Do current methods of measuring the impact of chronic pain on work reflect the experience of working-age adults? An integrated mixed-methods systematic narrative review

ABSTRACT

Chronic pain affects individuals' work participation. The impact of chronic pain on work has historically been measured through sickness absence, though it is now appreciated that the impacts on work are far wider. This mixed-methods review aimed to identify the full range of impacts of pain on work in addition to impacts that are currently measured quantitatively to inform the development of a new questionnaire assessing the wider impacts of chronic pain on work. MEDLINE, Embase, PsychINFO, and CINAHL were searched for studies that included quantitative measures of the impact of chronic pain on work and for qualitative studies where individuals described impacts of their chronic pain on work. Quantitative measures, and text from qualitative studies, were analysed thematically. A thematic framework was developed for establishing the types of impacts measured or described in the literature. Forty-four quantitative and 16 qualitative papers were identified. The literature described impacts within 5 areas: changes at work and to working status; aspects of the workplace and work relationships; pain and related symptoms at work; psychological factors; and factors and impacts outside the work environment related to work. Quantitative measures mainly assessed impacts related to the quantity and quality of work (29 of 42 measures). Seventeen aspects were only discussed within the qualitative literature. This study identifies a discrepancy between the impacts that have been the focus of quantitative measures and the range that individuals working with chronic pain experience and highlights the need for a new measure assessing a wider range of issues.

Suffering out of sight but not out of mind - interpreting experiences of sick leave due to chronic pain in a community setting: a qualitative study

OBJECTIVE

Chronic pain is a complex health problem affecting about one-fifth of the European population. It is a leading cause of years lived with disability worldwide, with serious personal, relational and socioeconomic consequences. Chronic pain and sick leave adversely affect health and quality of life. Thus, understanding this phenomenon is essential for reducing suffering, understanding the need for support and promoting a rapid return to work and an active lifestyle. This study aimed to describe and interpret persons' experiences of being on sick leave due to chronic pain.

DESIGN

A qualitative study with semistructured interviews analysed using a phenomenological hermeneutic approach.

SETTING

Participants were recruited from a community setting in Sweden.

PARTICIPANTS

Fourteen participants (12 women) with experiences of part-time or full-time sick leave from work due to chronic pain were included in the study.

RESULTS

Suffering out of sight but not out of mind was the main theme of the qualitative analysis. This theme implies that the participants' constant suffering was invisible to others, causing them to feel they were not being justly treated in society. Feeling overlooked led to a continuous struggle for recognition. Moreover, the participants' identities and their trust in themselves and their bodies were challenged. However, our study also revealed a nuanced understanding of the experiences of sick leave as a consequence of chronic pain, where the participants learnt important lessons, including coping strategies and re-evaluated priorities.

CONCLUSIONS

Being on sick leave due to chronic pain threatens a person's integrity and leads to substantial suffering. An enhanced understanding of the meaning of sick leave due to chronic pain provides important considerations for their care and support. This study highlights the importance of feeling acknowledged and being met with justice in encounters with others.

Aligning stakeholders' understandings of the return-to-work process: a qualitative study on workplace meetings in inpatient multimodal occupational rehabilitation

Purpose: Although it is believed that involving the workplace and stakeholders in return-to-work interventions is beneficial, Norwegian occupational rehabilitation programmes rarely do. During 2015–2016, Hysnes Rehabilitation Centre provided inpatient multimodal occupational rehabilitation, including workplace meetings with employees, supervisors, and rehabilitation therapists. This study aims to explore the meetings´ content and stakeholders´ experiences.Methods: This was a multiple case study including non-participant observation of workplace meetings and interviews with participantsResults: Essential features of meetings included revealing and aligning the employee’s and supervisor’s understandings. Three components seemed instrumental in developing shared understandings leading to appropriate adjustments: 1) disclosing causes of absence, 2) validating difficulties, attitudes, and efforts, and 3) delimiting responsibility. Therapists played a vital role in addressing these components, supporting employees, and ensuring planning of appropriate solutions.Conclusion: Developing shared understandings by addressing and aligning illness- and return-to-work representations appears important for return-to-work interventions. Although pivotal to developing appropriate adjustments, disclosure depends upon supervisors’ display of understanding and should not be encouraged without knowledge of the employee´s work situation. How supervisors relate to employees and implement adjustments may be as important as the types of adjustments. The therapist’s support and validation of employees in vulnerable situations also seem valuable.Trial registration: The trial is registered at clinicaltrials.gov (NCT02541890), 4 September 2015. https://clinicaltrials.gov/ct2/show/NCT02541890.

