Managing pain in the workplace: a focus group study of challenges, strategies and what matters most to workers with low back pain

PURPOSE

Most working adults with low back pain (LBP) continue to work despite pain, but few studies have assessed self-management strategies in this at-work population. The purpose of this study was to identify workplace challenges and self-management strategies reported by workers remaining at work despite recurrent or persistent LBP, to be used as a framework for the development of a workplace group intervention to prevent back disability.

METHOD

Workers with LBP (n = 38) participated in five focus groups, and audio recordings of sessions were analysed to assemble lists of common challenges and coping strategies. A separate analysis provided a general categorisation of major themes.

RESULTS

Workplace pain challenges fell within four domains: activity interference, negative self-perceptions, interpersonal challenges and inflexibility of work. Self-management strategies consisted of modifying work activities and routines, reducing pain symptoms, using cognitive strategies and communicating pain effectively. Theme extraction identified six predominant themes: knowing your work setting, talking about pain, being prepared for a bad day, thoughts and emotions, keeping moving and finding leeway.

CONCLUSIONS

To retain workers with LBP, this qualitative investigation suggests future intervention efforts should focus on worker communication and cognitions related to pain, pacing of work and employer efforts to provide leeway for altered job routines.

Validation of a risk factor-based intervention strategy model using data from the readiness for return to work cohort study

BACKGROUND

Low back pain (LBP) is a common and in some cases disabling condition. Until recently, workers presenting with non-specific LBP have generally been regarded as a homogeneous population. If this population is not homogeneous, different interventions might be appropriate for different subgroups. We hypothesized that (1) Clusters of individuals could be identified based on risk factors, (2) These clusters would predict duration and recurrences 6 months post-injury.

METHODS

The study focuses on the 442 LBP claimants in the Readiness for Return-to-Work Cohort Study. Claimants (n = 259) who had already returned to work, approximately 1 month post-injury were categorized as the low risk group. A latent class analysis was performed on 183 workers absent from work, categorized as the high risk group. Groups were classified based on: pain, disability, fear avoidance beliefs, physical demands, people-oriented culture and disability management practice at the workplace, and depressive symptoms.

RESULTS

Three classes were identified; (1) workers with 'workplace issues', (2) workers with a 'no workplace issues, but back pain', and (3) workers having 'multiple issues' (the most negative values on every scale, notably depressive symptoms). Classes 2 and 3 had a similar rate of return to work, both worse than the rate of class 1. Return-to-work status and recurrences at 6 months were similar in all 3 groups.

CONCLUSION

This study largely confirms that several subgroups could be identified based on previously defined risk factors as suggested by an earlier theoretical model by Shaw et al. (J Occup Rehab 16(4):591-605, 2006). Different groups of workers might be identified and might benefit from different interventions.

Development and validation of competencies for return to work coordinators

INTRODUCTION

Return to work (RTW) coordinators are a key element in programs that facilitate RTW of injured or ill workers, yet little research documents the competencies required for success in this role.

METHODS

Competencies were defined as knowledge, skills, attitudes, and behaviors. Eight focus groups were conducted with 75 experienced RTW coordinators to identify 904 individual competencies. These were subsequently reduced to 234 unique items through affinity mapping, and sorted into eight groups: administration, individual personal attributes, information gathering, communication, professional credibility, evaluation, problem-solving, and conflict management. A subset of 100 items, including 88 items most often cited, were incorporated in an Internet-based survey that sampled a broad range of RTW coordinators from three countries.

RESULTS

Eighty-three of the questionnaire items were rated 4 or 5 (very important or essential) by over half of the 148 respondents. There were no differences in affinity group mean ratings by country, employer, profession, or type of clients. The highest-rated items reflect general personal characteristics, or specific skills related to coordinating among all involved with the RTW process. RTW coordinators with nursing backgrounds provided slightly higher ratings for items related to medical knowledge, but otherwise their ratings were similar to non-nurses.

CONCLUSIONS

These findings indicate a consensus across a wide range of RTW coordinators, and results can be applied to improve coordinator selection, training, and development. Certain key competencies may be well-established individual attributes, and others may be best developed through mentorship. Most of these competencies are probably best evaluated by direct observation.

