision to bring in corporate ACPOHE membership. Welcome to physiotherapists at IPRS who have joined us through this route. Corporate membership is for larger organisations that employ five or more occupational health physiotherapists and gives a 20% discount. However, organisations taking corporate membership will need to demonstrate that they will be working towards SEQOHS accreditation. There are now 74 registered members. Registered members willing to act as mentors are still required. You may have a specialist area of knowledge, work in a particular field or just want to have the opportunities to help other ACPOHE members going through the registered membership process or who work alone. This is an ideal CPD opportunity. Registered members can help to mark case studies submitted by applicants for registered membership. If you are interested, support and training will be provided and there is payment for marking. Please let me know if you are interested in either of these opportunities: tracey. email@example.com
and exercise advice, or tweeting our W@WD messages, through to larger events like cycling challenges and Pilates classes. Once again, we are excited to be partnering with ACPOHE for W@WD 2015 and want to thank all members for their ongoing hard work and support of the campaign. Registration is open now until 5pm on Friday May 15. Don’t forget to register your event to receive a member pack full of exercise and postural advice leaflets, a new W@WD poster and two W@WD t-shirts. Visit the W@WD webpage www.csp.org.uk/workoutatwork or contact the Enquiry Handling Unit for more information on firstname.lastname@example.org or 0207 306 6666. Michelle Carnovale PR and Social Media Officer The Chartered Society of Physiotherapy
Work on your local employers Why not contact your local employers and get them to sign up and take part in W@WD even if you cannot join them on the day. Send them a simple message like this: Workout at Work Day is an annual awareness day organised by the Chartered Society of Physiotherapy (CSP) and will be held on Friday, June 12. Sign up your workplace and join hundreds of other UK employers in supporting employee health and wellbeing. Visit the W@WD webpage www.csp.org.uk/workoutatwork for more information and to register as an employer. It takes only one step to get started!
Research funds for PhD studies
ACPOHE research officer Heather Gray sends news that research funding for MSc/PhD studies is available at the Colt Foundation www.coltfoundation.org.uk/ body_prog.html. OHP VOLUME 19.1
New council member
Jan Vickery (immediate past chair of ACPOHE) is taking over the CSP seat on the Council for Work and Health from Natalie Beswetherick. Mark Armour (ACPOHE chair) continues to represent ACPOHE.
Routes of advance Congratulations and welcome to five new ACPOHE registered members. Achieved Route 1 – Jane Illingworth. Achieved Route 2 – Kirsty Kendrick, Charlie Cousin, Linda Fridd and Jonathan Hill.
MARCH 2015 fit for work
How the Fit for Work service is intended to help people back into the workplace After a long labour, the Fit for Work service is being delivered in stages. It allows GPs to refer patients, or employers to refer employees, off sick for four weeks for a free assessment of their condition. What should employers be doing to prepare? After a quiet launch, most people, including employers and GPs, do not know it is happening. Since December 2014, there has been online and telephone advice from OH professionals and website information resources. The second level of service, the telephone and face-to-face assessment service, is still being piloted in Sheffield. The plan is for it to roll-out gradually after May; the Midlands, North West and Wales are the next in line. WHAT IS THE AIM? If a health condition is affecting their job, employees, employers or GPs will be able to obtain advice and support on adjustments which could assist in helping employees stay in, or return to, employment. HOW WILL REFERRALS BE MADE? The Government expects that the majority of referrals will be made by GPs. However, employers can also make referrals, if the employee consents. Once an employee has reached, or is expected to reach, four weeks of sickness absence, their GP will be able to refer them to the Fit for Work service for a free OH assessment. GPs will be able to exercise their own judgement when making referrals and on the timing of referrals. If the GP has not already referred an employee, the employer can do so, but only when they have been absent for four weeks. If the employer makes the referral, they must consider it possible that the employee would be able to make at least a phased return to work.
IS IT VOLUNTARY? Consent is a key factor. The employee must agree to participate in the process regardless of who refers them. The employee can withdraw consent at any time. WHAT IS THE PROCESS? Once an employee is referred, an OH professional will contact them within two working days to carry out a telephone assessment. In the few cases where face-to-face assessment is needed, it will be within five days and within 90 minutes’ travelling time by public transport of the employee’s home. Using a biopsychosocial model, the OH professional will identify all health, work, personal and social issues preventing the employee from returning to work. The aim is for the employee and the OH professional (acting as case manager) to agree a Return to Work plan, the “Plan”. On the basis that the employee consents, the case manager may contact relevant individuals such as HR or a line manager to assist in formulating the Plan. The Plan will then be shared with the employee, the employer and GP. The Plan will detail any recommendations, but it will remain the decision of the employee and employer on whether to implement them. Employers are encouraged to act on the recommendations and advice in the Plan although this will not be mandatory. If litigation were to arise later, a failure to follow recommendations could become evidence in a reasonable adjustments claim, or an unfair dismissal claim. For example, an employee dismissed for poor performance or attendance could argue that they would have performed better had the recommended adjustments been made.
WHAT IF THE EMPLOYER HAS ITS OWN OH SERVICE? Employers do not have to use the Fit for Work service and the Fit for Work service will not replace the existing OH service of an employer, but will seek to complement and work in conjunction with it. A Fit for Work case manager who becomes involved is likely to get in touch with the employer’s OH adviser. WHAT IF TREATMENT IS RECOMMENDED? The Government has introduced tax exemption for amounts up to £500 paid by employers for medical treatment for employees by employer-arranged OH services in addition to those recommended by the new Health and Work Service. HOW DOES THE FIT NOTE FIT IN? The issuing of a Return to Work plan will replace the need for a fit note. Employers are advised not to request further fit notes, in order to prevent unnecessary consultation with GPs. Get ready: ●● update sickness absence policies to reflect the new service ●● training should be provided to managers and HR staff to make them aware of the scheme ●● employees should be made aware ●● consider how consent will be taken and recorded ●● possibly appoint one person, probably in HR, to be point of contact for any Fit for Work enquiries ●● employers/HR teams need to consider how to liaise with GPs. Fit for Work guides are available at www.gov.uk/government/collections/ fit-for-work-guidance
OHP VOLUME 19.1
Shortage of OH doctors on the horizon A crisis is looming – the number of doctors choosing to train in occupational medicine is in decline. The Faculty of Occupational Medicine (FOM) estimates that the annual intake of specialist trainees required to meet the demand for accredited consultants is less than half of what is required. To address this gap, a multidisciplinary group of OH professionals met recently for a oneday workshop to identify the added value that a consultant brings to an
OH service and suggest practical solutions to the potential shortfall. It was noted that consultants were required for NHS OH services to comply with SEQOHS accreditation and to supervise the training of junior colleagues to specialist level. There was also the perception that consultants were necessary to conclude complex case management, particularly when the outcome may have significant impact such as litigation or dismissal. Additionally, consultants were thought to add value
by increasing levels of clinical governance, expertise and strategic development. The group agreed that a different model of OH delivery was needed for the short term. Urgent action was advised to address the staffing difficulties in some NHS trusts. It was hoped that enhanced training of OH advisers, accessing the expertise of other clinical specialities and further use of the wider OH MDT would at least partly fill the supply/demand for consultants.