Attending work with chronic pain is associated with higher levels of psychosocial stress

Background and Aims: Much is known about the impact of pain in terms of medical costs and missed work. Less is known about its associations when individuals are present for work. This study examines "presenteeism" by analyzing the psychosocial costs of pain in the workplace, using the 2015 European Working Conditions Survey (EWCS). Methods: We conducted cross-sectional analysis of 2384 individuals with chronic pain and 2263 individuals without pain (matched by age and sex) using data from the 2015 EWCS. We compared groups in terms of the following psychosocial factors: supervisor support, job responsibility, team cohesion, discrimination, threats/abuse, job competency, job reward, sexual harassment, stress, and job security. The groups were also compared in terms of days lost due to illness. Results: People with pain were 64% less likely to view their job as rewarding (odds ratio [OR] = 0.61; 95% confidence interval [CI], 0.57-0.65), 47% more likely to be subjected to threats/abuse in the workplace (OR = 0.68; 95% CI, 0.63-0.73), 30% more likely to report poor supervisor support (OR = 0.77; 95% CI, 0.73-0.82), and 28% more likely to perceive discrimination in the workplace (OR = 0.78; 95% CI, 0.71-0.85). People with pain missed approximately nine more days of work per year than respondents without pain. Conclusions: Chronic pain was associated with lower vocational fulfillment and feelings of being ostracized in the workplace. These findings suggest that the presence of pain in the workplace goes well beyond lost productivity due to absenteeism.

Developing guidelines to support injured workers who live and work with chronic pain

BACKGROUND

Living and working with chronic pain requires persons to alter lifestyles and have the knowledge as well as support to manage unforeseen challenges. Knowledge for persons living with pain who want to participate in meaningful paid and unpaid work is not easily accessible. While there is literature on chronic pain management, work transitions and return to work, less emphasis has been placed on the complexity of living and working with chronic pain. The Creating a Way Forward Project was envisioned to address this gap and to identify the informational needs of workers with pain, health/helping professionals (workers' advisors, return to work specialists, legal representatives), and stakeholders. The overarching aim of the project was to use evidence and experiential knowledge to inform the development of a foundation for educational guides and toolkits to support workers with pain to achieve their outcomes for remaining at work.

METHODS

Phase one of the project involved a scoping review of chronic pain and work. Phase two involved stakeholder consultations, a focus group and knowledge integration of the literature and experiential insights. Knowledge synthesis drew on a Template Analysis of multiple sources of data.

RESULTS

Knowledge domains and key components were identified for persons with pain and for the health/helping professions.

CONCLUSION

These domains reflect a foundation for knowledge in practical training and the development of curriculum for education in self-management program and in inter professional health profession education. These knowledge domains provide a basis for future research in integrated approaches and knowledge use toward improving transitions for persons living with chronic pain who want to participate in productive paid and unpaid work. Ongoing research in knowledge domains that health providers and persons with pain need will expand the potential for improving health outcomes in living with and managing pain.

