Optimizing Care Approaches for Work-Related Shoulder Conditions: A Multifaceted Investigation

Shoulder pain represents a significant challenge for workers, workplaces, and healthcare systems, necessitating a multifaceted approach to understand its impact and improve outcomes. This doctoral project investigated the most effective care approaches for work-related shoulder conditions. It focused on evaluating the effectiveness of exercise therapy with/without adjunct therapies, analyzing how care delivery impacts return-to-work (RTW) outcomes, and identifying the determinants of claim duration on an aging workforce within the Workers' Compensation Board in Alberta. Exercise therapy (ET) is frequently an early treatment of choice when managing shoulder pain, yet evidence on its efficacy to expedite recovery is inconsistent. Moreover, the value of adding adjunct therapies (i.e. injections, manual therapy, electro-physical agents) to ET is currently unclear. The first plan of work of this doctoral work determined the effectiveness of ET with or without adjunct therapies compared to usual medical care through a network meta-analysis. Analysis of 54 studies with 3,893 participants showed that ET targeting shoulder muscles significantly reduces pain (Mean Difference (MD)= -2.1; 95% confidence interval (CI)= -0.7 to -3.5) compared to usual care. Additional adjunct therapies like electro-physical agents (MD= -2.5; 95% CI= -0.7 to -4.2), injections (MD= -2.4; 95% CI= -1.04 to -3.9), or manual therapy (MD= -2.3; 95% CI= -0.8 to -3.7) added little value in reducing pain compared to ET alone. Given that pain is a primary reason for seeking treatment among patients with shoulder injuries, healthcare professionals may consider ET as a first-line treatment, exercising caution when considering adjunct therapies. Global evidence on the impact of care pathways for workers is limited. Effective care for shoulder injuries is essential for improving efficiency, reducing costs, and optimizing RTW outcomes. In this thesis, the second plan of work focuses on assessing the effect of care delivery—comparing usual care with a care pathway—on RTW among workers with shoulder injuries. The primary distinction between the two groups lies in their diagnostic and treatment coordination approach. In the usual care cohort, initial consultations and decisions regarding diagnosis and treatment were made by a general family physician, including requests for diagnostic imaging and surgical referrals. Conversely, the care pathway model involved specialized assessments by both physicians and physical therapists, who collaboratively reached a consensus on diagnosis and treatment. Moreover, the care pathway used streamlined collaborative team meetings to develop and execute RTW plans involving all relevant stakeholders. Multinomial logistic regression determined the effect of delivery of care on RTW levels (primary objective) and identified determinants associated with RTW levels (secondary objective). While the usual care cohort had a higher likelihood of RTW at pre-accident levels (Relative Risk Ration (RRR):1.8. 95%CI=1.4; 2.3), the relationship between cohorts and RTW levels was impacted by claim duration. For claims exceeding 12-months, the care pathway cohort had higher likelihood of returning to pre-accident (RRR=2, 95%CI=1.3; 3.3). Number of days receiving wage-replacement benefits one-year post-claim closure is similar between cohorts (P-value>0.05), reinforcing that RTW at modified duties in a shorter period of time is not detrimental and implementing a care pathway seems beneficial. This underscores the importance of proactive intervention strategies like care pathways in optimizing workplace rehabilitation outcomes and minimizing long-term disability. The third plan of work determined the impact of age on claim duration among workers with work-related shoulder injuries treated under a standardized care pathway. Through a Cox proportional hazards regression with time-varying covariates (TVC), we were able to show that early treatment for work-related shoulder injuries is a large determinant of claim duration. Expedited treatment start decreased claim duration significantly (Hazard Ratio (HR): 0.005, 95%CI: 0.002; 0.01). While age wasn't a large determinant of claim duration, workers aged 50 and above often experienced delayed treatment compared to younger workers (p<0.0001) despite being under an equitable care pathway, possibly due to age-related biases. Through a comprehensive research framework encompassing synthesis and modeling, this doctoral project contributes to advancing understanding and optimizing care approaches for work-related shoulder conditions. By addressing distinct aspects of treatment, care delivery, and age-related considerations, this study aims to inform evidence-based practice, policy development, and employer interventions, ultimately enhancing workforce productivity and promoting the wellbeing of workers affected by shoulder injuries.

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