What is the volume, quality and characteristics of evidence relating to the effectiveness and cost-effectiveness of multi-disciplinary occupational health interventions aiming to improve work-related outcomes for employed adults? An evidence and gap map of systematic reviews

Background

In the UK, tens of millions of working days are lost due to work-related ill health every year, costing billions of pounds. The role of Occupational Health (OH) services is vital in helping workers to maintain employment when they encounter injury or illness. OH providers traditionally rely on a clinical workforce to deliver these services, particularly doctors and nurses with OH qualifications. However, the increasing demand for OH services is unlikely to be met in the future using this traditional model, due to the declining number of OH-trained doctors and nurses in the UK. Multi-disciplinary models of OH delivery, including a more varied range of healthcare and non-healthcare professionals, could provide a way to meet this new demand for OH services. There is a need to identify collaborative models of OH service delivery and review their effectiveness on return-to work outcomes. There is an existing pool of systematic review evidence evaluating workplace based, multi-disciplinary OH interventions, but it is difficult to identify which aspects of the content and/or delivery of these interventions may be associated with improved work-related outcomes.

Objectives

The aim of this evidence and gap map (EGM) was to provide an overview of the systematic review evidence that evaluates the effectiveness and cost-effectiveness of multi-disciplinary OH interventions intending to improve work-related outcomes.

Search Methods

In June 2021 we searched a selection of bibliographic databases and other academic literature resources covering a range of relevant disciplines, including health care and business studies, to identify systematic review evidence from a variety of sectors of employment. We also searched Google Search and a selection of topically relevant websites and consulted with stakeholders to identify reports already known to them. Searches were updated in February 2023.

Selection Criteria

Systematic reviews needed to be about adults (16 years or over) in employment, who have had absence from work for any medical reason. Interventions needed to be multi-disciplinary (including professionals from different backgrounds in clinical and non-clinical professions) and designed to support employees and employers to manage health conditions in the workplace and/or to help employees with health conditions retain and/or return to work following medical absence. Effectiveness needed to be measured in terms of return to work, work retention or measures of absence, or economic evaluation outcomes. These criteria were applied to the title and abstract and full text of each systematic review independently by two reviewers, with disagreements resolved through discussion. We awarded each systematic review a rating of 'High', 'Medium' or 'Low' relevance to indicate the extent to which the populations, interventions and their contexts synthesised within the review were consistent with our research question. We also recorded the number of primary studies included within each of the 'High' and 'Medium' reviews that were relevant to research question using the same screening process applied at review level.

Data Collection and Analysis

Summary data for each eligible review was extracted. The quality of the systematic reviews, rated as 'High' or 'Medium' relevance following full text screening, was appraised using the AMSTAR-2 quality appraisal tool. All data were extracted by one reviewer and checked by a second, with disagreements being settled through discussion. Summary data for all eligible systematic reviews were tabulated and described narratively. The data extracted from reviews of 'High' and 'Medium' relevance was imported into EPPI-Mapper software to create an EGM.

Stakeholder Involvement

We worked alongside commissioners and policy makers from the Department of Health and Social Care (DHSC) and Department of Work and Pensions (DWP), OH personnel, and people with lived experience of accessing OH services themselves and/or supporting employees to access OH services. Individuals contributed to decision making at all stages of the project. This ensured our EGM reflects the needs of individuals who will use it.

Main Results

We identified 98 systematic reviews that contained relevant interventions, which involved a variety of professionals and workplaces, and which measured effectiveness in terms of return to work (RTW). Of these, we focused on the 30 reviews where the population and intervention characteristics within the systematic reviews were considered to be of high or medium relevance to our research questions. The 30 reviews were of varying quality, split evenly between High/Moderate quality and Low/Critically-Low quality ratings. We did not identify any relevant systematic review evidence on any other work-related outcome of interest. Interventions were heterogenous, both within and across included systematic reviews. The EGM is structured according to the health condition experienced by participants, and the effectiveness of the interventions being evaluated, as reported within the included systematic reviews. It is possible to view (i) the quality and quantity of systematic review evidence for a given health condition, (ii) how review authors assessed the effectiveness or cost-effectiveness of the interventions evaluated. The EGM also details the primary studies relevant to our research aim included within each review.