Qualitative Evidence from Studies of Interventions Aimed at Return to Work and Staying at Work for Persons with Chronic Musculoskeletal Pain

Chronic musculoskeletal pain is a significant burden for employees, employers, and society. However, more knowledge is needed about which interventions reduce sick leave. Interventions were defined as the act or an instance of intervening, provided by different stakeholders. This review synthesizes the experiences of patients, employers, and health professionals concerning the interventions that influence returning to work and staying at work for persons with chronic musculoskeletal pain. A literature search was performed using several combinations of key terms. Overall, 18 qualitative studies published between 2002 and 2018 were included. Qualitative analysis assessed how much confidence could be placed in each review finding. Moderate evidence was found for factors improving the return to work process such as collaboration between stakeholders, including the persons with chronic musculoskeletal pain and support from all involved actors in the process. Moderate evidence was found for self-management strategies and workplace adjustments needed to facilitate more persons to returning to work and staying at work despite pain. This review provides stakeholders, employers, and health professionals’ information that could be used to develop and implement interventions to increase the possibilities for persons with chronic musculoskeletal pain returning to work or staying at work.

A Healing Journey with Chronic Pain: A Meta-Ethnography Synthesizing 195 Qualitative Studies

Objective

There is a large body of research exploring what it means for a person to live with chronic pain. However, existing research does not help us understand what it means to recover. We aimed to identify qualitative research that explored the experience of living with chronic pain published since 2012 and to understand the process of recovery.

Design

A synthesis of qualitative research using meta-ethnography.

Methods

We used the seven stages of meta-ethnography. We systematically searched for qualitative research, published since 2012, that explored adults’ experiences of living with, and being treated for, chronic pain. We used constant comparison to distill the essence of ideas into themes and developed a conceptual model.

Results

We screened 1,328 titles and included 195 studies. Our conceptual model indicates that validation and reconnection can empower a person with chronic pain to embark on a journey of healing. To embark on this journey requires commitment, energy, and support.

Conclusions

The innovation of our study is to conceptualize healing as an ongoing and iterating journey rather than a destination. Health interventions for chronic pain would usefully focus on validating pain through meaningful and acceptable explanations; validating patients by listening to and valuing their stories; encouraging patients to connect with a meaningful sense of self, to be kind to themselves, and to explore new possibilities for the future; and facilitating safe reconnection with the social world. This could make a real difference to people living with chronic pain who are on their own healing journeys.

Resilience and return-to-work pain interventions: systematic review

BACKGROUND

Resilience is a developing concept in relation to pain, but has not yet been reviewed in return-to-work (RTW) contexts.

AIMS

To explore the role of resilience enhancement in promoting work participation for chronic pain sufferers, by reviewing the effectiveness of existing interventions.

METHODS

Resilience was operationalized as: self-efficacy, active coping, positive affect, positive growth, positive reinforcement, optimism, purpose in life and acceptance. Five databases were searched for randomized controlled trials (RCTs) whose interventions included an element of resilience designed to help RTW/staying at work for chronic pain sufferers. Study appraisal comprised the Cochrane risk of bias (RoB) tool and additional quality assessment. Findings were synthesized narratively and between-group differences of outcomes were reported. Heterogeneous PICO (population, intervention, comparator, outcome) elements precluded meta-analysis.

RESULTS

Thirty-four papers from 24 RCTs were included. Interventions varied; most were multidisciplinary, combining behavioural, physical and psychological pain management and vocational rehabilitation. Four found RTW/staying at work improved with intensive multidisciplinary interventions compared with less intensive, or no, treatment. Of these, one had low RoB; three scored poorly on allocation concealment and selective outcome reporting. Four trials had mixed results, e.g. interventions enabling reduced sick leave for people on short-term not long-term leave; 16 showed no improvement. Five trials reported resilience outcomes were improved by interventions but these were not always trials in which RTW improved.

CONCLUSIONS

Effectiveness of resilience interventions for chronic pain sufferers on RTW is uncertain and not as helpful as anticipated. Further agreement on its conceptualization and terminology and that of RTW is needed.

