JWCRR Research Forum 2015
Rehabilitation and Recovery after injury
Final Report (30 July 2015)
Summary of the keynote speakers:
John Walsh – The value of research in assisting scheme planning and analysis
Insurance schemes focus on balancing positive outcomes for injured people and costs. This
was not always the case. During the crisis in the 1970s and early 1980s, the insurance
schemes suffered from increasing costs and claim numbers, and there was poor consideration
of outcomes of injured persons. This crisis resulted in reform of the systems in 1980s,
focusing on principles such as comprehensive entitlement, complete rehabilitation, and
administrative efficiency. The transition did not go particularly well, with too much focus on
either rehabilitation or costs, leading to a volatile and uncertain environment for a number of
years. An underlying cause may have been the lack of understanding of injury outcomes and
management. In recent scheme development of the NDIS and Lifetime Care and Support
scheme, research implementation has been critical in the development of the reporting
framework. The challenge that now lies ahead is the implementation of research findings into
the education and training of the day to day culture of insurance systems. The value to
insurers in embracing research lies in the opportunity to manage their portfolios by
understanding their claimants and policy holders to optimise return to work at an attractive
cost.
Ian Cameron - Research informing the development of NIIS, NDIS, and injury
compensation schemes: what is needed?
For research to inform compensation schemes, it is important to determine the key outcomes.
An important key outcome is (workforce) participation (International Classification of
Functioning ICF –WHO). Furthermore, we need to know how many people are eligible for
the scheme. This is readily apparent for some schemes such as NIIS but unclear for others
like NDIS. It is also important to determine what support is reasonable. Evidence informed
guidelines are often not available. And a compensation scheme needs to be fair. For example,
taking a 65 year cut off would mean that younger people with “old” health conditions (such
as Alzheimer’s disease) or older people with “younger” health conditions (such as SCI and
severe TBI) would fall between the cracks. To inform scheme development, the JWCRR has
analysed predictors of participation and cost of spinal cord injury and traumatic brain injury
for the NSW Lifetime Care and Support Scheme (LTCS). People with Traumatic Brain Injury
in the LTCS showed reduced disability compared to people injured prior to scheme
establishment. Other specific projects are the Care and Needs Scale, physiotherapy
exercises.com, and psychosocial care after spinal cord injury. JWCRR research priorities for
informing scheme development are, among others, to determine how best to help participants
recover, provide evidence based outcomes, determine strategies for improving outcomes, and
determine the cost effectiveness of improving outcomes.
Michele Sterling - WAD: latest evidence for rehabilitation and recovery
Consistent international data indicate that up to 50% of people will not have recovered one
year post whiplash injury. The results of cohort studies indicate that most recovery occurs in
the first 2-3 months after injury with little if any change after this point. Whilst there is
variability in recovery pathways, recent exploration using trajectory modelling of analytical
techniques has identified distinct recovery pathways (trajectories). Various physical and
psychological factors have also been identified as being predictive of poor health outcomes
1
following whiplash injury, including initial pain intensity, initial disability, pain
catastrophizing, posttraumatic stress symptoms, recovery expectations and signs of centrally
sensitised pain pathways. The results of clinical trials for the treatment of WAD are
equivocal. Many trials have investigated relatively simple interventions such as exercise
programs that may not be sufficient to address the complex clinical presentation seen in those
with already chronic symptoms or those individuals with acute whiplash pain identified as
being at high risk of poor-recovery. A recent high quality trial showed little benefit of an
early multi-disciplinary intervention on the incidence of chronic pain development. Another
high quality trial of an intensive physical rehabilitation program for people with chronic
WAD showed no greater effect than simple advice. In overall terms, currently available trials
for WAD could be described as showing only small, if any, effect in improving health
outcomes. Whilst the question of how to prevent the transition from acute to chronic pain
after whiplash injury cannot yet be answered. This presentation outlined and discussed
possible approaches to assessment and management that could be and are being explored.
Alex Collie - How can we achieve a public health approach to injury compensation?
Compensation schemes are the primary means by which Australian governments have chosen
to address the major public health issue of injury. Our state and territory injury schemes are
managed using an insurance model of injury compensation that seeks to achieve a balance
between the costs and benefits to the community. It is suggested that financial objectives
have become the primary focus of government and scheme managers, sometimes to the
detriment of important public health objectives. In other words, the balance between cost and
benefit is not being achieved. Ten evidence-based principles for achieving a greater focus on
health in our injury compensation schemes are proposed. These include: (i) defining
improvements in public health as the primary objective of injury schemes; (ii) a renewed
focus on injury prevention; (iii) identifying and removing policies and practices that are
harmful to health; (iv) recognising and treating the important non-compensable factors that
affect injury recovery; (v) ensuring scheme processes and procedures are fair and just; (vi)
enhancing the use and useability of scheme data; (vii) developing and encouraging health
promoting skills amongst frontline injury case managers; (viii) taking a systems approach to
working with stakeholders; (ix) active participation of end-users in scheme design and
operation, and last, (x) growing and using the research evidence base. The financial
performance of injury schemes is directly related to the burden of ill health within a scheme.
A greater focus on health will ensure that both public health and financial objectives are
achieved in the long-term.
Number of attendees: 130
Summary of feedback attendees:
Attendees were happy with the forum. The keynote talks were appreciated. John Walsh, Ian,
Michele, and especially Alex’ talk was valued a lot. A couple of individual presentations
from the symposia were specifically mentioned as highly relevant. One appreciated the mix
of researchers, clinicians and insurers in the audience.
There were some improvement suggestions: Some insurers preferred to have more
implications for practice, more research focused on solutions and scheme design, more on
how other schemes deal with the same issues, and more focus on workers’ compensation and
NDIS. Some would like to have speakers from insurance companies and lawyers, to hear
more about screening tools for insurers for rehab management.
2