Victorian WorkCover Authority Clinical Framework
Making it Work for You in Practice
by Peter Werth BAppSc(Chiropractic)

It has been twelve months since the Victorian WorkCover Authority (VWA) released the Clinical Framework for the Delivery of Health Services to Injured Workers to the chiropractic and osteopathic professions in Victoria. The framework is relevant and applicable to the management of many of our patients, not just those with work-related injuries. This article will review the purpose of the Clinical Framework, its application in practice and the potential advantages it has to offer to the practising chiropractor or osteopath.

The Clinical Framework was established to;

1. Optimise return to work outcomes.
2. Inform health professionals of the VWA’s expectations for the management of injured workers.
3. Provide a set of guiding principles for the provision of health services for workers, health professionals and VWA agents.
4. Assist in the resolution of disputes.

In essence the Clinical Framework enables all participants involved in managing a worker’s injury to have a consistent basis for the service that they provide. This would apply to the treating chiropractor or osteopath and VWA Insurance Agent alike. The Clinical Framework assists in setting the expectations with respect to the patient’s management with the aim of returning the patient to work and to maximise their recovery from injury as soon as possible.

The implementation of new procedures in practice, whether by choice or as a requirement by an external source, such as a third party payor can seem daunting and an added burden to the already challenging requirements of day-to-day practice. However, there are potentially many benefits to be derived from adopting the Clinical Framework principles in practice, both for WorkCover patients and also for private patients.

How is the Clinical Framework useful for the treating chiropractor or osteopath?
a.) Using functional outcome measures
Patients naturally expect to see results with treatment, and expect a reduction in pain and return to normal functioning as soon as possible. There have been many tools and devices produced to help educate the patient and to show the effectiveness of treatment. Some of these rely on fairly sophisticated technology (such as surface EMG and computerised goniometers) and others use educational charts or the like to assist the practitioner get the message across to the patient. While some of these tools appear to be useful, most tools have not been validated to demonstrate functional improvement^1-4.

On the other hand, standardised functional outcome measures are simple, easy to use questionnaires that have been validated in the literature^5-8. They are quick to complete, and provide valuable additional information on the patient’s progress. Outcome measures are also useful because they are standardised across all professions. They are able to show changes in activity limitation or participation restrictions which are directly related to the functional requirements of day-to-day tasks and in particular work duties. Hence, functional outcome measures can be a very useful addition to patient management by showing the rate and direction of change in patients’ ability to function. This can be an excellent objective way to demonstrate to the patient the benefits or your treatment, and how it is assisting their recovery.

Should these measures not show significant improvement over time, it can act is the catalyst to review the patient’s treatment and activities of daily living to determine why expected progress is not being made. Combined with other information, the measures can help identify aggravating factors and potentially stimulate a change in treatment to further progress the patient’s recovery. Outcome measures may also be a guide to indicate when further treatment will not likely be of benefit to the patient, and in turn lead to referral of the patient for further investigations or alternative treatment.

Using outcome measures is an excellent tool for the treating chiropractor or osteopath to report to the insurer, employer or referring doctor to show how the patient is progressing. Clear and concise reports can be generated that are informative and do not require a long narrative to explain the patient’s progress. It is a quick and efficient way of keeping all of the stakeholders informed of the patient’s progress.

b.) Following a biopsychosocial approach
Chiropractors and osteopaths have historically, always viewed patients holistically and considered their injury not only from a physical viewpoint, but also from how this injury affects their ability to work, relate to their family and function in their environment in general.