Barriers to and Facilitators of Implementing Programs for Return to Work (RTW) of Cancer Survivors in Four European Countries: A Qualitative Study

Purpose Implementation of return to work (RTW) programs for cancer survivors has proved to be challenging. The purpose of our study was to gather experiences about barriers to and facilitators of implementing RTW programs for cancer survivors in four European countries. Methods Separate multidisciplinary focus groups were held in Belgium (n = 8), the Netherlands (n = 8), Ireland (n = 6), and UK (n = 4) in 2017 and included among others a physician, and a representative of an employer, a cancer society, and the government. Primary focus of thematic analysis was what could be done to improve the implementation of RTW programs for cancer survivors. Analysis used the 'Arena in work disability prevention model' as the conceptual framework. Results Many barriers to and facilitators of implementing RTW programs for cancer survivors were described including the personal, workplace, healthcare and legislative system as well as the overall societal and political context. That is, for example cooperation between stakeholders, time, money and ability issues at the workplace, and insufficient/inadequate legislation. Insufficient knowledge of cancer and its implications for work was identified as an overarching theme in all countries leading to stigma, misconceptions and lack of communication. This was mentioned in relation to the workplace, personal and healthcare system, and in the overall societal context. Conclusions Results indicate that a prerequisite for implementing RTW programs is raising sufficient knowledge regarding cancer and its implications for work. Greater knowledge could be a first step to better implement RTW programs which may result in better supporting cancer survivors with their RTW .

Engaging workplace representatives in research: what recruitment strategies work best?

Background

Workplaces are key stakeholders in work and health but little is known about the methods used to recruit workplace representatives (WRs), including managers, occupational health advisers and colleagues, to externally funded healthcare research studies.

Aims

To detail the strategies used in recruiting WRs from three areas of the UK to a qualitative study concerning their experience of employees undergoing hip or knee replacement, to compare the strategies and inform recruitment methods for future studies.

Methods

Six strategies were used to recruit WRs from organizations of different sizes and sectors. Data on numbers approached and responses received were analysed descriptively.

Results

Twenty-five WRs were recruited. Recruitment had to be extended outside the main three study areas, and took several months. It proved more difficult to recruit from non-service sectors and small- and medium-sized enterprises. The most successful strategies were approaching organizations that had participated in previous research studies, or known professionally or personally to team members.

Conclusions

Recruiting a diverse sample of WRs to healthcare research requires considerable resources and persistence, and a range of strategies. Recruitment is easier where local relationships already exist; the importance of building and maintaining these relationships cannot be underestimated. However, the potential risks of bias and participant fatigue need to be acknowledged and managed. Further studies are needed to explore how WRs can be recruited to health research, and to identify the researcher effort and costs involved in achieving unbiased and representative samples.

Systematic review of fit note use for workers in the UK

OBJECTIVES

The fit note, introduced in England, Wales and Scotland in 2010, was designed to change radically the sickness certification process from advising individuals on their inability to work to advising them on what they could do if work could be adapted. Our review aimed to evaluate the following: (1) Is the 'maybe fit' for work option being selected for patients? (2) Are work solutions being recommended? (3) Has the fit note increased return to work? (4) Has the fit note reduced the length of sickness absence? We considered the way in which outcomes vary according to patient demographics including type of health problem.

METHODS

Studies were identified by a systematic search. We included all studies of any design conducted in the UK with working age adults, aged 16 or over, from 1 April 2010 to 1 Nov 2017. Risk of bias was assessed using a modified Newcastle-Ottawa Scale.

RESULTS

Thirteen papers representing seven studies met inclusion criteria. In the largest study, 'maybe fit' for work was recommended in 6.5% of fit notes delivered by general practitioners (GP; n=361 801) between April 2016 and March 2017. 'Maybe fit' recommendations were made in 8.5%-10% of fit notes received by primary care patients in employment, and in 10%-32% of patients seen by GPs trained in the Diploma in Occupational Medicine. 'Maybe fit' was recommended more for women, those with higher socioeconomic status, and for physical, as opposed to psychiatric disorders. The majority of fit notes with the 'maybe fit' option selected included work solutions. There was inconclusive evidence to suggest that the introduction of the fit note has reduced sickness absence among patients in employment.

