Workplace involvement improves return to work rates among employees with back pain on long-term sick leave: a systematic review of the effectiveness and cost-effectiveness of interventions

Effects of work-directed interventions on return-to-work in people on sick-leave for to common mental disorders-a systematic review

PURPOSE

To evaluate the body of evidence of the effects of work-directed interventions on return-to-work for people on sick leave due to common mental disorders (i.e., mild to moderate depression, anxiety, adjustment disorders and reactions to severe stress).

METHODS

The systematic review was conducted in accordance with an a priori developed and registered protocol (Prospero CRD42021235586). The certainty of evidence was assessed by two independent reviewers using the Grading of Recommendations, Assessment, Development and Evaluations.

RESULTS

We reviewed 14,794 records published between 2015 and 2021. Of these, eight RCTs published in eleven articles were included in the analysis.

POPULATION

Working age adults (18 to 64 years), on sick leave due to mild to moderate depression, anxiety, adjustment disorders or reactions to severe stress.

INTERVENTION

Work-directed interventions.

COMPARATOR

No comparator, Standard care, or other measures.

OUTCOME

return to work, number of days on sick leave, income. Overall, the effects of work-focused CBT and work-focused team-based support on RTW resulted in increased or faster return-to-work compared with standard care or no intervention (low certainty of evidence). The effects of Individual Placement and Support showed no difference in RTW compared with standard care (very low certainty of evidence).

CONCLUSION

Interventions involving the workplace could increase the probability of RTW. Areas in need of improvement in the included studies, for example methodological issues, are discussed. Further, suggestions are made for improving methodological rigor when conducting large scale trials.

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.

Which interventions are used in the rehabilitation, return, and stay at work process of aging workers having suffered an occupational injury? A scoping review

BACKGROUND

Considering current labour shortages, the recent increase in the number of aging workers in the labour market is deemed economically beneficial. However, due to specific characteristics (e.g. biological, generational), aging workers take longer to recover and return to work after an occupational injury. Yet, few studies have examined the rehabilitation, return, and stay at work process of aging workers and current knowledge makes it difficult for stakeholders to identify which interventions to use with this specific population.

OBJECTIVE

This study aimed to describe which interventions are used in the rehabilitation, return, and stay at work process of aging workers having suffered an occupational injury.

METHODS

We conducted a five-step scoping review. Five databases were used for the literature search. A qualitative analysis of the retained manuscripts was conducted.

RESULTS

Our analysis led to the extraction of information from seven manuscripts that concern the rehabilitation, return, and stay at work process of aging workers who suffered an occupational injury exclusively. We identified 19 interventions (e.g. work capacity development, work task modifications, permanent part-time work, and alternative roles) and were described according to the different phases of the Cycle of Work Disability Prevention (CWDP).

CONCLUSIONS

This study offers informative, non-prescriptive, and operational interventions useful for stakeholders who support aging workers. Furthermore, it is a knowledge base to develop future projects that promote the rehabilitation, return, and stay at work process of aging workers.

Active engagement of managers in employee RTW and manager-employee relationship: managers' experiences of participating in a dialogue using the Demand and Ability Protocol

PURPOSE

To describe how managers of employees on sick-leave, due to chronic pain conditions, experience participating in a three-party meeting using the Demand and Ability Protocol (DAP) in the return-to-work process.

MATERIALS AND METHODS

This study is based on individual semi-structured interviews with 17 managers of employees with chronic pain. Interviews were conducted after participating in a three-party meeting including the employee, manager, and a representative from the rehabilitation team. The data were analyzed using thematic analysis with an inductive approach.

RESULTS

Two main themes were identified - "to converse with a clear structure and setup" and "to be involved in the employee's rehabilitation." The first theme describe experiences from the conversation, and the second theme reflected the managers' insights when being involved in the employee's rehabilitation. The themes comprise 11 sub-themes describing how the DAP conversation and the manager's involvement in the rehabilitation may influence the manager, the manager-employee relationship, and the organization.