Early patient screening and intervention to address individual-level occupational factors ("blue flags") in back disability

OBJECTIVE

To develop a consensus plan for research and practice to encourage routine clinician screening of occupational factors associated with long-term back disability.

METHODS

A 3-day conference workshop including 21 leading researchers and clinicians (the "Decade of the Flags Working Group") was held to review the scientific evidence concerning clinical, occupational, and policy factors in back disability and the development of feasible assessment and intervention strategies.

RESULTS

The Working Group identified seven workplace variables to include in early screening by clinicians: physical job demands, ability to modify work, job stress, workplace social support or dysfunction, job satisfaction, expectation for resuming work, and fear of re-injury. Five evaluation criteria for screening methods were established: reliability, predictive performance, feasibility, acceptability, and congruence with plausible interventions. An optimal screening method might include a stepped combination of questionnaire, interview, and worksite visit. Future research directions include improving available assessment methods, adopting simpler and more uniform conceptual frameworks, and tying screening results to plausible interventions.

DISCUSSION

There is a clear indication that occupational factors influence back disability, but to expand clinician practices in this area will require that patient screening methods show greater conceptual clarity, feasibility, and linkages to viable options for intervention.

Data equivalency of an interactive voice response system for home assessment of back pain and function

BACKGROUND

Interactive voice response (IVR) systems that collect survey data using automated, push-button telephone responses may be useful to monitor patients' pain and function at home; however, its equivalency to other data collection methods has not been studied.

OBJECTIVES

To study the data equivalency of IVR measurement of pain and function to live telephone interviewing.

METHODS

In a prospective cohort study, 547 working adults (66% male) with acute back pain were recruited at an initial outpatient visit and completed telephone assessments one month later to track outcomes of pain, function, treatment helpfulness and return to work. An IVR system was introduced partway through the study (after the first 227 participants) to reduce the staff time necessary to contact participants by telephone during nonworking hours.

RESULTS

Of 368 participants who were subsequently recruited and offered the IVR option, 131 (36%) used IVR, 189 (51%) were contacted by a telephone interviewer after no IVR attempt was made within five days, and 48 (13%) were lost to follow-up. Those with lower income were more likely to use IVR. Analysis of outcome measures showed that IVR respondents reported comparatively lower levels of function and less effective treatment, but not after controlling for differences due to the delay in reaching non-IVR users by telephone (mean: 35.4 versus 29.2 days).

CONCLUSIONS

The results provided no evidence of information or selection bias associated with IVR use; however, IVR must be supplemented with other data collection options to maintain high response rates.

Shared and Independent Associations of Psychosocial Factors on Work Status Among Men With Subacute Low Back Pain

OBJECTIVES

Psychosocial variables are acknowledged predictors of back disability, but multivariate studies are needed to understand their independent and overlapping effects. The objective of this prospective cohort study was to evaluate independent and shared associations of psychosocial variables on work status after first onset of low back pain (LBP) in working men.

METHODS

One hundred forty male military personnel reporting subacute, first onset LBP (2 mo average duration) completed an interview-based and survey-based psychosocial assessment within the domains of job satisfaction, stress and coping, pain perceptions and beliefs, perceived functional disability, and mood disturbance. Work status was assessed at baseline, 6 and 12-month postpain onset.

RESULTS

In logistic regression analyses at baseline, work status was associated with pain interference and perceptions of physical impairment. Beyond 2 months, the extent to which pain was believed to interfere with function was the only significant predictor of subsequent changes in work status. Job dissatisfaction was associated with more impaired work status, but not after controlling for income. Depressive and anxious mood symptoms were prevalent but failed to explain additional variance in work status.

DISCUSSION

After first onset of men with subacute LBP, self-reported pain intensity and functional limitation account for most of the variance in work status explained by psychosocial factors; however, the resulting disability can be accompanied by mild to moderate mood symptoms. This suggests that interventions to improve function, if commenced early in the course of subacute pain, might prevent work disability.

Patient clusters in acute, work-related back pain based on patterns of disability risk factors

OBJECTIVE

To identify subgroups of patients with work-related back pain based on disability risk factors.

METHODS

Patients with work-related back pain (N = 528) completed a 16-item questionnaire of potential disability risk factors before their initial medical evaluation. Outcomes of pain, functional limitation, and work disability were assessed 1 and 3 months later.