There is now very good evidence that this approach of taking into consideration the psychological and social effects of the injury, along with the biological/physical effects is of vital importance in managing patients with pain^9,10. A work related injury provides another dimension to the injury, with consideration needed to be given to the impact both physically and psychologically of the patient’s ability to perform their job. Psychosocial factors may have a significant impact upon the patient’s wellbeing and ability to manage their injury. Poor coping strategies and resultant illness behaviour may prove to be a vital constraint on the patient’s ability to recover from a work injury. Employing cognitive behavioural principles such as focusing on productive behaviours like gentle exercise with pacing of tasks, rather than focusing on pain and the need for ongoing rest have been shown to be of benefit to patients.^11,12 If the practitioner encourages rest, regular passive treatment and not moving if painful, there is a risk of fostering illness behaviour and, in all likelihood, promoting further disability and dependency on passive treatment.

These psychosocial factors associated with an injury are termed “Yellow Flags” and the presence of these flags is considered predictive of chronic disability following a work injury.¹³ There are various means to screen patients for these risk factors including a Yellow Flags Questionnaire (also known as Orebro Musculoskeletal Pain Questionnaire) or Fear Avoidance and Beliefs Questionnaire. These or similar questionnaires are available along with some of the commonly used functional outcome measure forms on the Victorian WorkCover Authority website at www.workcover.vic.gov.au.

A biopsychosocial approach to managing work-related injuries will assist in promoting a faster response and maximise the recovery from injury for your patient. Good outcomes may in turn lead to more referrals from referral sources such as employers and local medical practitioners who will seek out practitioners who “get results”.

c.) Empowering patients
A key focus early in the management following an injury is to educate patients with respect to the nature of their injury and prognosis if managed appropriately. Dispelling myths and unrealistic expectations will assist the patient return to normal functioning as soon as possible. By setting expectations early and actively involving the patient in their rehabilitation it is possible to limit the level of disability and potential for development of chronic pain¹⁴.

By having the patient play a passive role in their recovery (ie. attending for regular treatment which passes on the responsibility for pain control to the practitioner) without promoting active and functional rehabilitation such as exercise, as well as self-management strategies (eg home-based exercises and pacing of activities), the patient may become dependent on the passive treatment with the expectation that the treating practitioner is in control of their pain and overall management. This may lead to the patient becoming chronically disabled by persistent pain. Having an early and active “self-help” focus with management promotes early recovery and assists in limiting disability associated with injury^15,16.

d.) Goal setting to promote recovery
An active focus in managing the work injury by progressive goal-setting has been identified as being important in patient recovery¹⁷, especially setting goals relating to tasks that are required at work. Setting goals should be encouraged from the outset with the expectation that these goals will be achieved. This can be best done by establishing goals that replicate the work duties, and are progressed in small incremental steps. This helps to empower the patient that they have control of their recovery, whilst also focusing on their functional abilities, rather than continuing to focus on their pain levels and related behaviour. This becomes of vital importance as they move out of the acute phase of their injury.

e.) Treat using the best available evidence
Practising in the current climate comes with an expectation that all practitioners will keep abreast of the latest evidence and apply that evidence in treating patients. Thankfully much of the evidence has been sifted through and evaluated for quality in the form of meta-analyses and clinical guidelines that can be readily applied in practice for the busy clinician. This is especially so with managing acute low back pain which still remains a large focus of the chiropractor’s work, particularly those treating work injuries.

The above principles of the Clinical Framework are largely derived from the current evidence and encapsulate a best-practice approach to patient care. The expectation of patients and third party payors alike is that practitioners will provide the most up-to-date approach to manage the patient’s injury. By doing this the likelihood of a successful outcome ie returning the patient to work and to their pre-injury status is optimised.

Conclusion
Although introduced to provide guidance and set expectations for providers and insurers, the Victorian WorkCover Authority (VWA) Clinical Framework for the Delivery of Health Services to Injured Workers is a very useful tool to assist the practising chiropractor or osteopath in managing all patients that present to their practice. The outcome measures, biopsychosocial model, principles of empowerment and goal setting using a best practice approach from the current evidence should underpin contemporary chiropractic and osteopathic practice. The Clinical Framework is a succinct tool that will assist the chiropractor or osteopath manage patients more effectively and optimise the outcome of interventions, whatever assessment methods and techniques are employed.

References

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