CONCLUSIONS

This study show, from a manager's perspective, how having a dialogue with a clear structure and an active involvement in the employee's rehabilitation may be beneficial for the manager-employee relationship. Insights from participating in the DAP may also be beneficial for the organization.IMPLICATIONS FOR REHABILITATIONA structured dialogue between the employee, employer, and rehabilitation supports the return to work (RTW) processA structured dialogue and collaboration may strengthen the relationship between the manager and employeeAn active engagement of managers in the employeès RTW process is beneficial for the manager-employee relationship, and for the organisationHealthcare professionals should collaborate with the workplace to promote participation of managers.

Six-month cost-effectiveness of adding motivational interviewing or a stratified vocational advice intervention to usual case management for workers with musculoskeletal disorders: the MI-NAV economic evaluation

OBJECTIVES

This study evaluates the six-month cost-effectiveness and cost-benefits of motivational interviewing (MI) or a stratified vocational advice intervention (SVAI) added to usual case management (UC) for workers on sick leave due to musculoskeletal disorders.

METHODS

This study was conducted alongside a three-arm RCT including 514 employed workers on sick leave for at least 50% for ≥ 7 weeks. All participants received UC. The UC + MI group received two MI sessions, and the UC + SVAI group received 1-4 SVAI sessions. Sickness absence days, quality-adjusted life-years (QALYs), and societal costs were measured between baseline and six months.

RESULTS

Adding MI to UC, resulted in incremental cost-reduction of -2580EUR (95%CI -5687;612), and a reduction in QALYs of -0.001 (95%CI -0.02;0.01). Secondly, adding MI to UC resulted in an incremental cost-reduction of -538EUR (95%CI -1358;352), and reduction of 5.08 (95%CI -3.3;13.5) sickness-absence days. Financial return estimates were positive, but not statistically significant. Adding SVAI to UC, resulted in an incremental cost-reduction of -2899 EUR (95% CI -5840;18), and a reduction in QALYs of 0.002 (95% CI -0.02;0.01). Secondly, adding SVAI to UC resulted in an statistically significant incremental cost-reduction of -695 EUR (95% CI -1459;-3), and a reduction of 7.9 (95% CI -0.04;15.9) sickness absence days. Financial return estimates were positive and statistically significant. The probabilities of cost-effectiveness for QALYs were high for adding MI or SVAI (ceiling ratio 0.90).

CONCLUSIONS

In comparison to UC only, adding MI to UC tends to be cost-effective. Adding SVAI to UC is cost-effective for workers on sick leave due to musculoskeletal disorders.

TRIAL REGISTRATION

ClinicalTrials.gov (identifier: NCT03871712).

Preventing Pain and Stress-Related Ill-Health in Employees: A 6-Months Follow-Up of a Psychosocial Program in a Cluster Randomized Controlled Trial

Purpose Pain and stress-related ill-health are major causes of long-term disability and sick leave. This study evaluated the effects of a brief psychosocial program, which previously has been tested for an at-risk population of employees. Methods The Effective Communication within the Organization (ECO) program, where supervisors and employees were trained in communication and problem solving, was compared to an active control consisting of psychoeducative lectures (PE) about pain and stress in a cluster randomized controlled trial. First-line supervisors were randomized to ECO or PE, and a total of 191 mainly female employees with self-reported pain and/or stress-related ill-health were included. The hybrid format programs consisted of 2-3 group sessions. Sick leave data was collected from social insurance registers, before and 6-months after the program. Secondary outcomes (work ability, work limitations, pain-disability risk, exhaustion symptoms, perceived stress, perceived health, quality of life, perceived communication and support from supervisors) were assessed at baseline, post intervention, and at 6-months follow-up. Results No effects were observed on primary or secondary outcome variables. Pain symptoms were common (89%), however a lower proportion (30%) were identified as at risk for long-term pain disability, which might explain the lack of evident effects. The Covid-19 pandemic affected participation rates and delivery of intervention. Conclusion In this study, preventive effects of the ECO program were not supported. Altogether, the findings point at the importance of selecting participants for prevention based on screening of psychosocial risk. Further research on workplace communication and support, and impact on employee health is warranted.