RESULTS

A K-Means cluster analysis of 5 disability risk factors (pain, depressed mood, fear avoidant beliefs, work inflexibility, and poor expectations for recovery) resulted in 4 sub-groups: low risk (n = 182); emotional distress (n = 103); severe pain/fear avoidant (n = 102); and concerns about job accommodation (n = 141). Pain and disability outcomes at follow-up were superior in the low-risk group and poorest in the severe pain/fear avoidant group.

CONCLUSIONS

Patients with acute back pain can be discriminated into subgroups depending on whether disability is related to pain beliefs, emotional distress, or workplace concerns.

Reducing sickness absence from work due to low back pain: how well do intervention strategies match modifiable risk factors?

OBJECTIVE

To assess, from the review literature, the extent to which effective strategies for reducing work absence after acute low back pain (LBP) match empirical risk factors.

METHODS

From 17 recent review articles (2000-2005), disability risk factors and interventions were cross-tabulated to assess levels of relative concordance.

RESULTS

Potentially modifiable risk factors included 23 variables describing 3 workplace and 3 personal domains. Effective interventions included 25 strategies that were personal (physical or behavioral), engineering, or administrative in nature. There was a strong risk factor concordance for workplace technical and organizational interventions, graded activity exposure, and cognitive restructuring of pain beliefs. There was less risk factor concordance for exercise, back education, and RTW coordination. Few interventions focused on relieving emotional distress or improving job dissatisfaction, two well-supported risk factors.

DISCUSSION

Gaps between the epidemiological and intervention research of back disability prevention could be reduced by testing mediators of intervention effects or by stratifying outcomes according to pre-intervention risk factors.

Initial Patient and Clinician Expectations of Return to Work After Acute Onset of Work-Related Low Back Pain

OBJECTIVE

The objective of this study was to compare patient and provider expectations of return to work (RTW) after acute onset of low back pain (LBP).

METHODS

Workers sick-listed after onset of LBP (N = 300) completed a questionnaire about work, injury, and psychosocial disability risk factors and rated their likelihood of full RTW within 4 weeks. Clinicians provided an independent estimate of work absence, and patients were followed for 3 months.

RESULTS

Clinician and patient expectations were weakly correlated, and both were predictive of actual RTW outcomes. Patient expectations were associated with differences in pain, mood, prior back pain, job demands, functional limitation, and marital status. Factors associated with clinician prognosis were similar but with more emphasis on physical examination findings.

CONCLUSIONS

Even before treatment, patients may form a negative expectation for RTW that is associated with a longer duration of work absence.

Concerns and expectations about returning to work with low back pain: identifying themes from focus groups and semi-structured interviews

PURPOSE

Studies of occupational low back pain (OLBP) have shown that return to work after injury is influenced by workers' concerns and expectations; however, these theoretical constructs have not been explored. The specific aim of this study was to identify themes related to self-efficacy and outcome expectancy for returning to work using qualitative research methods.

METHOD

Twenty-eight individuals who recently returned to work (< 6 months) after an onset of OLBP responded to a newspaper advertisement and participated in focus groups. In a second phase of the study, patients with OLBP and an impending return to work (n = 23) were referred by their physiotherapists and interviewed to provide more immediate accounts of their concerns and experiences. Notes and recordings from both sources were searched for utterances describing beliefs about self-efficacy or outcome expectancy for returning to work.

RESULTS

Two primary self-efficacy constructs emerged: self-efficacy for resuming physical activity and self-efficacy for resuming work. Self-efficacy for resuming physical activity included 8 sub-domains: lift, carry, sit, stand, push/pull, bend, climb, and reach. Self-efficacy for resuming work included 3 sub-domains: pain control, obtaining help, and meeting job demands. Outcome expectancy included four sub-domains: financial/job security, re-injury, workplace support, and self-image.

CONCLUSIONS

Hesitation to return to work after OLBP involves not only concerns about pain and re-injury, but also the perceived ability to perform physical tasks, meet role expectations, obtain workplace support, and maintain job security.