Authors’ Conclusions

This EGM map highlights the array of systematic review evidence that exists in relation to the effectiveness or cost-effectiveness of multi-disciplinary, workplace-based OH interventions in supporting RTW. This evidence will allow policy makers and commissioners of services to determine which OH interventions may be most useful for supporting different population groups in different contexts. OH professionals may find the content of the EGM useful in identifying systematic review evidence to support their practice. The EGM also identifies where systematic review evidence in this area is lacking, or where existing evidence is of poor quality. These may represent areas where it may be particularly useful to conduct further systematic reviews.

Do worksite health promotion programs (WHPP) influence presenteeism among employees? A systematic review1

BACKGROUND

Worksite health promotion programs (WHPP) aiming to reduce presenteeism are rapidly increasing. However, program-efficacy seems impaired by lack of conceptual understanding and theoretical frameworks related to presenteeism.

OBJECTIVES

To study (1) the concept of presenteeism, (2) the causes of the phenomenon and (3) which WHPP affect presenteeism.

METHODS

We followed the PRISMA 2020 guidelines for mapping relevant literature in seven databases. The main search-terms were "worksite", "WHPP", "presenteeism", "employee productivity" and "interventions". Reviews and review of reviews were included and analysed according to research questions and ecological theory.

RESULTS

Of 2196 studies identified, 14 reviews were included, comprising 1390 single studies. Conceptually, presenteeism was poorly defined, mostly related to productivity/performance limitations due to ill health. Factors causing presenteeism addressed individual health or lifestyle (78%), and, to a lesser extent work and organisational factors (management/job stress) (22%). Forty-five highly diverse WHPP were identified, about 90% focusing health outcomes. 22/45 WHPP affected presenteeism/productivity positively. Multi-component WHPP implemented at multi levels accounted for 55%. Single-component programs, implemented at individual level, were mostly targeting health-risk subgroups. No specific WHPP seems preferable. Methodological quality seems highly associated with worksite intervention-efficacy.

CONCLUSION

Increased telework opportunities due to COVID-19 experiences has affected working conditions worldwide, for better and worse, requiring adaptions at employee, management, organisational and socio-cultural levels. Our results showed high program diversity, several adaptable to future needs (e.g., digital solutions), however hampered by narrow focus on individual health. Future research should focus on theory-based high quality multilevel WHPP comprising contextual, work, and organisational factors.

Participatory Ergonomics Intervention to Prevent Work Disability Among Workers with Low Back Pain: A Randomized Clinical Trial in Workplace Setting

Purpose In order to support people with low back pain (LBP) to stay at work, work arrangements are regarded important. This study aimed to evaluate the effectiveness of a workplace intervention using a participatory approach on work disability of workers with ongoing or recurrent LBP. Methods A total of 107 workers with LBP, with duration of pain for at least two consecutive weeks or recurrent pain of any duration during the last year, were randomized either to the intervention (n = 51) or control group (n = 56). The intervention included arrangements at the workplace, along with individual guidance provided by an occupational physiotherapist (OPT). The randomized intervention study used standard counselling and guidance by an OPT without workplace intervention as a comparison. Surveys were completed at baseline, and 6 and 12 months after baseline. Results There were no statistically significant differences between the intervention and control groups on the primary outcome measure, i.e. self-assessed work ability. We found no between-group differences in perceived health, self-assessed work productivity, number of sickness absence days and severity of back pain. However, there were significant positive within-group changes in the intervention group in the intensity of LBP, perceived health and the number of sickness absence days due to LBP. Conclusion Workplace arrangements are feasible using participatory ergonomics, but more quantitative and qualitative research is needed on its utilization and effectiveness among workers with LBP.