Half the world ‘will be obese’ by 2030 Research by the McKinsey Global Institute says that 30% of the world’s population is obese and this could rise to nearly 50% by 2030. Obesity costs the UK £47bn a year. The institute says that UK government efforts to tackle obesity were “too fragmented to be effective”, and investment was “relatively low given the scale of the problem”. Relying on education and personal responsibility are critical intervention elements, but not sufficient on their own, the MGI report states. Other required interventions rely less on conscious choices by individuals and more on changes to OHP VOLUME 19.1
the environment and societal norms. Examples include reducing default portion sizes, changing marketing practices and restructuring urban and education environments to facilitate physical activities. Capturing the full potential impact requires engagement from as many sectors as possible, including governments, retailers, consumer-goods companies, restaurants, employers, media, educators and healthcare providers as well as individuals. http://www.mckinsey.com/Insights/Economic_Studies/ How_the_world_could_better_fight_obesity
MARCH 2015 â€‚â€‚ news
Walk to Work Week 11-15 MAY Walk to Work Week is a national challenge run by the charity Living Streets. The week aims to encourage employees to walk more as part of their commute and working day, and to help workplaces encourage and promote walking to their workforce. Walk to Work Week takes place as part of National Walking Month, which runs throughout May. http://www.livingstreets.org.uk/ walk-with-us/events/walk-towork-week
Trials to help arthritis sufferers to stay in work Worldwide about 3% of people have inflammatory arthritis (IA). The disease usually begins when people still have many years of working life left. Therefore, it is important to know if there are effective ways to help people with IA stay at work. This Cochrane Review focuses on non-drug interventions. The literature search identified three randomised controlled trials (414 participants) who had IA and who were at risk of losing their jobs. These trials first evaluated how the work environment could be adapted and then
provided counselling, advice or education for work problems, workplace visits or visits with an occupational physician. The evidence from the three trials was of very low quality, but positive results from one RCT with long-term follow-up show potential for job loss prevention interventions in helping workers with inflammatory arthritis to stay at work. Non-pharmacological interventions for preventing job loss in workers with inflammatory arthritis: Cochrane Review November 2014.
National bike week 13-21 JUNE Bike Week is an annual opportunity to promote cycling and show how it can easily be part of everyday life. Demonstrating the social, health and environmental benefits of cycling, the week aims to get people to give cycling a go all over the UK. http://www.bikeweek.org.uk/ OHP VOLUME 19.1
Exercise guidelines are ‘unrealistic’ – doctors Exercise guidelines are unrealistic and doctors should instead be advising small increases in activity, according to new research. It warns that the 150 minutes a week target is beyond some people, particularly older individuals, and that striving to reach these goals could overlook some of the benefits of lighter exercise. However, public health officials say that current recommendations have proven benefits in lowering the risk of heart disease; heart disease, type 2 diabetes and some cancers are linked to inactivity. UK guidelines currently recommend at least 2½ hours of moderate activity a week, in sessions of 10 minutes or more. Two articles in the BMJ argue that OHP VOLUME 19.1
the message needs to change, with greater emphasis in making inactive people move. Professor Philipe de Souto Barreto advises people who are sedentary to make small incremental increases in their activity levels rather than push to achieve current goals. He points to previous studies which show even short periods of walking or just 20 minutes of vigorous activity a few times a month can reduce the risk of death, compared to people who do no exercise. In the second article, Professor Phillip Sparling says doctors should tailor their advice, particularly for older patients. He suggests that GPs discuss “realistic options” with people over 60 to increase activity, such as getting them to stand up and move during TV commercial breaks.
World Day for Safety and Health at Work 28 APRIL Celebrate World Day for Safety and Health at Work on 28 April to promote the prevention of occupational accidents and diseases globally. It is an awareness-raising campaign intended to focus international attention on emerging trends in the field of occupational safety and health and on the magnitude of work-related injuries, diseases and fatalities worldwide. http://www.ilo.org/safework/ events/safeday/lang--en/index. htm
MARCH 2015 news
Major NHS action needed to tackle physical inactivity The NHS needs to step up and do more to tackle physical inactivity, claims a new report from the Scottish Academy of Medical Royal Colleges and Faculties. The group, which includes the Faculty of Occupational Medicine, delivered its recommendations to the Scottish Government. Recommendations to be implemented in the next two years include: ●● Every GP in Scotland should have the training and mechanisms to give their patients advice and interventions for physical inactivity, in the same manner as currently delivered for smoking and alcohol ●● All hospital assessments to include questions about physical activity levels and diet alongside questions
about smoking and alcohol ●● Every person entering the care
system will have their physical activity levels assessed ●● All medical schools in Scotland will include educational sessions on physical activity and health behaviour change ●● All Scottish hospitals will have clearly defined walking routes from the hospital to enable staff, patients and visitors to exercise. The group says that healthcare leaders in policy, medical education, health boards, hospitals and Royal Colleges must renew their focus on tackling physical inactivity and that increasing knowledge of the required levels of physical activity among the
public is imperative. The group supports the UK Chief Medical Officer’s recommendation of 150 minutes of physical activity a week for adults and 60 minutes a day for schoolchildren. “The Scottish Academy’s view is clear that the priorities of doctors should not only be to provide excellent treatment of disease, but to do more to promote health and prevent disease. The NHS provides world-class medical treatments, but at its core is the word “health” and we can, should and will help boost physical activity levels in Scotland by prioritising this important area more.” www.fom.ac.uk/wp-content/ uploads/27-01-2015-ScottishAcademy-report-on-physicalinactivity.pdf
Diary dates 2015 IEHF n 13-16 April n Daventry
Backcare week n 6-12 October
WCPT Congress n 1-4 May n Singapore
Physiotherapy UK n 16-17 October n Liverpool
IOSH n 16-17 June n Excel London
ACPOHE REGIONAL CPD GROUPS YOUR VIEWS ON CPD Mixed feedback was received from members on use of webinars for ACPOHE CPD. Overall, it appears that members still wish to meet face to face with their peers alongside or in addition to webinars. Further consideration is required on webinar topics and how these should be mapped against ACPOHE competencies and objectives on learning. Further investigation into the mechanisms and costs of delivering webinars is being undertaken.
Supporting a Healthy Workforce: the role of education and training in occupational health. There are more details of this on page 4.
FUTURE OF EDUCATION IN OH ACPOHE education officer Katharine Metters has been in discussion with Health Education England and the National School for Occupational Health about the current structure and future needs of postgraduate training for OH physiotherapists. CPD lead Katherine Roberts attended a CSP hosted multi-professional workshop this month entitled
Meetings have been held by the London and South/East and the Yorkshire and Humberside groups this month.
ROUND THE REGIONS We are still looking for regional CPD leads for London and the South/East and for the East of England. If you are interested in taking this role, please contact Katherine Roberts on 07718 541554.
