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Diagnoses and treatment recommendations on workers compensation medical certificates
Eva Schönstein and Dianna T Kenny
MJA 2000; 173: 419-422
For editorial comment, see Bogduk
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More articles on Occupational health
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Objective: To review the diagnostic descriptions
and treatment recommendations for back and neck pain on the new
workers compensation medical certificates and compare these with
evidence-based guidelines. Design: Retrospective analysis of 251 medical certificates of workers with compensable neck and back pain held by a workers compensation insurer. Main outcome measures: Diagnoses given and treatments prescribed by the nominated treating doctors. Results: The diagnoses most frequently used were "sprain/strain" and "pain/ache". Physiotherapy was the most frequently prescribed treatment, followed by rest and medication. Rest was prescribed for 68 (27%) workers, 87% of whom were classified as having an acute injury. Activity-based treatments were prescribed for 45 (18%) workers. Conclusions: Not all doctors used diagnostic terms consistent with recommended anatomical taxonomy. The drug therapy prescribed was consistent with current evidence-based treatment guidelines. However, the prescribing of rest, and the omission, in most cases, of explicit recommendations to resume normal activities, including work, are not consistent with current guidelines. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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The cost of managing workplace back injuries is increasing. Figures
for 1997-98 show that back injuries accounted for 30% of the cost of all
workplace injuries (gross cost, $224 million),1 while
comparable figures for 1996-97 were 36% and $212.5
million.1,2
In an effort to reverse the growing WorkCover Authority (WCA) debt ($1.7 billion at the time of writing),3 the 1997 Grellman Report4 made recommendations which resulted in the Workplace Injury Management and Workers Compensation Act 1998 (NSW). A new medical certificate intended to streamline reporting and management of compensable work-related injuries was introduced, as well as the concept of the "nominated treating doctor" (NTD) -- a general practitioner nominated by the injured worker who agrees to provide continuity of care until a return to work is achieved (Box 1). In recent years, national and international guidelines and systematic reviews -- some evidence-based -- have established standards for diagnosis and treatment of people with back or neck pain,5-10 including the most recent National Health and Medical Research Council (NHMRC) guide to acute pain management11 and the definitive publication on classification of pain by the International Association for the Study of Pain (IASP).12 To streamline management and reduce the costs associated with prolonged disability and time off work, it is important that the NTDs' diagnoses and treatment recommendations conform with evidence-based guidelines. We compared the diagnoses and treatments given on Part 1 of a sample of medical certificates of workers (who had work-related back or neck pain) with the taxonomic guidelines for diagnosis and the emerging guidelines for management. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Methods |
We examined retrospectively all the medical certificates related to
neck and back pain of a NSW workers compensation insurer for the period
1 October 1998 - 15 February 1999. Medical certificate entries
were de-identified.
Diagnosis and treatment were coded according to the most common wording used by doctors. Diagnoses were further grouped into those indicating and those not indicating a specific pathological condition. Treatments were further coded according to the amount of rest and/or activity prescribed. Active treatments involved exercise, work conditioning/work hardening, and maintenance of normal activity (including work). Diagnoses were then compared with taxonomic guidelines, and treatments were compared, wherever possible, with evidence-based guidelines for the management of spinal pain. According to the time between the date of injury on the certificates and the date of the medical certificate, the worker's condition was classified as acute (< 6 weeks), subacute (6-12 weeks) or chronic (> 12 weeks). Ethical approval: Approval for the study was obtained from the Human Ethics Committee, The University of Sydney. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Results | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Diagnosis |
On 227 of 251 certificates examined (90%), doctors did not specify a
patho-anatomical diagnosis: on 92 certificates (37%) the diagnosis
was sprain/strain; on 68 (27%) ache/pain; and on 67 (26%) injury
(mechanical, lumbago, dysfunction, whiplash, discopathy,
myalgia).
The location of the pain was lumbar spine (131; 52%), back (42; 17%), cervical spine (39; 16%), and other (39; 16%). Thirty-four doctors (14%) used at least two diagnostic descriptors, and, of these, six used at least three. Examples included "back pain due to low back strain", "thoracolumbar spinal pain, right sciatica", and "lumbar disc degeneration, right low back pain, and right sciatica pain". | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Treatment |
The most frequently prescribed treatments (Box 2) were
physiotherapy (116; 46%); rest (68; 27%); non-steroidal
anti-inflammatory drugs (NSAIDs) (64; 25%); and analgesia,
analgesics or "painkillers" (56; 22%). Specific active management
advice, such as exercise, a return to work, suitable duties, work
conditioning, hydrotherapy or work rehabilitation, was
recommended for 45 (18%) workers. Many had more than one treatment
prescribed, with the total sample of 251 being prescribed 455
treatments.