Reported Outcomes in Interdisciplinary Pain Treatment: An Overview of Systematic Reviews and Meta-Analyses of Randomised Controlled Trials

Background

There is considerable diversity of outcome selections and methodologies for handling the multiple outcomes across all systematic reviews (SRs) of Interdisciplinary Pain Treatment (IPT) due to the complexity. This diversity presents difficulties for healthcare decision makers. Better recommendations about how to select outcomes in SRs (with or without meta-analysis) are needed to explicitly demonstrate the effectiveness of IPT.

Objective

This overview systematically collates the reported outcomes and measurements of IPT across published SRs and identifies the methodological characteristics. Additionally, we provide some suggestions on framing the selection of outcomes and on conducting SRs of IPT.

Methods

Three electronic databases (PubMed, Cochrane Library, and Epistemonikos) and the PROSPERO registry for ongoing SR were supplemented with hand-searching ending on 30 September 2021.

Results

We included 18 SRs with data on 49007 people from 356 primary randomised controlled trials (RCTs); eight were followed by meta-analysis and ten used narrative syntheses of data. For all the SRs, pain was the most common reported outcome (72%), followed by disability/functional status (61%) and working status (61%). Psychological well-being and quality of life were also reported in half of the included SR (50%). The core outcome domains according to VAPAIN, IMMPACT, and PROMIS were seldom met. The methodological quality varied from critically low to moderate according to AMSTAR2. The AMSTAR2 rating was negatively correlated to the number of outcome domains in PROMIS, and VAPAIN was positively correlated with IMMPACT and PROMIS, indicating the intercorrelations between the reported outcomes.

Conclusion

This systematic overview showed wide-ranging disparity in reported outcomes and applied outcome domains in SRs evaluating IPT interventions for chronic pain conditions. The intercorrelations between the reported outcomes should be appropriately handled in future research. Some approaches are discussed as well.

Clinical Guidance to Optimize Work Participation After Injury or Illness: The Role of Physical Therapists

Work rehabilitation refers to the process of assisting workers to remain at work or return to work (RTW) in a safe and productive manner, while limiting the negative impact of restricted work, unemployment, and work disability. The primary purpose of this clinical practice guideline (CPG) is to systematically review available scientific evidence and provide a set of evidence-based recommendations for effective physical therapy evaluation, treatment, and management of individuals experiencing limitations in the ability to participate in work following injury or illness. J Orthop Sports Phys Ther 2021;51(8):CPG1-CPG102. doi:10.2519/jospt.2021.0303.

[Stay at Work - Feasibility and Acceptance of a Part-Time Medical Rehabilitation]

PURPOSE

Back pain is associated with significant impairments of participation, which should be prevented by medical rehabilitation programs. The existing evidence shows that the German rehabilitation model is not effective for all target groups. In addition to intensified measures for patients with a high risk of failed return to work, a less intense rehabilitation form could be useful for patients with moderate disabilities. Therefore, in this study the feasibility of a part-time medical rehabilitation (German abbreviation: BbR) was examined. The BbR was designed as a closed group program with a therapy duration of 48 hours (2 appointments per week over 12 weeks). Furthermore, different access paths to BbR as well as the effects were focused.

METHODS

Twelve groups with 6 to 12 participants each were planned in 3 outpatient rehabilitation centers. In addition to the regular application process, insured persons were recruited via the network of rehabilitation centers as well as the company service of the German Pension Insurance. The BbR focused on employed patients who were not on sick-leave and had the need for rehabilitation due to back pain. The evaluation was multi-perspective and multi-methodical. All participants completed questionnaires at admission, while and at discharge of the BbR. In addition, discussions in groups were conducted with representatives of the rehabilitation centers, the pension insurance and employers.