NORTHERN IRELAND After a short break from organising meetings, Brendan McConaghy is now back organising forthcoming events email@example.com OHP VOLUME 19.1
HORIZON SCANNING COMPILED BY JONATHAN HILL
professional advice on diet and physical activity, as well as a free pedometer and motivational support. n www.cipd.co.uk/pm/ peoplemanagement/b/weblog/ archive/2015/01/06/airport-staffslim-down-and-boost-health-withwellbeing-intervention-pilot.aspx
WORK FOUNDATION CALLS FOR GREATER FLEXIBILITY ON SICKNESS ABSENCE A “part-time sick pay” system like one operating in Nordic countries is proposed for staff with fluctuating health. The quality of support offered to employees with fluctuating health conditions is inconsistent across UK businesses, The Work Foundation has found. The report, published by the foundation’s Health at Work Policy Unit, warns that, by 2030, 40 per cent of the working age population will have chronic and fluctuating health conditions. This will present a real challenge, Dame Carol Black said. “Particular difficulties are presented by fluctuating health conditions. Their unpredictability is a substantial problem when arrangements are being made to provide appropriate support. Symptoms are subjective and their effects often difficult for employers and co-workers to fully understand.” n www.cipd.co.uk/pm/ peoplemanagement/b/weblog/ archive/2015/01/22/workfoundation-calls-for-greaterflexibility-on-sickness-absence.aspx
with new statistics showing that the number of people who received Access to Work support in the first half of 2014 increased to 28,580 – 1,560 more than in the same period the previous year. n www.gov.uk/government/news/ thousands-of-disabled-peoplesupported-by-access-to-work
THOUSANDS OF DISABLED PEOPLE SUPPORTED BY ACCESS TO WORK The number of disabled people being supported into jobs through Access to Work is increasing, new figures show. Access to Work provides financial support towards the extra costs faced by disabled people who are looking for work or need support to stay in their job. Last year, more than 35,000 people benefited from the programme. And the numbers are continuing to grow
AIRPORT STAFF SLIM DOWN AND BOOST HEALTH WITH WELLBEING PILOT Employees advised on diet and physical activity at work reaps benefits, says a report. Security staff at Gatwick Airport lost weight and reduced their cholesterol among other health improvements as part of a 12-week work wellbeing intervention trial with 35 shift-workers. The pilot project offered employees
OHP VOLUME 19.1
GMC REVIEWS CONFIDENTIALITY GUIDANCE The GMC will be consulting during 2015. If you would like to contribute, go to their public consultation site and respond to one of three detailed questionnaires: l questions for doctors and organisations that work for or represent doctors l questions for patients and organisations that work for or represent patients l questions for other individuals and organisations (such as healthcare professionals, researchers, administrators, regulators) that have an interest in the use of patient information. n www.gmc-uk.org/guidance/news_ consultation/25893.asp
WHAT TO CONSIDER WHEN EMPLOYEES’ SICKNESS ABSENCE IS LONG-TERM Employers still need to think for themselves as the new “Fit for Work” service beds down. In due course, employees may also be referred to an independent health assessment service aimed at facilitating their return to, or retention in, work. Addressing sickness absence can introduce an array of legal issues, from discrimination to breach of contract, pay queries and matters of health and safety, and these will be just as relevant when the new scheme is implemented. Also, decisions over the dismissal of sick employees (if applicable) will still need to be approached with fairness and a fair procedure. n www.cipd.co.uk/pm/ peoplemanagement/b/weblog/ archive/2014/12/02/what-toconsider-when-employees-sicknessabsence-is-long-term.aspx SHIFT WORK DAMAGES EMPLOYEES’ ABILITY TO THINK, WARNS STUDY Staff who regularly work hours that go against their natural body clock face significant damage to their ability to think and remember, a study has found. A team of researchers, from Swansea University and Toulouse University, found a substantial decline in brain functions such as memory, speed of thought and wider cognitive ability among people who worked shifts. n www.cipd.co.uk/pm/ peoplemanagement/b/weblog/ archive/2014/11/04/shift-workdamages-employees-ability-tothink-warns-study.aspx
MARCH 2015 SEQOHS
Opportunity to become a SEQOHS assessor Nicola Hunter takes you through the training step-by-step WE HAVE DONE IT! ACPOHE occupational health physiotherapy practices can now become accredited under the Faculty of Occupational Medicine’s SEQOHS scheme. This is a great achievement so well done and a big thank you to all the six physiotherapy clinics who participated in the pilot during 2014. You have done a great job in developing the relevant evidence requirements for physiotherapy. It has been an interesting learning experience for us all. Now that we are in the SEQOHS scheme we need occupational health physiotherapists to train to become SEQOHS assessors. Glyn Smyth and I were trained to be assessors for the pilot and are now completing our training to become fully fledged SEQOHS assessors. Each of the pilot sites has been asked to put forward someone involved in the pilot as an assessor. We hope ACPOHE registered members will also put themselves forward to be trained as assessors. It really helps if you have been involved in a quality assurance scheme already, the SEQOHS pilot or/and ISO accreditation, as this gives you a working understanding of what is involved. We also recommend that physiotherapists training to be SEQOHS assessors work towards SEQOHS accreditation for their own practice as this helps you to understand what’s really involved. The assessor training is rigorous. The first step is a preparatory reading followed by one day introductory training. You must learn in detail the SEQOHS standards and evidence requirements for OH physiotherapists. This involves you being familiar with all the ACPOHE guidance documents and understanding what good practice looks like for occupational health physiotherapy. The next step is to shadow a couple of SEQOHS assessments. This is done in
two stages. The first is to shadow and participate in an on-line evidence review. To do this you have to work at your computer for a day reading and reviewing the evidence provided by a practice to demonstrate how they meet each standard. You have to decide whether the evidence is satisfactory and provide feedback. You can ask questions and request that additional evidence is provided during stage one. Once the online evidence is satisfactorily completed, a site visit is arranged. This is stage two. The purpose is to verify the online assessment. You will interview staff and check that what has been said on paper is what happens in practice. During training, you shadow and learn from experienced SEQOHS assessors. Once you fully understand the scheme, you become a technical
assessor for the OH physiotherapy elements of the process. You work alongside another assessor so that learning continues until you can lead an assessment. It’s an impressive, wellmanaged process. There is ongoing quality assurance of your work as an assessor with peer review of each assessment and 360º feedback. This is in place to ensure consistency in the assessment process. Assessors are paid a daily rate and expenses. This is a great opportunity for your professional development and will look very good on your CV. You will also learn a huge amount about working in occupational health and with colleagues from different professions. Potential applicants should contact tim.shaw@ rcplondon.ac.uk for an application pack and further information.
Introduction of physiotherapist OH services to SEQOHS As part of the launch of the 2015 SEQOHS standards, The Faculty of Occupational Medicine (FOM) is enabling physiotherapy Occupational Health services to register with SEQOHS. This decision follows a successful pilot scheme run in collaboration with The Association of Chartered Physiotherapists in Occupational Health and Ergonomics (ACPOHE), which tested the applicability of the SEQOHS standards and underpinning processes for this type of service. SEQOHS is a set of standards and a process of voluntary accreditation that aims to help to raise the overall standard of care provided by occupational health services. The benefits of SEQOHS are diverse. It can afford a commercial advantage, helps
to generate a culture of continual improvement and offers independent validation of a safe, effective and quality service. SEQOHS is encouraging all physiotherapy OH services to register with the scheme. Although the standards will be identical for all types of OH service, SEQOHS and ACPOHE have designed a bespoke evidence guide for physiotherapy OH services and will be holding its first training day for these services in the summer. If you would like to register with SEQOHS or learn more about the scheme, go to www.seqohs.org or contact us at firstname.lastname@example.org Oliver Campbell SEQOHS Accreditation Manager Royal College of Physicians OHP VOLUME 19.1
14 resolving chronic pain
The triggers of pain may not be physical Author: GEORGIE OLDFIELD Georgie Oldfield MCSP is a leading physiotherapist, author, speaker and chronic pain specialist, promoting a pioneering approach to resolving chronic pain through her SIRPA Recovery Programme and her clinics in London and Yorkshire.