Most workers were seen by their doctors in the acute phase of injury (208; 83%), with the remainder in the subacute (18; 7%) or chronic (21; 8%) categories. Of the workers prescribed rest, 87% were classified as having an acute injury. Fifty-six workers (22%) were certified fit for suitable duties, 24 of these (43%) on their initial visit to their NTD. Ninety-two workers (37%) were deemed unfit for work. This information was not included on the remaining certificates. Of the 92 workers deemed unfit for work, 59 (64%) were on their first visit to their doctor, 13 (14%) were being issued with a progress medical certificate, and 8 (9%) were making their final visit. The remaining 20 (22%) certificates did not have this information. The treatments prescribed on the medical certificates and available evidence for their efficacy are summarised in Box 3. Wherever possible, the evidence is presented according to the NHMRC level-of-evidence ratings. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Discussion |
We found that doctors completing medical certificates for workers
with back and neck pain generally did not indicate a specific
pathoanatomical diagnosis. This is consistent with
epidemiological evidence:6,7 in 85%-90% of back
complaints, a pathoanatomical diagnosis can not be made from the
history, examination or even medical imaging. One of the primary aims
of the initial assessment is to exclude "red flag" conditions such as
tumours, fractures, disc prolapses, herniations, or infections.
According to the NHMRC,11 this exclusion is the key
to managing acute spinal pain, and for this purpose the history is the
most valid tool.13 The diagnoses given on
medical certificates for back and neck pain should explicitly
reflect the exclusion of "red flag" conditions, and the presence of a
benign, self-limiting condition which generally resolves within
four weeks of onset of pain.14
The certificates showed that the doctors used a variety of (implicit) taxonomic systems to describe "non red flag pain"; for example, anatomical (eg, "back pain", "thoracolumbar spinal pain"), aetiological or mechanical (eg, "mechanical back pain", "injury"), or descriptive pathological (eg, "sprain", "tear", "degeneration"). Only anatomical classification is consistent with the IASP classification.12 However, the precise terminology used to describe pain of this type is contentious. Terms such as "non-specific back pain",6,15 "simple back pain",14 or "back pain of unknown or uncertain origin"12 have been proposed. NSAIDs and analgesics were the most frequently prescribed medical therapy. Their use for spinal pain is consistent with current evidence-based practice,9 but support for the use of NSAIDs is limited and applies only in the short term.9,11 Although physiotherapy, either alone or in combination with other treatments, was the most frequently prescribed treatment, the NTD generally did not specify the exact nature of the physiotherapy intervention. While scientific evidence for the efficacy of specific physiotherapy treatments for neck and back pain has been published,8,9,16 there is great variability in treatments among physiotherapists,17,18 and the extent to which they adhere to evidence-based practice has not been studied. The Australian Physiotherapy Association has made a concerted effort to educate and inform its members by producing position statements on neck pain and back pain. These as yet unpublished statements are based on randomised controlled trials and systematic reviews (some by the Cochrane Collaboration). A Physiotherapy Evidence Database has also been created (PEDro).19 When reviewing their patients, doctors need to consider the evidence for the efficacy of the specific physiotherapy treatment received. "Rest" was the second most common word included in treatment recommendations (27% of cases), and most workers for whom rest was prescribed were in the acute phase of their injury. In contrast, activity-based treatments were recommended in only 18% of cases. Both in terms of what was prescribed and what was omitted, this is contrary to current evidence. There is now Level I evidence that bed rest should not be prescribed for acute back pain;20 and Level II evidence that advising patients to return to normal activity (including work),21-24 providing reassurance, and discouraging fear of activity and illness behaviour, are effective for managing acute and subacute spinal pain. It is acknowledged that the use of the word "rest" may not necessarily mean "bed rest". However, even when used in combination with an activity-based treatment, the word "rest" may be construed to mean a cessation of all, most, or some of a person's normal functional and work activities. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Recommendations | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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As a result of our study, we recommend that:
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Acknowledgements | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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We thank HIH Insurance (Injury Management Department) for providing
access to workers compensation medical certificates, and Dr C Maher
and Dr J Latimer, from the School of Physiotherapy, Faculty of Health
Sciences, The University of Sydney, for their support and helpful
comments.
Competing interests: No conflict of interest exists and the study received no funding. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| References |
(Received 3 Sep 1999, accepted 31 Jul 2000) | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Faculty of Health Sciences, The University of Sydney, Sydney, NSW.
Eva Schönstein, BAppSc(Phty), MHPEd, Lecturer, School of Physiotherapy. Dianna T Kenny, PhD, MAPsS, Associate Professor of Psychology.
Reprints will not be available from the authors. ©MJA 2000
Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company. Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 2000 Medical Journal of Australia. We appreciate your comments. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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