RESULTS

In total, 7 groups with 56 participants could be realized in 2 rehabilitation centers. The typical BbR-participant was female, married, without children, 48 years old and working full for medium-sizes enterprise without shift work. The majority had no or minor no time of sick-leave in the year prior to rehabilitation. 59% of them were recruited by the rehabilitation centers; only few persons were assigned by the pension insurance. Two thirds would not have applied for a medical rehabilitation without the offer of BbR. Overall, the participants were very satisfied with the BbR. However, the compatibility of the BbR with the job and everyday life was perceived as a challenge. A pre-post comparison showed moderate to strong differences in self-rated health, pain, functional status and work ability.

CONCLUSION

The BbR seems to be a useful additional concept in the German rehabilitation system for patients with moderate disabilities. Before dissemination, the identified challenges should be solved. This applies in particular to the recruitment and compatibility of rehabilitation with work and everyday life.

Implementation of the Ottawa Hospital Pain Clinic stepped care program: A preliminary report

BACKGROUND

Access to multidisciplinary pain management treatment in Canada is limited, with wait times up to 4 years. Stepped care approaches to mental health treatment have led to substantial reduction and elimination of wait times and may be applicable to chronic pain settings. There is no unifying framework for stepped care chronic pain programs. A systematic review of the efficacy of stepped care in chronic pain management conducted by the Canadian Agency for Drugs and Technologies reported varied results that may be due to heterogeneous stepped care models across facilities.

AIM

We propose a unifying framework for multidisciplinary stepped care chronic pain programs and present its application at The Ottawa Hospital Pain Clinic. The Ottawa Hospital stepped care framework is an eight-tiered approach that allows patients the opportunity to decide collaboratively with a health care professional which treatment program will best suit their needs for the management of chronic pain. As levels of stepped care increase, the time and resource commitment to each step will also increase. Treatment is stepped up or down, depending on patient needs.

METHOD

This is a descriptive case study.

RESULTS

Implementing the interprofessional model of care with the stepped care program has eliminated wait times for access to The Ottawa Hospital Pain Clinic Interprofessional Chronic Pain Management Program and has improved communication between professions of the interprofessional team, resulting in better care for patients.

CONCLUSION

More research is needed to further develop and evaluate the clinical efficacy of stepped care to manage chronic pain.

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.

The clinical utility of repetitive transcranial magnetic stimulation in reducing the risks of transitioning from acute to chronic pain in traumatically injured patients

Pain is a multifaceted condition and a major ongoing challenge for healthcare professionals having to treat patients in whom pain put them at risk of developing other conditions. Significant efforts have been invested in both clinical and research settings in an attempt to demystify the mechanisms at stake and develop optimal treatments as well as to reduce individual and societal costs. It is now universally accepted that neuroinflammation and central sensitization are two key underlying factors causing pain chronification as they result from maladaptive central nervous system plasticity. Recent research has shown that the mechanisms of action of repetitive transcranial magnetic stimulation (rTMS) make it a particularly promising avenue in treating various pain conditions. This review will first discuss the contribution of neuroinflammation and central sensitization in the transition from acute to chronic pain in traumatically injured patients. A detailed discussion on how rTMS may allow the restoration from maladaptive plasticity in addition to breaking down the chain of events leading to pain chronification will follow. Lastly, this review will provide a theoretical framework of what might constitute optimal rTMS modalities in dealing with pain symptoms in traumatically injured patients based on an integrated perspective of the physiopathological mechanisms underlying pain.

Treatment Efficacy, Clinical Utility, and Cost-Effectiveness of Multidisciplinary Biopsychosocial Rehabilitation Treatments for Persistent Low Back Pain: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVES

To review the current literature on the treatment efficacy, clinical utility, and cost-effectiveness of multidisciplinary biopsychosocial rehabilitation (MBR) for patients suffering from persistent (nonspecific) lower back pain (LBP) in relation to pain intensity, disability, health-related quality of life, and work ability/sick leave.

