Assisting injured workers to return to work can be a complex process involving multiple stakeholders with different agendas and an injured or ill worker who may be in various stages of recovery, sometimes with additional issues from pre-existing conditions and with multiple simultaneous barriers to returning to work. In a domain with so many uncertainties, it can be refreshing to hear that there are some predictable aspects to healing and recovery.
Let’s consider Bob who stepped out of his truck awkwardly onto uneven ground, rolling his ankle and jarring his back.
At first Bob didn’t think much of it; His ankle was sore and his back a little stiff but he was able to continue working and finished his shift. At home that night he put ice on his ankle and went to bed. He woke the next morning with terrible back pain and couldn’t come in to work. His ankle was a little swollen and sore to walk on but he was not overly concerned. He saw his doctor, got a medical certificate for 2 days off and planned to return to work later that week.
Bob is in the acute phase of injury and healing which lasts 2-4 days and involves bleeding, swelling and pain. Tissues require protection during this time to minimise further damage. Bob did the right thing resting, using ice and taking pain relief.
All tissues go through a similar process when they heal whether they are tissues of the gut, skin, muscle, bone or ligament, however the rate of healing varies depending on the blood supply. Tissues that are well vascularised, that have a good blood supply such as skin and muscle, heal quicker than less vascularised tissues such as ligament and discs. Nevertheless, all tissues have capacity to heal and the resulting healed tissue is called a scar. The word ‘scar’ tends to have a negative association however scar tissue is simply the resultant healed tissue which initially is not as strong as it’s pre-injury state but over time can become equally strong.
After a few days Bob saw his doctor again and reported that his ankle was feeling better but that his back pain was worse. Bob reported that he could not do his normal work with the pain he was experiencing so he got another medical certificate, this time for 1 week. Bob continued resting at home.
Bob is now in the sub-acute phase of healing which lasts up to 8 weeks. For instance, lower limbs fractures take 6-8 weeks to heal, upper limb and finger fractures 3-4 weeks. A grade 1 ankle sprain in which the ligaments are merely stretched and not torn can heal in 5-8 days while a grade 3 tear might take 2-4 weeks. A stretched spinal ligament might take 1-2 weeks and a back muscle strain a similar time frame. During the subacute phase, new tissues are made and laid down and the need to protect the injured tissue reduces. There should be a shift from rest to resumption of activity taking place during the sub-acute phase.
In Bob’s case, suitable duties were not available and this shift from rest to resumption of activity did not occur. His employer was concerned about having him at work with an injury. They were a small employer and didn’t have the benefit of on staff rehab professionals who know and understand the importance of finding suitable duties. Bob called every few days to let his boss know how he was going, but he never heard from anyone at work enquiring about how he was doing. At around 3 weeks post injury Bob was still sore in his back and his GP referred him for physiotherapy and ordered x-rays and a CT scan. The scan showed multi-level degenerative changes with broad-based paracentral disc bulges at L4-5 and L5-S1. Bob was now getting pretty concerned. His GP made a referral to an orthopaedic specialist.
By 6 weeks, Bob’s ankle was fully healed and causing him no trouble but his back pain was persistent. He was waiting on the specialist appointment and starting to worry about what was going to happen with his job. He was feeling pretty flat being at home all day with no routine. He saw his wife and teenage kids head out the door each morning and the day at home on the couch stretched ahead like an eternity.
At 6 weeks post back injury, Bob is among the 10% of people whose back injury results in persistent pain. At 6-8 weeks, the healing stage is known as the remodeling phase and this is a time when healed tissues are reshaped, hardened and strengthened depending on the loading applied. Bones, muscles, skin, ligaments, cartilage and tendons will continue to remodel for 12-18 months after an injury however healing is considered complete within 3 months. The rate of this remodeling and return to function will depend largely on the stresses and loads applied, that is, the amount of exercise and physical activity performed. For a number of people, pain or dysfunction persists for longer than 3 months despite the fact that tissue healing is complete.
Physiotherapists from Back on Track are often asked to see people in Bob’s situation, that is, people with persistent pain who face barriers in resuming their pre-injury level of activity and returning to work. Workplace rehabilitation providers are independent physiotherapists and occupational therapists who are free from conflicts of interest. Our role is to facilitate recovery and return to work to improve the overall health outcomes for Australian workers.
Follow this blog next month to hear how Bob’s recovery progresses and to learn more about the management of people with persistent pain. For information about back pain clinical guidelines please refer to the previous post. http://backontrackqld.com.au/back-pain-what-really-works/