A controlled case study of supervisor training to optimize response to injury in the food processing industry

The role of supervisors to aid injured workers, access health care, and provide reasonable accommodation may prevent prolonged disability among workers reporting musculoskeletal pain. Although supervisor training has been a common element of broad-based ergonomic interventions to prevent injuries, the impact of supervisor training alone to improve injury response has not been studied. In a controlled design, 11 supervisors in an intervention group and 12 supervisors in a delayed intervention control group from the same plant were provided a 4-hour training workshop. The workshop emphasized communication skills and ergonomic accommodation for workers reporting injuries or health concerns. Workers' compensation claims data in the 7 months before and after the workshop showed a 47% reduction in new claims and an 18% reduction in active lost-time claims versus 27% and 7%, respectively, in the control group. Improving the response of frontline supervisors to employees' work-related health and safety concerns may produce sustainable reductions in injury claims and disability costs.

Factors affecting the organizational responses of employers to workers with injuries

The organizational responses of employers to work-related injuries is one of several significant influences on return-to-work outcomes. Thus, understanding the factors that lead to better or worse organizational responses to work injuries may ultimately help to improve success in this area. The purpose of this study was to systematically explore factors that might influence the organizational responses of employers to injured workers, based on employee perceptions. Cross-sectional survey data were collected from 2,943 subjects with work-related injuries which had occurred less than eight weeks prior to survey completion. Measured variables included pre-injury demographic and job factors, injury circumstances, and a measure of post-injury events that comprised the organizational response. Multivariate linear regression results show that age, gender, job dissatisfaction before injury, prior difficulty performing job tasks, injury severity, back injury and lost time were all associated with negative organizational responses, suggesting potential opportunities for intervention.

Perceptions of Provider Communication and Patient Satisfaction for Treatment of Acute Low Back Pain

OBJECTIVE

We sought to assess the relationship between perceptions of provider communication and treatment satisfaction for acute, work-related low-back pain (LBP).

METHODS

In a prospective cohort study, 544 working adults (67% men) with acute LBP provided 1- and 3-month assessments of pain, function, and work status.

RESULTS

In a multiple regression analysis, positive provider communication (took problem seriously, explained condition clearly, tried to understand my job, advised to prevent re-injury) explained more variation in patient satisfaction at 1 month than was explained by clinical improvements in pain and function. At 3 months, clinical improvement variables surpassed provider communication as predictors of patient satisfaction.

CONCLUSIONS

Patients with work-related LBP place a high value on provider counseling and education, especially during the acute stage (<1 month) of treatment.

Early disability risk factors for low back pain assessed at outpatient occupational health clinics

STUDY DESIGN

Inception cohort (<or=14 days after pain onset) with 1-month follow-up.

OBJECTIVE

To determine whether disability risk factors provided by patients and clinicians at a first medical visit for acute occupational low back pain predict outcomes.

SUMMARY OF BACKGROUND DATA

Improving health and work outcomes for patients with occupational low back pain may require early identification of risk factors for persistent pain and disability. Previous studies of back pain prognosis have not assessed patients at the time of initial provider contact, and many have not differentiated between occupational and nonoccupational injuries.

METHOD

Patients (183 female, 385 male) presenting to occupational health clinics with recent onset occupational low back pain (<or=14 days duration) completed a 16-item survey of potential disability risks including demographic, injury, workplace, psychosocial, and symptom factors. After the initial visit, clinicians completed an additional 10-item questionnaire of symptoms and initial prognosis. Outcome variables of functional limitation and work status were assessed 1 month after pain onset.

RESULTS

In multivariate analyses, functional improvement and return to work were more strongly predicted by employer factors (job tenure, physical work demands, availability of modified duty, earlier reporting to employer) and self-ratings of pain and mood than by health history or physical examination. A logistic regression model had a sensitivity of 74.3% to predict those remaining out of work and a specificity of 70.1%.

CONCLUSIONS

Early screening for disability risk factors may be helpful to identify those patients at greatest risk for delayed recovery from occupational low back pain. Intervention strategies for high-risk patients might be improved by focusing on job factors, pain coping strategies, and expectations for recovery.