When patients understand beliefs and behaviours feeding chronic pain, recovery is possible, says Georgie
2007 was a year when a number of my belief systems were turned on their heads, having a massive impact on me professionally and personally. It takes time for our views to change, or reach the point of questioning that what we believed to be fact might not be so. My transformation began in the NHS and after starting up my own Physiotherapy Pain Relief Centre in Huddersfield, West Yorkshire in 2005. In the 1990s, like many physiotherapists, I became caught up in the excitement about core stability and its importance in back pain. I did some Pilates courses and attended a four-day back pain course, believing this might provide me with specialised knowledge and tools to help my patients. I attended manual handling courses and, on leaving the NHS, went on a PhysioFirst course aimed specifically at being able to manage musculoskeletal disorders believed to be due to poor posture, OHP VOLUME 19.1
mechanics, or repetitive use of a mouse or keyboard. It was becoming clear to me that the application of all this knowledge seemed to make little difference in either my patients’ symptoms, or mine. Over the years, I was experiencing more frequent episodes of back or neck pain, sciatica, knee pain and shoulder pain. I blamed my recurring back pain/ sciatica on all the lifting and handling I had done over the years before the EEC regulations came into being. Now I wonder why I didn’t question why I would be absolutely fine for months between episodes. I worked for months to improve my slightly side flexed and protracted neck posture, believing that the frequent attacks of pain, pins and needles and burning arms must relate to
…there is “no link between pain and posture, structure and biomechanics”.
an accident decades earlier. No exercises or therapy caused any long-term relief of my symptoms. I began to question why so many of my patients told me they had just woken up with pain, or it had come on while doing something completely innocuous. Many patients came to me having spent months working on core stability, with no easing of symptoms, yet often their pain would resolve with my gentle treatments. Patients would present with RSI symptoms which began while doing something they had done with no problem, often for years. I began to question why we accepted this when usually the more we do something, the easier and more fluent it becomes. Numerous patients presented with non-specific neck and back pain, despite there being no physical “abnormality” and, even when there was, the signs and symptoms didn’t match. Even when patients came to me having been refused spinal surgery, many became pain free despite me clearly not being able to resolve their stenosis, for example. Physiotherapists are generally confident when treating acute injuries, but I became intrigued by the anomalies I observed. I grew frustrated with often only being able to help people manage chronic pain. I spent a number of years researching, reading and discussing these concerns with others, yet no-one could provide an answer until finally, in 2007, I came across the book Healing Back Pain, one of the earlier books by John E Sarno MD. Dr Sarno was a rehabilitation specialist at the New York University School of Medicine and a pioneer in the treatment of chronic musculoskeletal conditions, which he
MARCH 2015 resolving chronic pain then called Tension Myoneural Syndrome, or TMS. Dr Sarno’s basic theory is that pain (and many other symptoms) is a result of repressing how we feel, with symptoms manifesting physically because there is no other outlet. The more I looked into this, the more it made sense and actually answered my questions. I began recommending the books to patients if I felt they might be open to it. The results were more than I could have hoped for and I soon realised this wasn’t something I could ignore. I began to research more specifically and found numerous studies1-4 demonstrating that spinal degeneration is just as common in people without pain and is just a normal part of ageing. Clearly, if that’s the case, something else must be causing the pain. In fact, one recent paper5 looked at the previous 20 years of research into back pain and concluded that there is “no link between pain and posture, structure and biomechanics”. Quite challenging for those of us trained in the biomedical model! I continued my investigations and soon found many research papers linking adverse childhood experiences6,7 and chronic pain. I also began to understand why more people were developing RSI and back pain, despite increasingly strict manual handling8 and the Health and Safety9 regulations. More surprising to me was the lack of evidence10 that manual handling training and provision of assistive devices prevents low back pain! After a few months observing often life-changing results in my patients, I knew I had to find out more about this concept and approach. On finding there was no-one specialising in this field in the UK or Europe, I got in touch with Dr Sarno himself, who was kind enough to allow me to observe him at work in New York, despite only ever having accepted doctors before then. Afterwards, I set up my own TMS (now SIRPA) Recovery Programme and began working successfully with more and more people suffering from chronic pain.
During this time two patients were referred to me with a h/o five years of bilateral, debilitating RSI. Despite multiple investigations and therapy, plus the use of voice-activated software, there had been no real improvement. They recovered within six weeks after accepting that their pain was due to the stress of being under threat of redundancy for five years and learning some simple, self-empowering strategies. Although psychophysiological (stress-induced) pain can develop after an acute injury should have healed, it is commonly triggered as part of a protective or maladaptive fight or flight response, as a reaction to an emotional trauma. These days, threats to our lives tend to be few and far between, but our primal instincts are still present and most of our perceived threats tend to be psychological. Just as fear or sexual arousal result in very real physiological changes in the body, so our brain reacts to emotions related to a perceived threat causing physiological changes in the body. Unfortunately, when a psychosocial cause is missed and symptoms are blamed on a physical “abnormality”, plus the individual starts down the conventional route for a physical problem, the symptoms can easily become chronic. The fears and frustrations related to the pain and diagnosis also fuel the pain cycle and anxiety and depression can also develop, which further exacerbate the situation. Once it is recognised that the pain is due to learned nerve pathways and is not a physical disorder, plus the underlying causes are identified and dealt with (often through simple selfempowering strategies), full recovery is possible, no matter how severe the pain or how longstanding. Triggers can be related to a number of things, including; past events, current stressors, personality and learned
behaviours (which determine how we respond to what’s happening in our lives), plus the sheer pace of life and information overload result in us being less stress-resilient and less able to cope. From early childhood we learn to bottle up how we feel and to conform to society’s expectations, often resulting in what could be described as a pressure cooker of unresolved emotional turmoil/ trauma building up unconsciously. Not surprisingly, the trigger can be quite minor, yet can lead to a devastating decline purely because the underlying cause was not identified and addressed. The following are some real-life examples of psychosocial causes of pain of people who fully recovered once they understood the concept and followed educational and self-empowering advice. 1) Young fireman: seven years of back pain, two operations for prolapsed discs with no ease. Previously fit and healthy, yet his pain came on after returning to work just a month after his sister died in tragic circumstances. 2) Young lady: RSI developed just before handing in her dissertation and then recurred when she began her first job. 3) Financial Director of a global business: 12 months of back pain was triggered after he had to make 200 people redundant. 4) Young lady: sciatica began when she was promoted and had to begin assessing her colleagues’ work and feeding back to their bosses. 5) Neck and shoulder pain: developed after working on a CV before having to look for a new job due to financial difficulties. 6) 35-year-old lady: two years of persistent Piriformis Syndrome which only cleared once she identified that the sexual harassment she was suffering at work was the cause. With studies in the workplace now demonstrating that the most consistent predictors of back pain are psychosocial11-13, such as whether an individual has any control over decisions or empowering and fair leadership13, we should search beyond the area in which OHP VOLUME 19.1
16 resolving chronic pain the pain is felt. Although not directly linked with the workplace, the fact that a study14 demonstrated with 92% accuracy through personality profiling who would develop chronic whiplash following an accident indicates that we should be considering the mind’s involvement in any treatment approach. Research studies of the mind’s involvement in chronic pain in the past 10 years have provided a lot of support for the concept on which our work is based. The evidence for Cognitive Behavioural Therapy and Mindfulness, which are so commonly used in pain management programmes these days, has also been hugely helpful in moving people away from the restrictive biomedical model. I would suggest that the main, yet crucial, difference between the concept behind our work and that of the biopsychosocial model, is our finding that chronic pain is not just affected by stress, but is actually stress-induced. In fact, where any more serious tissuedamaging conditions have been ruled out (such as cancer, infection, fracture or an auto-immune disorder), you can almost guarantee that if pain/symptoms are persistent or recurring, the condition will be psychophysiological. This is an important point for the patient to accept because this enables them to work on any fears related to a physical diagnosis they have been given. Also, because the cause is due to learned nerve pathways and we know
that the brain is neuroplastic, full recovery is possible. This might purely be through understanding and acceptance, plus acknowledging the underlying emotional cause, but it often also includes the need to understand and apply self-empowering advice and strategies to reduce self-induced stress and improve stress-resilience. Although there was little evidence for this work when I began eight years ago, this is now changing and we have a number of practice-based retrospective case series, a published study15 and a number of studies currently on the go. As a global community of specialists, we are developing a protocol to build a large collection of case studies to enable us to demonstrate the short-term and long-term results of our approach to recovery from chronic pain. Setting up my company, SIRPA™, in 2010 was primarily aimed at raising awareness by training other health professionals to integrate this approach into their own work. It also provided me with peer support in the UK and as the first course offered worldwide it meant that people didn’t have to go to the lengths I had, to feel confident to work in this field. My main five-year goal was to write a book (which was published last year – Chronic Pain: your key to recovery) and to run the first conference outside the US. The latter is actually being held on Sunday 26 April 2015 at the Royal Society of Medicine and five of the world leaders in this field have
Some basic treatment suggestions ●● Gain a good understanding of the concept (e.g. read one of the books) ●● Identify the psychosocial links and triggers for pain (e.g. use a timeline) ●● Therapeutic journaling
▲ Outwardly express any past or current unresolved emotional turmoil (e.g. by writing an unsent letter to their boss/colleague/partner/parent etc.) ▲ Put things into perspective (this will help them reach a point of acceptance in order to be able to let go/forgive and move on) ●● Use self-empowering strategies to deal with fears related to pain/diagnosis/ condition and to regain a full active life ●● Look at ways they can become more stress-resilient (e.g. practising mindfulness/meditation, gratitude, CBT strategies etc.)