[Holistic clarification of the need for intervention at the interface of rehabilitation and occupational medicine when work participation is at risk]

Introduction

For employees whose work participation is at risk, a comprehensive and workplace-oriented diagnosis is required in order to understand the health problems and to support affected persons with individual solutions. We developed a novel diagnostic service to ensure work participation that combines rehabilitative and occupational health medicine. The aim of this feasibility study was to evaluate the implementation and to analyze changes in health and working ability.

Methods

The observational study (German Clinical Trials Register: DRKS00024522) included employees with health restrictions and limited working ability. Participants received an initial consultation from an occupational health physician, a 2-day holistic diagnostics work-up at a rehabilitation center and up to four follow-up consultations. Questionnaire data collected at the initial consultation and at the first and last follow-up consultations included subjective working ability (0-10 points) and general health (0-10).

Results

Data from 27 participants were analyzed. The participants were 63% female and on average 46 years old (standard deviation, SD = 11.5). From the initial consultation to the final follow-up consultation, participants reported improvement in their general health (difference = 1.52; 95% confidence interval. CI: 0.37-2.67; d = 0.97).

Discussion and conclusion

The model project GIBI offers low-threshold access to a confidential, comprehensive and workplace-oriented diagnostic service to support work participation. Successful implementation of GIBI requires intensive cooperation between occupational health physicians and rehabilitation centers. To evaluate the effectiveness, a randomized controlled trial (n = 210) with a waiting list control group is currently underway.

Disability and return to work after a multidisciplinary intervention for (sub)acute low back pain: A systematic review

Objective

This systematic review aimed to examine pain, functional status and return to work after a multidisciplinary intervention, with or without additional workplace intervention, for (sub)acute low back pain among adults.

Data sources

A comprehensive search was completed (November 2022) in six electronic databases (Embase, MEDLINE, Web of Science, Cochrane, CENTRAL and Scopus) and in the reference list of all identified studies.

Review methods

The search results were screened against predefined eligibility criteria by two independent researchers. Included articles were systematic reviews or randomized controlled trials examining the effect of a multidisciplinary intervention, with or without workplace intervention, in working adults with (sub)acute low back pain. Relevant information was summarized and clustered, and the methodological quality and certainty of evidence were assessed respectively using the RoB 2-tool, the ROBIS tool and the GRADE criteria.

Results

The search resulted in a total of 3020 articles. After the screening process, 12 studies remained (11 randomized controlled trials and 1 systematic review), which studied overall 2751 patients, with a follow-up period of at least 12 months.

Conclusions

A multidisciplinary intervention is favorable compared to usual care for pain intensity and functional status but this is less clear for return to work. Comparable work-related effects were found when comparing a multidisciplinary intervention with a less extensive intervention, whereas uncertainties exist regarding outcomes of pain intensity and functional status. Furthermore, adding a workplace intervention to usual care and subdividing patients based on work-related characteristics seems beneficial for return to work.

Including a Three-Party Meeting Using the Demand and Ability Protocol in an Interdisciplinary Pain Rehabilitation Programme for a Successful Return to Work Process

The Demand and Ability Protocol (DAP) is used in three-party meetings involving an employee, an employer, and a representative from the rehabilitation team. The aim of this study is to investigate the inclusion of an intervention using the DAP in an interdisciplinary pain rehabilitation programme (IPRP) compared to usual care. This non-randomised controlled trial included patients assigned to an IPRP in Sweden. The intervention group received a DAP intervention targeting their work situation in addition to the usual care provided by the IPRP. The control group received IPRP only. Outcome measures were collected from the Swedish Quality Registry for Pain Rehabilitation. Results demonstrated improvements in both groups regarding self-reported anxiety, depression and EQ5D. Sleep was improved in the intervention group but not in the control group. No statistical differences in outcomes were observed between the groups. In conclusion, adding the DAP intervention to IPRP seemed to have the potential to improve sleep among the patients, which may indicate an overall improvement regarding health outcomes from a longer perspective. The results were less clear, however, regarding the work-related outcomes of sickness absence and workability.