Generating workplace accommodations: lessons learned from the integrated case management study

Modified duty and other accommodations by employers have been shown to be helpful in managing workplace disability associated with injuries and illnesses. Benefits of accommodation have been attributed to both reduced physical and psychosocial exposures. Although many employers have adopted proactive return to work policies that emphasize temporary work modifications, standardized methods for specifying appropriate accommodations have been elusive. On the basis of the experiences and results of a randomized controlled study of case management services for work-related upper extremity disorders, we describe issues pertaining to the application of self-report measures of function and exposure assessment for generating accommodations. Challenges of this approach are 1) including specific work tasks on measures of physical function; 2) improving concordance between ergonomic exposure categories and methods of accommodation; and 3) providing a structured process for negotiating employee and employer preferences. To improve the effectiveness and efficiency of accommodation efforts, new tools for assessing function and ergonomic exposures in the workplace should be developed to specify accommodations more directly.

From confounders to suspected risk factors: psychosocial factors and work-related upper extremity disorders

Psychosocial variables have recently been more prominent among epidemiologic risk factors for work-related upper extremity disorders (WRUEDs), but bio-behavioral mechanisms underlying these associations have been elusive. One reason is that the psychosocial domain has included many broad and disparate variables (e.g. mood, coping skills, job control, job satisfaction, job stress, social support), and this lack of specificity in the conceptualization of psychosocial factors has produced limited hypothesis testing opportunities. Therefore, recent research efforts have focused on identifying and conceptualizing specific psychosocial factors that might more clearly delineate plausible bio-behavioral mechanisms linking psychosocial factors to WRUEDs. One such factor is workstyle, a strategy that workers may employ for completing, responding to, or coping with job demands that might affect musculoskeletal health. Preliminary studies have provided support for measurable differences in workstyle among individual workers and an association with upper extremity pain and discomfort. An initial self-report measure of workstyle has been pilot tested among office workers and shown acceptable reliability and validity. Future studies are needed to study this construct among other working populations and to determine its relationship with other clinical endpoints. Nevertheless, early findings suggest workstyle may be a potential focus of WRUED prevention efforts.

Worker perceptions of organizational support and return-to-work policy: associations with post-injury job satisfaction

This study evaluates the psychometric properties of an industry-based employee measure of employer responses to injuries (i.e., organizational support and return-to-work policies) and explores the relationship of these variables to post-injury job satisfaction. Survey data were collected from 1438 employees with work-related injuries in 13 construction companies and 13 transportation companies. Factor analyses supported the two-factor structure of the scale, and both organizational support and return-to-work policies were independently associated with post-injury job satisfaction. The results suggest a need for understanding organizational responses to injuries, employee perceptions of injury response, and the impact of both on organizational outcomes.

Reducing the sexual risk behaviors of HIV+ individuals: outcome of a randomized controlled trial

Testing behavioral interventions to increase safer sex practices of HIV+ individuals has the potential to significantly reduce the number of new infections. This study evaluated a behavioral intervention designed to reduce the sexual risk behaviors of HIV+individuals. HIV+individuals (N = 387) who reported engaging in unprotected sex with HIV- or partners of unknown serostatus were randomly assigned to (a) a single counseling session targeting problem areas identified by the participant in 3 possible intervention domains (i.e., condom use, negotiation, disclosure); (b) a single-session comprehensive intervention that covered all 3 intervention domains; (c) the same comprehensive intervention, plus 2 monthly booster sessions; or (d) a 3-session diet and exercise attention-control condition. The median number of unprotected sex acts decreased from 14 at baseline to 6, 6, and 4 at 4-, 8-, and 12-month follow-ups, respectively. A repeated measures analysis of variance revealed a significant decrease in unprotected sex acts across all groups across time. A significant Group x Time interaction revealed that the comprehensive-with-boosters group had the most unprotected sex at 8-month follow-up as compared to the other 3 groups. These findings suggest that a brief intervention can result in large reductions in HIV transmission risks among HIV+individuals, but the relative benefit of one intervention approach over another remains unclear.

Employee perspectives on the role of supervisors to prevent workplace disability after injuries

After workplace injuries, supervisors can play an important role in aiding workers, accessing health care services, and providing reasonable accommodation. However, few studies have identified those aspects of supervisor involvement most valued by employees for postinjury recovery and return to work. As part of needs assessment for a supervisory training program, 30 employees from four companies were interviewed about the role of supervisors to prevent workplace disability after injuries. From interview notes, 305 employee statements were extracted for analysis. An affinity mapping process with an expert panel produced 11 common themes: accommodation, communicating with workers, responsiveness, concern for welfare, empathy/support, validation, fairness/respect, follow-up, shared decision-making, coordinating with medical providers, and obtaining coworker support of accommodation. Interpersonal aspects of supervision may be as important as physical work accommodation to facilitate return to work after injury.