CONCLUSIONS

Fit notes represent a major shift in public policy. Our review suggests that they have been incompletely researched and not implemented as intended.

Therapeutic Work as a Facilitator for Return to Paid Work in Cancer Survivors

Purpose The increase of flexible employment in European labour markets has contributed to workers' risk of job loss. For sick-listed workers with chronic illnesses, such as cancer, and especially those without an employment contract, participation in therapeutic work may be an important step towards paid employment. The purpose of this study was to determine the role of therapeutic employment as facilitator for return to paid work, in a cohort of sick-listed cancer survivors (CSs) with and without an employment contract. Methods In this longitudinal study, data were used from a cohort of Dutch CSs (N = 192), who applied for disability benefits after 2 years of sick leave. The primary outcome measure was return to paid work after 1 year. Logistic regression analysis was applied. Results Of the participating CSs (mean age 50.7 years, 33 % male), 69 % had an employment contract at baseline. CSs without an employment contract participated significantly less in therapeutic work (p < 0.001) and were less likely to return to paid work after 1 year (p = 0.001), than those with a contract. Participation in therapeutic work significantly increased the chance of return to paid work after 1 year (OR 6.97; 95 % CI 2.94-16.51), adjusted for age, gender, level of work disability and having an employment contract. Conclusions Participation in therapeutic work could be an important facilitator for return to paid work in sick-listed CSs. The effectiveness of therapeutic work as a means to return to paid employment for sick-listed workers should be studied in an experimental setting.

Returning and staying connected to work after long-term sickness absence

BACKGROUND

Returning to work (RTW) after long-term sickness absence is a challenge for convalescent workers, co-workers, managers and organizations. Few studies have investigated the post-return phase after long-term sickness absence.

AIMS

To investigate the RTW process as experienced by returning workers, co-workers and managers at an emergency care service and a waste disposal company, exploring various perspectives related to early RTW before full recovery and changes in the returning workers' work positions.

METHODS

An ethnographic field work design was employed. Returning workers with musculoskeletal disorders, co-workers and managers at two different workplaces participated in individual and group interviews and underwent participant observation over 5 months. These were repeated in a 2-week period after a 4-month interval. Grounded theory analysis was used to identify themes of importance.

RESULTS

Four main themes were identified: (1) return before full recovery, (2) changes in work tasks, (3) changes in work position and (4) individual responsibility.

CONCLUSIONS

Our results illustrate how returning workers, co-workers and managers at two workplaces experienced the RTW process. The results highlight some of the challenges that occur when returning at an early stage before full recovery is obtained leading to changes in the returning worker's work position.

Vocational Rehabilitation: Supporting Ill or Disabled Individuals in (to) Work: A UK Perspective

Work is important for one's self-esteem, social standing and ability to participate in the community as well as for the material advantages it brings to individuals and their families. The evidence suggests that the benefits of employment outweigh the risks of work and are greater than the risks of long-term unemployment or sickness absence. Individuals may be born with physical or intellectual disadvantages (e.g., cerebral palsy), or they may be acquired during childhood or adult life. Some progressive conditions may present in childhood or adolescence (e.g., some muscular dystrophies) and these need to be distinguished from those presenting later in life (e.g., trauma, stroke). Vocational rehabilitation (VR) thus takes three forms: preparing those with a disability, health or mental health condition for the world of work, job retention for those in work and assisting those out of work into new work. Important components of VR consist of the attributes of the individual, the skills/knowledge of their health professionals, the knowledge and attitudes of actual or potential employers and the assistance that is provided by the state or other insurance facility. Charities are playing an increasing role.

Return-to-work outcomes and usefulness of actual fit notes received by employers

BACKGROUND

GPs can use the fit note to advise that a patient 'may be fit' or is 'not fit' for work. Previous employer-based research on the fit note is largely qualitative and based on general perceptions and past experience. Knowledge of the return-to-work outcomes and usefulness of actual fit notes is needed to strengthen the evidence-base and inform practice.

