As a family physician in primary care, you may encounter patients with soft-tissue injuries who do not recover as expected following a low-energy injury in a workplace setting—for example, a 33-year-old mechanic who has been away from work with lower-back pain for several months after reaching forward too far for a screwdriver.

Diagnostic clarification, natural history, and optimizing function are key considerations when assessing such patients.

For the mechanic, you might initially diagnose him with a quadratus lumborum sprain or strain given the low-energy mechanism and clinical findings: local muscle tenderness and normal neurologic exam. At that time, you recommend a few days of rest and a course of physiotherapy. He, however, reports ongoing back pain and remains off work 2 months later. At this stage, you begin reconsidering diagnosis and management, as prolonged disabling pain is not typical for most soft-tissue injuries at 2 months.

WorkSafeBC can help with diagnosis, treatment, and specialized programs

If you are uncertain about diagnosis

For medical imaging, WorkSafeBC can consider expediting MRI and CT scans if you complete and fax the Requisition for Medical Imaging and Interventional Procedures (Form 83D56) to us, available on www.worksafebc.com. Expedited image-guided diagnostic injections are also available via the Requisition for Expedited Image-Guided Diagnostic and Therapeutic Injections (Form 83D58). If your request is approved, we will refer your patient to our network of providers.

For specialist assessments, WorkSafeBC operates the Visiting Specialist Clinic in Richmond. You may request a referral to this clinic on the Physician’s Report (Form 8/11). If your request is approved, a WorkSafeBC physician will write the referral on your behalf, and you will receive a copy of the consultation report.

You may also refer to a specialist in your community who accepts expedited referrals for WorkSafeBC-related injuries. Consult Pathways (https://pathwaysbc.ca) to see which specialists do.

If other factors are affecting recovery

If you are certain about the diagnosis and your patient is still not improving with standard treatment under the biomedical model, consider inquiring about other factors that may be affecting recovery, including:

• Psychological factors (e.g., depression, anxiety, substance use).
• Social factors (e.g., stressful life events, social isolation, lack of support from family or community).
• Occupational factors (e.g., problems at work, such as interpersonal conflict or grievances; availability of modified work or accommodation; lack of support from supervisor and co-workers).

Screening for these factors (e.g., with the Patient Health Questionnaire-9 or the Generalized Anxiety Disorder-7) may help prevent your patient from experiencing additional disability.

WorkSafeBC has access to specialized treatment programs, such as pain and medication management, customized recovery and return to work, and return to work support services, to help you manage psychosocial and occupational factors. If you think your patient would benefit from one of these programs, please state this on the Form 8/11 or discuss it with a WorkSafeBC physician.

It is also important to consider that while nociception is a final common pathway of many pathophysiological processes that require thoughtful analysis and reanalysis, pain is experiential, and everyone experiences pain differently. Acknowledging and respecting that perspective does not preclude you from optimizing your patient’s function.

Progressive restoration of function and participation in life roles is a widely studied modality with a plethora of benefits when applied with care and safety in mind.[1] You can support your patient by providing reassurance (e.g., on hurt versus harm) and prescribing an activation program, with assistance from WorkSafeBC community-based occupational therapy and physiotherapy programs. (Indicate your request for this service on Form 11.) To support modified work duties for your patient while they continue to recover, you can acknowledge and describe the worker’s current abilities in relation to functional activities and, if necessary, prescribe restrictions to prevent harm.

WorkSafeBC can also facilitate the return-to-function process by assisting family physicians in understanding the legal duty for employers and injured workers to actively cooperate in the worker’s timely, safe return to work, as outlined at www.worksafebc.com/returntowork.

Returning to the mechanic, you recognize that his recovery is not progressing as expected, and you bring him in for review. He tells you that he is worried there is a more serious problem with his back and that he does not trust his employer to support modified duties based on his co-workers’ experiences. You send your patient for a lumbar X-ray, and the results are normal. You speak with a WorkSafeBC physician about the patient’s concerns and his fear of another injury (despite the reassuring X-ray). WorkSafeBC arranges a Visiting Specialist Clinic orthopaedic assessment on your behalf and engages its return-to-work support services to arrange modified duties. Your patient completes his recovery at work.
—Harvey Koochin, MD
Manager, Medical Services, WorkSafeBC
—A. Somani, MD, CCFP
Manager, Medical Services, WorkSafeBC

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This article is the opinion of WorkSafeBC and has not been peer reviewed by the BCMJ Editorial Board.

References

1.    Dubois B, Esculier J-F. Soft-tissue injuries simply need PEACE and LOVE. Br J Sports Med 2020;54:72-73. https://doi.org/10.1136/bjsports-2019-101253.