Expectations for Return to Work Predict Return to Work in Workers with Low Back Pain: An Individual Participant Data (IPD) Meta-Analysis

Purpose Low back pain is associated with disability and lost productivity due to inability of workers to return to work. Personal recovery expectation beliefs may be associated with return to work outcomes in those with low back pain at high risk for chronic disability. We aimed to (1) assess whether workers' expectations for return to work, following a low back pain episode, are associated with subsequent return to work; and (2) explore the relationships between return to work expectations and other prognostic factors in their association with work outcomes.Methods We conducted an Individual Participant Data (IPD) meta-analysis using data from five prospective cohort studies identified by a Cochrane prognostic factor review. A one-stage IPD meta-analysis approach was applied. Multi-level mixed effects models were used to determine the unadjusted and adjusted associations between expectations and return to work (logistic regression) and time to return to work (parametric survival models with Weibull distribution).Results The final dataset included 2302 participants. Positive expectations for return to work were associated with return to work at follow-up in both unadjusted (Odds Ratio (OR) 2.95; 95% Confidence Interval (CI) 2.21, 3.95) (n = 2071) and comprehensively adjusted (OR 2.01; 95% CI 1.46, 2.77) (n = 1109) models. Similar findings were identified for shorter length of time to return to work in both unadjusted (HR 2.40; 95% CI 2.09, 2.75) (n = 1156) and minimally adjusted (HR 2.43; 95% CI 2.12, 2.79) (n = 1154) models.Conclusions Results suggest workers with low expectations for return to work are at increased risk for long-term work disability.

Stakeholders' experience of collaboration in the context of interdisciplinary rehabilitation for patients with chronic pain aiming at return to work

BACKGROUND AND PURPOSE

Chronic pain is a major reason for sick leave worldwide. Interdisciplinary pain rehabilitation programs (IPRPs), workplace interventions, and stakeholder collaboration may support patients in their return to work (RTW). Few studies have examined stakeholders' experiences of important components in the RTW rehabilitation process for patients with chronic pain, especially in the context of IPRP. This study explores and describes stakeholders' experiences with stakeholder collaboration and factors related to RTW for patients with chronic pain who have participated in IPRP.

METHODS

Six focus groups, three pair and four individual interviews were conducted with a total of 28 stakeholder representatives from three societal and three health care stakeholders. Data were analyzed using qualitative content analysis.

RESULTS

The participants revealed that stakeholder collaboration and a tailored RTW rehabilitation plan were important strategies although they noted that these strategies were not working sufficiently efficient as presently implemented. The different stakeholders' paradigms and organizational prerequisites were described as hindrances of such strategies and that the degree of tailoring depended on individual attitudes.

CONCLUSIONS

More knowledge transfer and flexibility, clearer responsibilities, and better coordination throughout the RTW rehabilitation process may increase the efficiency of stakeholder collaboration and support for patients.Implications for rehabilitationStakeholders need to have a close dialogue initiated before IPRP to be able to reach consensus and shared decision making in the RTW rehabilitation plan throughout the RTW rehabilitation process.Individually tailored solutions based on a thorough assessment of each patient's work ability and context are identified during IPRP and shall be included in the shared RTW rehabilitation plan.The responsibilities of the stakeholders need to be clarified and documented in the RTW rehabilitation plan.The role of RCs should be developed to improve the coordination throughout the patients' RTW rehabilitation process.