Identifying barriers to recovery from work related upper extremity disorders: use of a collaborative problem solving technique

Improving health and work outcomes for individuals with work related upper extremity disorders (WRUEDs) may require a broad assessment of potential return to work barriers by engaging workers in collaborative problem solving. In this study, half of all nurse case managers from a large workers' compensation system were randomly selected and invited to participate in a randomized, controlled trial of an integrated case management (ICM) approach for WRUEDs. The focus of ICM was problem solving skills training and workplace accommodation. Volunteer nurses attended a 2 day ICM training workshop including instruction in a 6 step process to engage clients in problem solving to overcome barriers to recovery. A chart review of WRUED case management reports (n = 70) during the following 2 years was conducted to extract case managers' reports of barriers to recovery and return to work. Case managers documented from 0 to 21 barriers per case (M = 6.24, SD = 4.02) within 5 domains: signs and symptoms (36%), work environment (27%), medical care (13%), functional limitations (12%), and coping (12%). Compared with case managers who did not receive the training (n = 67), workshop participants identified more barriers related to signs and symptoms, work environment, functional limitations, and coping (p < .05), but not to medical care. Problem solving skills training may help focus case management services on the most salient recovery factors affecting return to work.

Integrated case management for work-related upper-extremity disorders: impact of patient satisfaction on health and work status

An integrated case management (ICM) approach (ergonomic and problem-solving intervention) to work-related upper-extremity disorders was examined in relation to patient satisfaction, future symptom severity, function, and return to work (RTW). Federal workers with work-related upper-extremity disorder workers' compensation claims (n = 205) were randomly assigned to usual care or ICM intervention. Patient satisfaction was assessed after the 4-month intervention period. Questionnaires on clinical outcomes and ergonomic exposure were administered at baseline and at 6- and 12-months postintervention. Time from intervention to RTW was obtained from an administrative database. ICM group assignment was significantly associated with greater patient satisfaction. Regression analyses found higher patient satisfaction levels predicted decreased symptom severity and functional limitations at 6 months and a shorter RTW. At 12 months, predictors of positive outcomes included male gender, lower distress, lower levels of reported ergonomic exposure, and receipt of ICM. Findings highlight the utility of targeting workplace ergonomic and problem solving skills.

Prediction of prolonged work disability in occupational low-back pain based on nurse case management data

This study evaluated whether risk prediction data captured by nurse case managers (NCMs) could predict prolonged disability from occupational low back pain. Cases of uncomplicated occupational low back pain referred to NCMs, with dates of injury between January 1, 1997 and June 30, 1998, were selected (n = 986). Predictive information was obtained from the NCM screening checklist of potential risk factors and other administrative claims data. Data were collected on 23 variables thought to predict work status at 6 months postinjury. In a multivariate logistic regression model, being out of work was significantly associated with older age, language barriers, earlier referral to NCM, and neutral or negative attorney attitude toward return to work. The overall predictive power of the model was low (area under curve = 0.6). Although NCM risk factor data collection is feasible and practical in insurance settings, future studies should explore additional variables and refined data collection methods in order to achieve a more accurate prediction.

Emotional expressiveness, hostility and blood pressure in a longitudinal cohort of Alzheimer caregivers

OBJECTIVE

To assess the interactive effect of chronic stress and emotional expressiveness (EE) on blood pressure (BP) in older adults.

METHOD

Among spousal caregivers (n=111) of Alzheimer's disease (AD) patients, BP was assessed at home by a visiting nurse every 6 months for 7 years. Caregiving demands, EE, social desirability and hostility were also assessed.

RESULTS

State hostility was more prevalent among newer caregivers and those encountering more dementia problem behaviors and ADL limitations but unrelated to BP or BP change (P>.05). In a cross-sectional analysis, higher diastolic BP was associated with more spousal problem behaviors and being less emotionally expressive (P<.05). Longitudinal (growth curve analysis) increases in diastolic BP were predicted by providing more spousal ADL assistance (P<.05) but not by EE.

CONCLUSION

Both caregiving stress and low EE may contribute independently to hypertension risk in the elderly.