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agreed to come over from the US to support us in this. Coming across Dr Sarno’s work answered the questions I was wrestling with. My learning and growth since then is reflected in SIRPA’s practitioner course and treatment programme. Throughout this time, I have been supported by some wonderfully helpful and altruistic colleagues in the US and we are determined to continue to evolve and raise awareness of this exciting concept and approach. To find out more, please go to www.sirpauk. com REFERENCES. 1) Jensen MC (1994). Magnetic resonance imaging of the lumbar spine in people without back pain. New England Journal of Medicine (PMID: 8208267), 69–73. 2) Kim SJ (2013). Prevalence of disc degeneration in asymptomatic Korean subjects. Part 1: lumbar spine. Journal of the Korean Neurosurgical Society (PMID: 23440899), 31–8. 3) Karppinen N (2001). Severity of symptoms and signs in relation to magnetic resonance imaging findings among sciatic patients. Spine (PMID: 11295915), 149–54. 4) Borenstein DG et al (2001). The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic subjects: a seven-year follow-up study. The Journal of Bone and Joint Surgery (American), 83: 1306–11. 5) The fall of the postural–structural– biomechanical model in manual and physical therapies: Exemplified by lower back pain. Professor Eyal Lederman, CPDO online journal (March 2010), 1–14 (www.cpdo.com). 6) Goldberg RT (1999). Relationship between traumatic events in childhood and chronic pain. Disability and Rehabilitation (PMID: 10070600), 21(1): 23–30.
MARCH 2015 resolving chronic pain 7) Jones GT (2009). Adverse events in childhood and chronic widespread pain in adult life: Results from the 1958 British Birth Cohort Study. Pain (PMID:19304391), 92–6. 8) The Workplace (Health, Safety and Welfare) Regulations 1992 (www. legislation.gov.uk/uksi/1992/3004/ contents/made). 9) The Health and Safety (Display Screen Equipment) Regulations 1992 (www.hse.gov.uk/msd/dse/). 10) Verbeek JH (2012). Proper manual handling techniques to prevent low back pain: a Cochrane systematic review. Work (PMID: 22317058), 41 (suppl. 1): 2299–301.
11) Feyer AM (2000). The role of physical and psychological factors in occupational low back pain: a prospective cohort study. Occupational and Environmental Medicine (PMID: 10711279), 116–20.
14) Castro WH (2001). No stress – no whiplash? Prevalence of “whiplash” symptoms following exposure to a placebo rear-end collision. International Journal of Legal Medicine (PMID: 11508796), 316–22
12) Sorour AS (2012). Relationship between musculoskeletal disorders, job demands, and burnout among emergency nurses. Advanced Emergency Nursing Journal (PMID: 22842970), 34(3): 272–82.
15) Hsu MC (2010). Sustained pain reduction through affective selfawareness in fibromyalgia: a randomized controlled trial. Journal of General Internal Medicine (PMID: 20532650), 25(10): 1064–70.
13) Christensen JO (2012). Work and back pain: a prospective study of psychological, social and mechanical predictors of back pain severity. European Journal of Pain (PMID: 22337583), 921–33.
PLAYING TO OUR STRENGTHS by Dr Julie Denning
CONTINUED PROFESSIONAL DEVELOPMENT is a phrase that we are all familiar with. In our working lives we have to think about what we haven’t yet achieved and where the gaps for improvement are. We have to focus on change. How do we go about this change process? How do we help ourselves to move forward? We know that simple small goals help us to change and we can plot an action plan super easily these days. But what we often don’t focus on, or even use, are tools that are right under our noses; our strengths.
But why is this? Let’s just pause for a moment. Right, now make a list of three things that you could do with improving on. Next, think of three strengths that you will use to help yourself to make those improvements. Which list was easier or quicker to create? When asked, people, more often than not, will very easily create a development list, but find the strengths list is harder. We seem to be uncomfortable saying we are good at something. So, if we tend to think in this way then why would our patients be any different? An important role we can play is to help them refocus on what they are already good at and then build on those skills to facilitate the next steps. This is beneficial for two reasons. One, the goal is more likely to be achieved because there
is a strong starting point, and two, the person’s self-esteem is bolstered because there is an emphasis on what is possible based on past experience. So, next time you enthuse “you can do it!”, remember to add “you have already started walking more, that’s great, let’s build on that. Let’s play to your strengths”. Let me know how it goes at www.linkedin.com/groups/ Working-Towards-Wellbeing-4591246
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18 clinical reasoning
Clinical reasoning in office workplace assessments ●● the specific scope of an individual
Author: SUDHIR DAYA Sudhir is director of Integrated Health (www. integratedh.com). Alongside his private clinical work, he is an ergonomics consultant and provides AXA ICAS with quality assurance and audit work for their nationwide network of assessors. He can be contacted on email@example.com
INTRODUCTION This article aims to enhance physiotherapists’ clinical reasoning processes in office workplace assessments, building on the knowledge and skills gained on a DSE assessor course. Clinical reasoning is a pivotal tenet to autonomous physiotherapy practice and has been defined as “the precursor to any clinical decision making or action: a complex reasoning process incorporating cognition, metacognition and specific knowledge that distinguishes healthcare professionals from technicians and ancillary staff”. (Gilliland 2014). There is no ideal clinical reasoning model. However, attempts have been made to represent graphically a generic hierarchical model that depicts the complex multifaceted processes of clinical reasoning in doctors (Charlin et al 2012). The importance of clinical reasoning OHP VOLUME 19.1
in occupational health and ergonomics has been reflected in Domain 15 of the ACPOHE competency framework (Hunter et al 2012). However, there is a dearth of research guiding physiotherapists’ clinical decision making (Wahlin et al 2012). This is at odds with the drive to be evidence-based. This article presents potential facilitators to the clinical reasoning process in an office workplace assessment and how these could be reflected in the assessment report/ summary. The article attempts to give physiotherapists the opportunity to bring their big toolbox of skills, experience and resources from the traditional hands-on clinical setting into the office workplace consultant role. This article will not cover: ●● the various clinical reasoning theories and research ●● the specifics of writing up a workplace assessment report
workplace assessment which will be determined upon engagement of the service. ●● workplace assessments that are not related to a musculoskeletal disorder such as visual impairment, learning difficulties etc. This article assumes that the physiotherapist: ●● has undertaken appropriate training and is competent to conduct an office workplace assessment ●● has undertaken a thorough and detailed assessment including in-depth task analysis, anthropometrics measurements etc ●● has an up-to-date knowledge of the “hard” reasonable adjustments currently available (this will be discussed in detail later). CLINICAL REASONING IN ASSESSMENTS Potential facilitators to the clinical reasoning process in an office workplace assessment are discussed below. The biopsychosocial model Physiotherapists bring a grounding in the biopsychosocial model (Smart & Doody 2012) to workplace assessments. The biopsychosocial model reflects the complex interactions between multiple variables that result in illness and fits well with the World Health Organisation’s International Classification of functioning, disability and health (Furze et al 2013). The author proposes the use of the following model to consider the numerous other conceptual frameworks of occupational health and ergonomics.