METHODS

We carried out a systematic search of Web of Science, Cochrane Library, PubMed Central, EMBASE, and PsycINFO for English- and German-language literature published between January 2010 and July 2017. Study selection consisted of exclusion and inclusion phases. After screening for duplication, studies were excluded on the basis of criteria covering study design, number of participants, language of publication, and provision of information about the intervention. All the remaining articles dealing with the efficacy, utility, or cost-effectiveness of intensive (more than 25 hours per week) MBR encompassing at least 3 health domains and cognitive behavioral therapy-based psychological education were included.

RESULTS

The search retrieved 1199 publications of which 1116 were duplicates or met the exclusion criteria. Seventy of the remaining 83 articles did not meet the inclusion criteria; thus 13 studies were reviewed. All studies reporting changes in pain intensity or disability over 12 months after MBR reported moderate effect sizes and/or p-values for both outcomes. The effects on health-related quality of life were mixed, but MBR substantially reduced costs. Overall MBR produced an enduring improvement in work ability despite controversy and variable results.

CONCLUSIONS

MBR is an effective treatment for nonspecific LBP, but there is room for improvement in cost-effectiveness and impact on sick leave, where the evidence was less compelling.

Psychological treatments for return to work in individuals on sickness absence due to common mental disorders or musculoskeletal disorders: a systematic review and meta-analysis of randomized-controlled trials

Purpose

Common mental disorders (CMDs) and musculoskeletal disorders are highly prevalent in the population and cause significant distress and disability, and high costs to society. The main objective of this systematic review and meta-analysis was to examine the outcome and comparative effectiveness of psychological interventions in reducing sickness absence (SA) due to CMDs or musculoskeletal disorders, compared to a waitlist control group, usual care or another clinical intervention.

Methods

We reviewed 3515 abstracts of randomized controlled trials published from 1998 to 2017. Of these, 30 studies were included in the analysis.

Results

The psychological interventions were overall more effective than treatment as usual in reducing SA (small effect sizes), but not compared to other clinical interventions. Results were similar for studies on CMDs and musculoskeletal pain. A few significant moderating effects were found for treatment-specific variables. However, these were  difficult to interpret as they pointed in different directions.

Conclusion

There was a small but significant effect of psychological treatments in reducing SA. We identified areas of improvement such as methodological problems among the included studies and failure to specifically address RTW in the interventions that were evaluated. Clinical implications of the findings, and ways of improving methodological rigour of future studies are discussed.

Electronic supplementary material

The online version of this article (10.1007/s00420-018-1380-x) contains supplementary material, which is available to authorized users.

Work Outcomes in Patients Who Stay at Work Despite Musculoskeletal Pain

Purpose To assess self-reported work impacts and associations between psychosocial risk factors and work impairment amongst workers seeking care for musculoskeletal pain while continuing to work. Methods Patients were recruited from Musculoskeletal Assessment Clinics at 5 hospitals across Ireland. Participants completed questionnaires including assessments of work impairment (Work Productivity and Activity Impairment Questionnaire), work ability (single item from the Work Ability Index) and work performance (Work Role Functioning Questionnaire; WRFQ). Logistic and hierarchical regressions were conducted to analyse the relation between psychosocial variables and work outcomes. Results 155 participants (53.5% female; mean age = 46.50 years) who were working at the time of assessment completed the questionnaires. Absenteeism was low, yet 62.6% were classified as functioning poorly according to the WRFQ; 52.3% reported having poor work ability. Logistic regression analyses indicated that higher work role functioning was associated with higher pain self-efficacy (OR 1.51); better work ability was associated with older age (OR 1.063) and lower functional restriction (OR 0.93); greater absenteeism was associated with lower pain self-efficacy (OR 0.65) and poorer work expectancy (OR 1.18). Multiple regression analysis indicated that greater presenteeism was associated with higher pain intensity (β = 0.259) and lower pain self-efficacy (β = - 0.385). Conclusions While individuals continue to work with musculoskeletal pain, their work performance can be adversely affected. Interventions that target mutable factors, such as pain self-efficacy, may help reduce the likelihood of work impairment.