OBJECTIVE

To investigate the return-to-work outcomes of fit notes issued to employed patients, and their employers' opinions as to the usefulness of each note.

METHODS

Participating organizations collecting fit notes were asked to rate the outcome and usefulness of each fit note via postal questionnaires. Quantitative data were analysed descriptively; qualitative data were analysed using thematic content analysis.

RESULTS

Five hundred and sixteen questionnaires were posted, with a 97% return rate (n=498). More than 80% of employees (n=44) returned to work after the expiry date of a 'may be fit' note compared with 43% (n=167) of those issued with a 'not fit' note. Fit notes were considered more useful if they provided information on the condition and its effect on the employee's ability to work, if they stated whether or not the employee needed reassessment and if clear advice regarding return-to-work had been provided.

CONCLUSIONS

'May be fit' notes are useful in helping employees return to work. However, this option is infrequently used, and the completion and content of many fit notes does not meet employers' needs. These factors need to be urgently addressed if the fit note is to reach its full potential.

Does the economy affect functional restoration outcomes for patients with chronic disabling occupational musculoskeletal disorders?

PURPOSE

To determine how the economy affects psychosocial and socioeconomic treatment outcomes in a cohort of chronic disabling occupational musculoskeletal disorder (CDOMD) patients who completed a functional restoration program (FRP).

METHODS

A cohort of 969 CDOMD patients with active workers' compensation claims completed an FRP (a medically-supervised, quantitatively-directed exercise progression program, with multi-modal disability management). A good economy (GE) group (n = 532) was released to work during a low unemployment period (2005-2007), and a poor economy (PE) group (n = 437) was released during a higher unemployment period (2008-2010). Patients were evaluated upon admission for demographic and psychosocial variables, and were reassessed at discharge. Socioeconomic outcomes, including work return and work retention 1 year post-discharge, were collected.

RESULTS

Some significant differences in psychosocial self-report data were found, but most of the effect sizes were small, so caution should be made when interpreting the data. Compared to the PE group, the GE group reported more depressive symptoms and disability at admission, but demonstrated a larger decrease in depressive symptoms and disability and increase in self-reported quality of life at discharge. The PE group had lower rates of work return and retention 1-year after discharge, even after controlling for other factors such as length of disability and admission work status.

CONCLUSIONS

CDOMD patients who completed an FRP in a PE year were less likely to return to, or retain, work 1-year after discharge, demonstrating that a PE can be an additional barrier to post-discharge work outcomes. A difference in State unemployment rates of <3% (7 vs. 5%) had a disproportionate effect on patients' failure to return to (19 vs. 6%) or retain (28 vs. 15%) work.

Has the fit note reduced general practice sickness certification rates?

BACKGROUND

In 2010, the fit note replaced the sick note to help focus on what people are capable of doing, rather than signing patients 'off sick'.

AIMS

To compare proportions of work-related ill-health issued with sickness certification pre- and post-fit note introduction and assess sickness absence trends.

METHODS

General practitioners (GPs) report data on work-related ill-health and sickness absence via The Health and Occupation Research network in General Practice. The proportion of cases issued with sickness certification 4 years before and 3 years after the fit note introduction were compared. Changes in certification incidence rate ratios were measured over time.

RESULTS

Participating GPs reported 5517 cases of work-related ill-health. Pre-fit note introduction 50% of cases were certified sick. There was no change in the proportion of cases certified sick in the first year post-fit note, despite 13% of cases classified as 'maybe fit'. However, in the second year, the proportion of cases certified sick had reduced significantly (41%) and a larger proportion (19%) was advised on workplace adjustments. In the third year post-introduction, there was a slight rise in the proportion of cases certified sick; therefore, although there was a fall of 2% per annum in certification rates, this was not significant.

CONCLUSIONS

In the first year post-fit note introduction, modifications to work were recommended for people who would previously have been declared fit. Trends analyses showed a slight decrease in the certification rate, possibly indicating GPs will become more practised in advising on workplace adjustments.