MARCH 2015 clinical reasoning
The national and international socio-cultural, economic, legal and political environment Quality The task
The user: physical psychology philosophy
Comfort and ease of use
Health and Safety
Productivity and efficiency The model provides a framework for the physiotherapist to obtain pertinent information during a workplace assessment. For example, consider the option of using the disabilities of arm, shoulder and hand (DASH) questionnaire for a client with a work-related upper limb disorder. This allows quantification of the client’s level of disability and may aid and justify decision making. It also provides the opportunity to observe the client doing a functional task (movement analysis) such as writing. Wahlin et al (2012) show that recommendations for work related interventions were influenced by the main clinical problem, the client’s educational level, social interaction skill and mobility. This suggests that the client’s health literacy is a factor in clinical decision making. The model supports the ultimate aim of occupational health and ergonomics which is to optimise health and safety, comfort and ease of use, efficiency and productivity, and quality (British Occupational Hygiene Society 2005). The assessment and any reasonable adjustments should ensure that the organisation is compliant with health and safety legislation such as the DSE regulations and will stand up to scrutiny in the event of an Employment Tribunal.
The flag system The flag system can also be used to aid clinical decision making (Gray 2012). Red flags relate to signs of serious pathology in musculoskeletal disorders that require urgent medical attention. The ability of a physiotherapist to screen these – hopefully rare in an office workplace assessment – is an asset. The author had a client referred to him with low back and right hip pain for a workplace assessment and found that the client was resting her right foot on a stack of boxes. Deeper questioning revealed a history of femoral vein thrombosis and previous hospitalisation for a pulmonary embolus. The client revealed that she had stopped taking anti-coagulation medication as she found the necessary monitoring to be disruptive to her life. She was resting her foot on the boxes to relieve the increasing swelling in her leg. This necessitated an urgent referral to occupational health. Orange flags relate to mental health issues that could have a serious psychiatric nature, such as clinical depression or personality disorder, which may require referral to an appropriate specialist. Tools such as Beck’s depression inventory or hospital anxiety and depression scale could be used to aid clinical decision making.
Yellow flags relate to unhelpful beliefs regarding pain, emotional responses to pain and pain behaviour. There are various self-reported measures that the client could complete to assess each of these, including the pain catastrophising scale, the fear avoidance beliefs questionnaire (for low back pain) and pain self-efficacy questionnaire. For acute and sub-acute low back pain, the Keele STarT Back screening tool may be useful in the physiotherapist’s decision making (Hill 2014). For example, a client with a high-risk score may need referral to psychologically informed physiotherapy as a “soft” recommendation from the assessment. Consideration of yellow flags could help to avoid unnecessary replacement of a chair for a client with unhelpful beliefs regarding his/her back and the current chair, negative illness perceptions, who takes insufficient breaks and adopts poor posture, despite the chair being suitable and well adjusted. Blue flags refer to perceptions about the relationship between work and health while black flags refer to the contextual or organisational barriers that affect the client’s return to work. Self-reported measures that can be useful in clinical decision making include the HSE return to work questionnaire, the obstacles to return to work questionnaire, brief illness perception questionnaire and the Orebro musculoskeletal pain screening questionnaire. Subjective and objective/physical information Both subjective and objective information must be collected during a workplace assessment. If the physiotherapist does not obtain adequate subjective and/or objective information, then this could adversely affect clinical decision making and the outcome for the report. For example, failing to assess the environment and display screen objectively when the client reports issues with glare and reflection. Congruence between the subjective and objective information eases decision OHP VOLUME 19.1
20 clinical reasoning
making. For example, a person of 1.98m stature reporting their chair to be uncomfortable when it clearly does not accommodate their stature and does not support them in a good sitting posture. Clinical reasoning may be challenged when the subjective and objective information are not congruent. For example, where a client reports their chair to be very uncomfortable yet assessment reveals the chair is DSE compliant, highly adjustable, fully functional, suits their anthropometrics and supports the client in a good sitting posture.
What would you recommend in this situation? A chair which is not compliant with DSE regulations supports the client in a good sitting position and they report no issues with it. Join the debate on Occupational Health and Ergonomics iCSP. A response to the debate will posted in the next journal. Helander & Zhang (1997) looked in detail at the various factors that influence comfort in sitting and have devised the final chair evaluation checklist. Using the checklist in the above scenarios could aid the physiotherapist’s clinical reasoning to understand if the client’s reported discomfort is related to aesthetics and the emotional value of design or poor biomechanics, fatigue and time at the task. The neuroscience underpinning pain is evolving and heavy reliance on clients’ subjective reporting of persistent pain as reliable information should be questioned. Research demonstrates that the physiotherapist’s beliefs and attitudes regarding musculoskeletal pain are associated with the beliefs of the clients and the clinical management (Nijs et al 2013). So, to assess if your own beliefs and attitudes are in line with the biopsychosocial model, complete the pain attitudes and beliefs scale for physiotherapists (PABS-PT). OHP VOLUME 19.1
Cost The cost of a reasonable adjustment may influence the physiotherapist’s clinical decision making and have a bearing on an “ideal” outcome versus a reasonably practicable outcome. For example, for some clients a varidesk may be a cost-effective reasonable alternative to an electronic height adjustable desk. A short-term affordable “quick fix” may not be the best as it may necessitate further expenditure in the long run. For example, a lumbar D-roll may not be the most appropriate recommendation despite being low in cost as it might be best to recommend a new chair from the onset. No cost solutions could include the use of keyboard shortcuts or the improvement in typing skills from a free online resource (http://alison.com/ courses/Touch-Typing-Training). Validated methods Validated tools such as the rapid upper limb assessment (RULA) may aid decision making and justification of a recommendation. RULA fits well with physiotherapists’ expertise in movement analysis and allows a form of quantification. Cornell University also has tools that
can be used online during the workplace assessment, such as the Homing task and the Fitts’ law spiral task (http:// ergo.human.cornell.edu/Homing/ HomingInstructions.html). Therapeutic concepts of clinical reasoning Kassirer (2010) discusses the clinical reasoning that doctors use when thinking about treatment options for patients. This could aid clinical reasoning in a workplace assessment as shown in the table below. The assessment summary would clearly reflect these considerations in the form of a SMART recommendation. SMART is an acronym standing for Specific, Measureable, Achievable, Relevant and Timely. An example would be: Ms Ex Ample is to try out her current chair set-up for two weeks. If she is still reporting discomfort, she is to have a meeting with a line manager with a view to providing her with a Bells & Whistles 007 chair with fully adjustable armrests, inflatable lumbar pump, and castors for a carpeted floor. Please note that the supplier provides a 14-day trial period and a chair set-up service. Intuition Intuition can be defined as “the ability
Treatment in a clinical assessment
Recommendation in a workplace assessment
Trade-offs between the risks and benefits of tests and treatments
What are the trade-offs between the risks and benefits of recommending a particular chair?
