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Medical Factors
Integrated case management for work-related arm pain

At a glance:
A number of factors influence return to work outcomes for people with arm pain. Successful approaches include:

1. Clearly understanding the issues that influence a return to work

2. Solving ergonomic
Designing activities and the workplace in a way to minimize discomfort. i.e. Adapting work tasks, hours, or workstation to accommodate people. An ergonomic computer workstation allows the person to work in the best position to relieve load on the muscles of the neck and arms.

3. Problem solving and working out positive ways of dealing with the situation

4. Effective communication between all parties
People with arm pain often expect their problems will be solved by curing the medical condition. There are some specific arm problems, such as a localised tendonitis,
Painful inflammation of a tendon. Tendonitis is often described by the body part affected, such as Achilles tendonitis.
 where medical treatment can make a difference. However, most people with arm pain do not gain significant improvement from medical treatment.

A case management approach is effective. Return to work outcomes are improved when there is good communication, some modification of the work tasks, and co-ordination.

Your situation can be improved by working with your return to work co-ordinator, developing a positive relationship with them, and discussing what action needs to be taken. When they understand you are motivated and keen to return to work, outcomes are improved.
This review shows that case management improves return to work outcomes. Case managers are focused on achieving results, and have an understanding of ergonomics, communication, and how to solve problems.

Being a return to work coordinator or case manager can be a challenging role. This review shows that case managers can be trained in a range of techniques ways beyond understanding the rules of the system. These include understanding how to modify jobs, problem solve, assess distress
Severe suffering, pain, anxiety or sorrow
 and fear, and support appropriate medical care.

The development of a case management plan and its implementation will improve return to work outcomes.
Managing a return to work can be difficult. However, a co-ordinated approach makes a difference. Case managers have variable levels of experience in co-ordinating a return to work, and will do better when working in partnership with the treating doctor. Case managers play a significant role at the workplace, and can provide considerable help to the employee.
Case managers have variable levels of experience. This review shows that a deeper level of case manager training can be provided effectively. It also shows that upper limb
upper limb
 return to work outcomes can be significantly improved through case manager involvement.
Original Article, Authors & Publication Details:
Feuerstein M, Huang GD, Ortiz JM, Shaw WS, Miller VI, Wood PM.

Integrated case management for work-related upper-extremity disorders: impact of patient satisfaction on health and work status. Journal of Occupational & Environmental Medicine 2003;45(8):803-12.
Background, Study Objectives, How It Was Done:
Work related upper extremity
arm (upper extremity) or leg (lower extremity)
 disorders are conditions in which a person has soreness somewhere in their upper limb or arm that impacts their ability to work.

During the 1980's, arm pain was a major problem in Australia, whilst it became substantial in the United States during the 1990's. The problem can become a long-term disability
A condition or function that leaves a person unable to do tasks that most other people can do.
 if poorly treated, and represent a disproportionate amount of health care and workers compensation costs.

This review assessed whether patients were happy with the management of their situation. Integrated case management systems have been put in place in the U.S. for government workers. The researchers analysed if patients were happy with their treatment, and whether this influenced final outcomes.

The integrated case management system included:

A standardised initial interview

Training in ergonomic assessment and problem solving skills

Assistance in developing a case management plan geared towards the individual

Other reviews have indicated that while patients were often reasonably satisfied with the treatment they received for arm or back pain, many now express dissatisfaction with some aspect of the care. For example, in one study half of the patients reported not receiving advice on preventative measures, and up to 20% felt that were not taken seriously or asked enough about their job tasks. Lack of attention to workplace and preventative practices may have contributed to high rates of ongoing pain in this group.

Some reviews have suggested patients who are more satisfied do better. The authors therefore wanted to study patient satisfaction to see if it would correlate with quality of outcomes.

Government workers who had arm pain were evaluated. Claim figures for a 20 month period up to December 2000 identified 581 people with an accepted upper limb claim that met the study criteria. 36% took part in the study. The authors looked at a range of factors to see if there was a difference between those who accepted the invitation to participate in the study and those who did not. There were no significant differences in gender, type of arm problem, agency of employment, or history of disputed claims. Those who agreed to participate in this study were on average two years older than those who declined to participate.

Those who agreed to participate in the study were randomly assigned to one of two groups. The first group received standard care; which was mainly focused on medical management and providing modified duties.

1. In the second group integrated case management care was provided by case management nurses who had been through a structured training workshop which taught: Ergonomic assessments

2. Psychosocial
Refers to psychological and social factors. Examples of psychosocial factors that affect return to work area include: a person's beliefs about how they will cope with their condition, the attitude of the inured worker's family to their condition and return to work, the employer's return to work policy and the influence of the WorkCover system on a person.

3. Problem-solving

4. Preventing re-injury

5. Quality medical care

6. Appropriate follow-up

At the commencement of their involvement, people with arm pain completed a series of questionnaires that obtained information on:

Their work history and current duties

Symptoms and their severity

The limitations their arm pain caused on a daily basis

General physical health

Level of distress

Workplace ergonomic factors

Problem solving abilities

The questionnaires were repeated at six and 12 months after the end of the intervention.
A treatment or management program. Interventions often combine several approaches. In this field approaches include training in problem solving, adaptation of work duties, graded activity, an exercise and stretching program and pain relief.

Patient satisfaction was measured using a specially validated scale:

Symptoms: Patients were asked about the ongoing level of symptoms, including pain, sleeplessness, numbness, weakness, and tingling.

Ability to function: They were asked about the general health status, current ergonomic risk factors, and ability to problem-solve.

Return to work was assessed through the compensation database
Store of information (e.g. published research articles). Information can be retrieved by searching (e.g. for key words, authors, or titles).

All the information was put in to appropriate statistical software for analysis.
Study Findings:
The study found that:

1. Patients in the integrated case management group had significantly higher satisfaction scores than the group who received standard care. The standard care average satisfaction score was 40, whilst the integrated case management average satisfaction score, 55.

2. Patient satisfaction predicted arm symptoms at six months, but did not predict the outcome at 12 months.

3. People with less ergonomic problems had fewer symptoms.

4. General distress levels predicted symptoms at six and 12 months after the intervention. People who were distressed were likely to have more symptoms.

5. Patient satisfaction was a predictor of the person's ability to function at six months after treatment. Greater levels of distress predicted lower levels of reported function.

6. Patients who were more satisfied had an earlier return to work than those who were not satisfied. The integrated case management group had an earlier return to work than the usual care group.
This evaluation of a specific integrated case management program demonstrated a return to work with arm pain can be improved when compared to standard care treatment. Better communication, shared decision-making, attention to ergonomic issues, help with problem-solving, and ergonomic modifications are the major components of the case management program. Patients in this program had greater levels of satisfaction about the care they received.
PubMed Abstract
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