Managing musculoskeletal problems
2010
A new evidence-based guide on musculoskeletal problems has been published with sponsorship from BackCare, intended for both the workplace and the clinic. It describes how to manage musculoskeletal problems effectively by addressing psychosocial obstacles taking account of biological and biomechanical factors.
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Sources of funding: |
Job title: Occupational Health Consultant with Kendallburton http://www.kendallburton.com/ Address for correspondence: |
A new evidence-based guide on musculoskeletal problems has been published with sponsorship from BackCare. Intended for both the workplace and the clinic, it describes how to manage musculoskeletal problems effectively by addressing psychosocial obstacles taking account of biological and biomechanical factors.2
We know that most people experience musculoskeletal problems some time during their lifetime, and this has considerable impact on individuals and their families, These problems are often a challenge to health professionals and are costly to industry, insurers and funders, the economy, and our societies, Most are either a minor injury or occur spontaneously, so people should recover: fortunately they generally do and the experience is temporary. The trouble is that some people develop persistent pain and have substantial difficulty getting on with their lives.
When people fail to recover and return e to activity and work in a timely way it is mainly because psychosocial obstacles impede progress, not because there is more serious injury or disease.1 Longgterm inactivity and time off work are detrimental to health and well being, so helping people to stay active or working should always be an imperative6. The best way to tackle musculoskeletal problems is to identify obstacles and develop a plan to deal with them, sooner rather than later. Overcoming obstacles needs action from the key players, including the person themselves.
In 1997, Kendall et al described an innovative approach to identifying and managing psychosocial factors in low back pain.3 They coined the term 'Yellow Flags' as an easily understood analogy to the widely adopted 'Red Flags'. This development created something of a sea change in the way common musculoskeletal problems such as low back pain were conceptualised and managed. Traditionally, the treatment of low back pain had been primarily biomedical or biomechanical in emphasis, but longitudinal studies consistently demonstrated the importance of psychosocial factors in the development of persistent or chronic problems.5 Widespread adoption of the Yellow Flags approach subsequently occurred. This innovative framework led to the conceptual development of Blue Flags to describe factors involving the workplace, and Black Flags to describe the context in which the person with the musculoskeletal problem functions including relevant people, systems and policies.4
Flags are not a diagnosis, and should not be used to label people - using Flags pejoratively defeats their whole purpose. Identifying Flags complements the diagnosis: their relevance is as contributors to the persistence of the problem.
A practical way to think of Flags is as 'obstacles'. Those that are modifiable can be overcome or got around. This perspective stresses 'ability' rather than 'disability', and shifts the emphasis to actions that facilitate recovery and return to participation. In this sense, obstacles can be transformed into opportunities. People usually need help to overcome or navigate round obstacles. This is where Flags come in - they point to the obstacles in need of action. Problem-solving approaches by the key players working together are often the most useful fruitful.
The identification of relevant obstacles that delay recovery and return to activity and work is now divided into three types:
Yellow Flags
are about the person - they are largely psychosocial factors associated with unfavourable clinical outcomes and the transition to persistent pain and disability.
Blue Flags
are about the workplace - they stem largely from perceptions about the relationship between work and health, and are associated with reduced ability to work and prolonged absence.
Black Flags
are about the context in which the person functions, and include relevant people, systems and policies. These may operate at a societal level, or in the workplace. They are especially important since they may block the helpful actions of healthcare and the workplace. Contextual factors that cannot be changed need to be identified so that they can be navigated around. Black Flags indicate the potential need to involve relevant others and/or other professionals.
This framework is easily remembered with the phrase: "Person, Workplace, Context". It places emphasis on appreciating how Flags contribute to creating an obstacle, and then working out how it can be overcome or bypassed.
The practical approach to using Flags is based on three key steps - recognising that looking for flags should be routine for all musculoskeletal problems.
Identify specific obstacles to recovery, activity and work. Develop a plan to target these obstacles, coordinated among key players with the goal of restoring the person to activity and work.
Implement it efficiently so that each responsible player knows what actions to take and when.
This is easily remembered by the phrase:
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IDENTIFY flags,
develop a PLAN, take ACTION. |
Identifying flags
Flags are features of the person, their musculoskeletal problem, and how they interact with the world around them. They can be identified by asking questions or making observations. Flags occur in three main domains and these are colour coded for convenience:
Person Flags (Yellow)
Thoughts
Feelings
Behaviours
Workplace Flags (Blue) Employee
Employee
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Context Flags (Black)
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Multiple flags - psychosocial variables can have a cumulative effect - because the Flags interact, people often have multiple obstacles across domains - a Flag in one domain does not exclude one from another: rather it makes it more likely.