Immediate action versus watchful waiting
Should you recommend the chair immediately or after a period of watchful waiting?
Decisional close calls and “toss-ups”
What do you “toss up” if it is a close call as to whether the client would benefit from a particular chair or not?
Treatment under conditions of uncertainty
Do you recommend this chair when the client mentioned that the office might be going through a refurbishment? Or the client may be thinking of leaving the job?
Therapeutic trial as a diagnostic test
Will the chair supplier allow the chair to be trialled for a week to determine suitability?
Choices based on the relation between the likelihood of disease and therapeutic risk
Will this particular chair possibly create problems elsewhere for the client?
MARCH 2015 clinical reasoning
Intuitive system How does this system operate?
Reflex, information Deliberate judgement of (usually visual) collected information actively collected automatically from the situation and environment “Gut feelings”
What is the speed Rapid of the system? When will I tend to use either system?
Rule governed Slow, you have to think
Higher level of situational When time permits certainty When there are higher stakes Time is lacking outcomes Complex situation Uncertain situation Ambiguous, non-routine or ill-defined problem.
to understand something instinctively, without the need for conscious reasoning”. Dual-process theory looks at two interrelated systems used to reason: the intuitive system and the analytical system (Pelaccia et al 2011). See the table above. Research suggests that neither system is superior and that they interact with each other, with intuition constantly involved in reasoning to some degree. So, when something doesn’t feel right, listen to your “gut” and ask yourself more challenging questions. The reliability of the intuitive system is, however, variable and is particularly sensitive to emotional factors. This suggests that a physiotherapist’s clinical reasoning could be influenced by their emotional intelligence – “the ability to monitor one’s own and others’ feelings, to discriminate among them, and to use this information to guide one’s thinking and action” (Pelaccia et al 2011). So next time you have a difficult client, see what emotions came up for you and what lies underneath them and consider what impact it had on your decision making. Expert versus novice Expertise has often been associated with experience but they are not necessarily synonymous. Jensen et al (2000) found that experts in physiotherapy displayed the following features: ●● a high level of clinical reasoning ●● a high level of knowledge
●● the centrality of the person/client ●● self-monitoring/reflection – “a
critique of their reasoning processes in order to detect inconsistencies or links between the data gathered, and what they know from past experience” ●● welcomed the challenge of tough cases and were comfortable with uncertainty and ambiguity ●● committed and caring professionals ●● they loved their work – on a personal quest for excellence. Consider how you perform on these in office workplace assessments. CLINICAL REASONING OF THE OUTCOMES There are three possible outcomes from a workplace assessment: ●● changes to the current setup ●● advice and education ●● recommendations. All the above can be regarded as reasonable adjustments (Equality Act 2010). Giving advice to a client, influencing behaviour and adjusting their existing set-up encourages a participatory ergonomics approach. This reduces the emphasis on, and expectation of, “hard” recommendations. Educating clients during a workplace assessment is vital and is a core physiotherapy skill. For clients with persistent pain, therapeutic
neuroscience education (TNE) is evolving and may form part of a client’s referral to psychologically informed physiotherapy. Unfortunately, the research suggests that information on its own is inadequate in promoting behaviour change, e.g. a good sitting posture, use of keyboard shortcuts, taking regular breaks etc. Physiotherapists are skilled at patient communication (both verbal and non-verbal) and are ideally positioned to explore and challenge a client’s unhelpful beliefs and behaviours by the use of powerful open questions within a workplace assessment. Darlow et al (2013) demonstrated the powerful impact of the words we use when communicating with clients: “recovery expectations can be heavily influenced by single, at times off-hand, statements”. Skills from motivational interviewing and acceptance and commitment therapy may be useful. Recommendations Recommendations can be either “hard” or “soft”. “Hard” recommendations refer to a piece of equipment, e.g. a chair, a desk raise, a bigger screen, assistive technology. A “soft” recommendation refers to the job, e.g. altering working hours, reviewing targets, reallocating duties, modifying the job design. “Soft” recommendations also refer to the client and their particular issues, e.g. providing mentoring/support, referring to occupational health, referring for a functional capacity assessment, referring to psychologically informed physiotherapy, referring to a specialist assessment, providing training, checking that an up to date personal evacuation plan is in place for someone with mobility issues in the workplace. The author proposes the use of the matrix overleaf (p22) to aid clinical reasoning for “hard” recommendations. In the matrix, an acceptable “hard” recommendation reflects the physiotherapist’s level of product/ equipment knowledge and the justification reflects the physiotherapist’s knowledge level and level of clinical reasoning. An ideal situation would be OHP VOLUME 19.1
22 clinical reasoning
An acceptable recommendation
An unacceptable recommendation
the marrying of these two factors. The use of the matrix will be illustrated in a simplified case study. Case study (see table below) Ms A reported pain in both wrists when typing. Assessment revealed that Ms A is a touch typist and she displayed acceptable key depression force, key depression rate and error correction rate. Ms A showed excessive side bend of her wrists when typing but not excessive flexion or extension. The strain on her wrists could be contributing to her symptoms. Ms A frequently uses the number pad and keyboard shortcuts. SUMMARY There is limited research on what is the ideal course of action to take when conducting an office workplace assessment. This article attempts to help physiotherapists enhance their decision making process by drawing on research from different fields. Various ideas are presented as potential facilitators to the clinical reasoning process in an office workplace assessment and how this could be reflected in the assessment report. The article shows how physiotherapists can bring their big toolbox of skills, experience and resources from the traditional hands-on clinical setting into the office workplace consultant role. Such clinical reasoning could enhance the quality of the assessment that the physiotherapist provides and differentiate them from other assessors. REFERENCES Charlin B et al (2012). Clinical reasoning processes: unravelling complexity through graphical representation. Medical education (46). 454-463. Darlow et al (2013). The enduring impact of what clinicians say to people with low back pain. Annals of Family Medicine (11:6): 527-534. OHP VOLUME 19.1
Jensen GM, Gwyer J, Shepard KF, Hack LM (2000). Expert practice in physical therapy. Physical Therapy (80:1): 28-43.
Equality Act (2010).) Available at: http://www.legislation.gov.uk/ ukpga/2010/15
Kassirer JP (2010). Teaching clinical reasoning. Academic Medicine (85): 1118-1124.
Furze J et al (2013). Describing the clinical reasoning process: application of a model of enablement to a pediatric case. Physiotherapy Theory and Practice (29:3): 222-231. Gilliland S (2014). Clinical reasoning and first-and third-year physical therapist students. Journal of Physical Therapy Education (28): 64-80. Gray H (2012). Return to work and blue flags assessment. ACPOHE and SOM conference PowerPoint slides. Helander MG, Zhang L (1997). Field studies of comfort and discomfort in sitting. Ergonomics (40:9): 895-915. Hill JC (2014). Implementing stratified care for back pain. In Touch (147): 36-39. Hunter N and OH working party (2012). Behaviours, knowledge and skills required by
An acceptable recommendation
physiotherapists for working in occupational health v4. ACPOHE website www.acpohe. org.uk/competency-framework-0.
Nijs J, Roussel N, van Wilgen CP, Koke A, Smeets R (2013). Thinking beyond muscles and joints: Therapists’ and patients’ attitudes and beliefs regarding chronic musculoskeletal pain are key to applying effective treatment. Manual Therapy (18) 96-102. Pelaccia T, Tardif J, Triby E, Charlin B (2011). An analysis of clinical reasoning through a recent and comprehensive approach:the dual-process theory. Medical Education Online (16: 5980): 1-9. Smart K, Doody C (2007). The clinical reasoning of pain by experienced musculoskeletal physiotherapists. Manual Therapy (12): 40-49. Wahlin C, Ekberg K, Oberg B (2012). Clinical reasoning in occupational health services for individuals with musculoskeletal and mental disorders. Advances in physiotherapy (14): 155-165.
Please provide Ms A with a Ms A adopted awkward and excessive side-bent Microsoft Ergo 4000 wrist postures when typing that could be keyboard contributing to her symptoms. The “split” design of the keyboard will reduce the excessive side bent wrist postures when typing. Ms A is a touch typist and uses the number pad frequently. An acceptable recommendation
Please provide Ms A with a The keyboard has a built in wrist support that will Microsoft Ergo 4000 reduce the excessive side bent wrist postures that keyboard. are placing strain on the wrist. An unacceptable recommendation
Please provide Ms A with an Ergostar Saturnus keyboard.
The scissor mechanism of this keyboard has a soft touch and will improve her wrist symptoms when typing.
An unacceptable recommendation
Please provide Ms A with an Ergostar Saturnus keyboard.
The low-profile design of the keyboard will improve the side bent wrist postures and improve her symptoms when typing.
MARCH 2015 benefit of exercise
Physical exercise keeps MSDs at bay Our regular contributor Dr Timothy Peter Hunter, a chartered physiotherapist and clinical scientist, reports on the effect of workplace versus home-based physical exercise on musculoskeletal pain among healthcare workers
WHAT IS THE BACKGROUND TO THIS WORK? Healthcare workers frequently perform patient handling activities, which involve known risk factors for MSDs, such as awkward postures and high biomechanical loading of the spine. Alongside the implementation of assistive devices, manual handling training and supervision, an additional strategy to reduce the risk of workrelated MSDs has been to increase the workers’ physical capacity by physical training. There is preliminary low-quality evidence that targeted physical training may reduce neck, shoulder and low back pain but low-exercise adherence is a commonly reported problem and the optimal exercise setting to achieve high adherence and effectiveness remains unknown. The aim of this study was to investigate the effect of workplace versus home-based physical exercise (Home versus Work) on musculoskeletal pain in the back and neck/shoulders among healthcare workers. WHAT DID THEY DO? Two hundred healthy, female healthcare workers were recruited to the study and were randomly allocated to either a Work (111 subjects) or Home (89 subjects) exercise group. Each 10-week training intervention involved both training groups completing 10 minutes of targeted exercises, five times a week. Each session included circuit exercises designed to progressively strengthen muscles in the shoulders, core and low back. Apart from the location difference, only the Work based exercises were supervised by an instructor and the participants in this group also had the option of five 45-minute motivational coaching sessions. In contrast, there was no direct
supervision or coaching for the participants in the Home exercise group. Furthermore, in order to make the Home group program low cost and safe, the participants in this group performed a slightly different range of exercises. Outcome measures included the pre-post intervention change in average pain intensity of the low back, neck and shoulder regions and self-rated use of analgesics. They also used a custombuilt dynamometer to measure back extensor isometric muscle strength. WHAT WERE THE KEY FINDINGS? Results from the study showed significant improvements in back muscle strength, average musculoskeletal pain intensity, and self-reported use of analgesics in subjects from the Work group compared to Home group. One factor that may have contributed to these differences is the exercise program adherence levels. The Work group trained 2.2 times a week on average, while the Home group trained only once a week. The authors did not attempt to delineate potential reasons for the differences in adherence, but based on previous research some potential factors that may have played a role include the presence of an instructor, the coaching sessions and the other individuals in the Work group. Despite the higher levels of adherence in the Work group, it is notable the compliance levels were still very low. This is not a new finding and reminds us of a fundamental problem in exercise prescription that urgently needs to be addressed. WHAT WERE THE KEY LIMITATIONS? A common limitation of behavioural interventions is that blinding of researchers and participants is difficult to achieve. Accordingly, self-reported
measures such as perceived pain may have been influenced by outcome expectations. The researchers attempted to control for this by including two intervention groups. When considering the differences in the self-reported pain results, it must also be remembered that although both intervention groups performed strengthening exercises for the shoulder, neck and lower-back regions, not all exercises were comparable. Therefore, the differences observed may have also been influenced by the exercises themselves. Indeed, the Work group were the only group to incorporate Kettlebell training which has previously been shown to reduce pain in the low back, neck and shoulder in adults with a high prevalence of reported musculoskeletal pain symptoms. References: Jakobsen MD (2015). Effect of workplace versus home-based physical exercise on musculoskeletal pain among healthcare workers: a cluster randomized controlled trial. Scand J Work Environ Health. doi:10.5271/sjweh.3479. Jordan JL (2010). Interventions to improve adherence to exercise for chronic musculoskeletal pain in adults. Cochrane Database Syst Rev. 2010;(1):CD005956. Jay K (2011). Kettlebell training for musculoskeletal and cardiovascular health: a randomized controlled trial. Scand J Work Environ Health. May;37(3):196-203. doi: 10.5271/ sjweh.3136
n If you have any questions about this article, please contact timothy.peter@ fluto.co.uk OHP VOLUME 19.1
physios for work and health
Full details of courses, including the course aims and objectives, pre-course requirements and profiles of the presenters, can be found at www.acpohe.org.uk in the events section. Courses are booked through the website and can be paid by PayPal, BACS or cheque. Attendance at ACPOHE courses is open to all ACPOHE members. Full membership of ACPOHE is available to all members of the CSP and those working in related professions may also join as Associate members. We welcome requests for course places from non-members on appropriate courses.
OFFICE WORKSTATION ERGONOMICS (DSE) LEVEL 2 18-19 April 2015 Venue Haywards Heath Tutors Katherine Roberts and Katharine Metters Cost £280 members, £340 non-members Lunch NOT included
AN INTRODUCTION TO OCCUPATIONAL HEALTH (This course is accredited by the CSP.) 23/24/25 September 2015 Venue Birmingham Tutors Nicola Hunter and Amanda Jones Cost £455 members, £515 non-members Lunch included
INTRODUCTION TO APPLIED ERGONOMICS 14-15 May 2015 Venue Birmingham Tutor Glyn Smith Cost £300 members, £360 non-members Lunch included
PHYSIOTHERAPY UK 2015 16-17 October 2015 Venue Liverpool Join us at Physio UK this year
OFFICE WORKSTATION ERGONOMICS (DSE) LEVEL 1 13-14 June 2015 Venue Guildford Tutor Katherine Roberts Cost £280 members, £340 non-members Lunch NOT included
OFFICE WORKSTATION ERGONOMICS (DSE) LEVEL 2 6-7 November 2015 Venue Haywards Heath Tutors Katherine Roberts and Katharine Metters Cost £280 members, £340 non-members Lunch NOT included
n For course information and to book online www.acpohe.org.uk/events
ACPOHE COURSES HOSTED BY BMI AN INTRODUCTION TO OCCUPATIONAL HEALTH 17/18/19 April 2015 Venue BMI The Park Hospital – Nottingham OFFICE WORKSTATION ERGONOMICS (DSE) LEVEL 2 3-4 October 2015 Venue BMI Shirley Oaks Hospital – Surrey If you are interested in either of the above two courses, please contact Mark Spiegel on 01923 834212 or email mark.spiegel@ bmihealthcare.co.uk
Published on Mar 20, 2015