The presence of Flags indicates an increased likelihood of an unfavourable course of recovery with respect to level of function and productive activity. They do not necessarily indicate the presence, or severity, of persisting pain.
Developing a plan
To make a difference all key players need to maintain a focus on activity and work. Helping people stay at or return to work depends on a combination of work-focused healthcare and an accommodating workplace. Both need to be coordinated. The imperative is to prevent development of negative psychosocial influences since these reduce the person's ability and willingness to participate in productive activity. Respond promptly when there is a lack of progress.
Communication and combining information is key to developing a successful plan to overcome obstacles. The use of written confidentiality waivers is recommended to facilitate this process. Key players combine information to identify the important obstacles for this person, in this workplace, in this context.
The key principles for developing a plan are to tackle specific obstacles using specific actions. Each action needs to have an agreed timeframe, and be assigned to a responsible player. All players should emphasise ability, not disability. Someone should be assigned responsibility to
- All players
- agree common goals
- ensure accommodating workplace
- Copy of plan to all players and person
- Provision for revising plan
Revising a Plan
becomes necessary when there is a lack of progress, or a lower level of activity and not returning to work indicate the need to re-evaluate Flags and identify new or changing obstacles.
Taking Action
This requires a number of simple steps - appreciation of the problem; awareness of the nature of obstacles; familiarity with the means of identifying obstacles (the Flags); development of a plan of action to tackle the obstacles; and implementation of the action plan by all key players.
The key actions in managing musculoskeletal problems are based on:
- Appropriate healthcare intervention to deal with biomedical issues
- Healthcare that supports, and does not hinder, early return to activity/ work
- Communication between the players to make it happen on time
- Workplace facilitation to ease the worker back to usual duties
- But these elements must be delivered simultaneously - they must be interwoven - they cannot be sequential.
The main principle of managing psychosocial factors effectively is that the intervention must address the identified Flags and obstacles, using both healthcare and the workplace. In practice these interventions address psychosocial factors, such as beliefs, fears, and avoidance behaviours. Psychosocial interventions such as problem-solving training and coping strategies can usefully supplement exercises and information/ advice, and contribute to increasing activity. An accommodating workplace can be the key to work retention and early return to work. Furthermore, it is important to ensure (through communication) that all players know what actions are to be done, by whom, and when.
Progress in managing psychosocial factors is best evaluated using objective measures such as actual behaviours (e.g. hours at work, duration of sitting tolerance, return to usual job etc). It is best to avoid subjective approaches, such as 'how are you feeling?' Ask instead 'what have you been doing?'
Stepped Approach to Managing Musculoskeletal Problems
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< 2 weeks: Provide support:
2-6 weeks: Light intervention:
6-12 weeks Shift up another gear:
> 12 weeks Multidisciplinary approach:
> 26 weeks: Move to social solutions:
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References
(1) ADDIN EN.REFLIST Burton, A P K., Kendall, N. A, Pearce, B. G., '" Birrell, l. N., & Bainbridge, L. C. u anagement of work-relevant upper limb disorders: a review. II, Occup Med (Lond), 2009; 59(1),44·52.
(2) Kendall, N. A S., Burton, A P K., Main, C. J., & Watson, P. A J. Tackling Musculoskeletal Problems - A guide for clinic and workplace: identifying obstacles using the psychosocial flags framework. www.tsoshop.co.uk/flags London: TSO. 2009
(3) Kendall, N. A. S., Linton, S. J., & Main, C. J. Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain: Risk Factors for Long-Term Disability and Work Loss. Wellington, New Zealand: Accident Rehabilitation & Compensation Insurance Corporation of New Zealand, and the National Health Committee, Ministry of Health. 1997.
(4) Main, C. J., Sullivan, M. J. L., & Watson, P. J. Pain Management: Practical applications of the biopsychosocial perspective in clinical and occupational settings. Second Edition. Edinburgh: Churchill Livingstone. 2008.
(5) Shaw, W. S., van der W.indt, D. A., Main, C. J., Loisel, P., & Linton, S. J. Early patient screening and intervention to address individual-level occupational factors ("blue flags in back diaability. J.Occup Rehabil. 2009, 19(1). 64-80
(6) Waddell, G., & Burton, A. K. Is Work Good for Your Health and Well-Being? London: TSO. 2006.
Click here to read the rest of the articles in the Winter 2009-10 copy of BackCare Journal