A comprehensive diagnostic service to clarify intervention needs when work participation is at risk: study protocol of a randomized controlled trial (GIBI, DRKS00027577)

Background

Effective care services for people whose work participation is at risk require low-threshold access, a comprehensive diagnostic clarification of intervention needs, a connection to the workplace and job demands, and interdisciplinary collaboration between key stakeholders at the interface of rehabilitation and occupational medicine. We have developed a comprehensive diagnostic service to clarify intervention needs for employees with health restrictions and limited work ability: this service is initiated by occupational health physicians.

Methods/design

Our randomized controlled trial tests the effectiveness of a comprehensive diagnostic service for clarifying intervention needs (GIBI: Comprehensive clarification of the need for intervention for people whose work participation is at risk). The comprehensive intervention comprises three elements: initial consultation, two-day diagnostics at a rehabilitation center and follow-up consultations. We will include 210 employees with health restrictions and limited work ability, who are identified by occupational health physicians. All individuals will receive an initial consultation with their occupational health physician to discuss their health, work ability and job demands. After this, half the individuals are randomly assigned to the intervention group and the other half to the waiting-list control group. Individuals in the intervention group start two-day diagnostics, carried out by a multi-professional rehabilitation team in a rehabilitation center, shortly after the initial consultation. The diagnostics will allow first recommendations for improving work participation. The implementation of these recommendations is supported by an occupational health physician in four follow-up consultations. The control group will receive the comprehensive two-day diagnostic service and subsequent follow-up consultations six months after the initial consultation. The primary outcome of the randomized controlled trial is self-rated work ability assessed using the Work Ability Score (0 to 10 points) six months after study inclusion. Secondary outcomes include a range of patient-reported outcomes regarding physical and mental health, impairment, and the physical and mental demands of jobs.

Discussion

This randomized controlled trial is designed to test the effects of a new complex intervention involving a comprehensive clarification of intervention needs in order to promote work participation and prevent the worsening of health and work disability.

Trial registration

German Clinical Trials Register (DRKS00027577, February 01, 2022).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08513-1.

How to strengthen the RTW process and collaboration between patients with chronic pain and their employers in interdisciplinary pain rehabilitation programs? Patients' experiences of the Demand and Ability Protocol

PURPOSE

To explore how patients who participate in an interdisciplinary pain rehabilitation program (IPRP) experience a three-party meeting based on the Demand and Ability Protocol (DAP) to assist in return to work (RTW). The DAP is a employee and his/her immediate manager under the guidance of medical staff with knowledge of the patient's work requirements and his/her current functional ability.

MATERIALS AND METHODS

Data included 18 semi structured individual interviews with persons having chronic pain, who participated in a DAP-dialogue during their IPRP. Thematic analysis was used to analyze the data.

RESULTS

Four themes were identified: A structured dialogue facilitated new insights; the dialogue enabled employer participation; the facilitator enabled experiences of feeling safe during the dialogue; and the dialogue created a link between rehabilitation and work.

CONCLUSIONS

The DAP dialogue was experienced as a supportive measure for RTW where the employer naturally participated in IPRP. The structure of the dialogue supported concrete planning for workplace adaptations. Furthermore, the dialogue enabled a connection between rehabilitation and the activity of work in everyday life. The results reinforce the importance of including efforts close to the workplace in IPRP in order to facilitate rehabilitation outcomes related to RTW.IMPLICATIONS FOR REHABILITATIONA structured collaboration and dialogue between the employee, employer, and rehabilitation supports the RTW process.Collaboration between stakeholders is important and should be intertwined in IPRP to jointly facilitate the employee's RTW.Clarifying the work demands provides motivation for the RTW process.Healthcare professionals should collaborate with the workplace to promote employer participation.

Implementing a Stratified Vocational Advice Intervention for People on Sick Leave with Musculoskeletal Disorders: A Multimethod Process Evaluation

Purpose To perform a process evaluation of a stratified vocational advice intervention (SVAI), delivered by physiotherapists in primary care, for people on sick leave with musculoskeletal disorders participating in a randomised controlled trial. The research questions concerned how the SVAI was delivered, the content of the SVAI and the physiotherapists' experiences from delivering the SVAI. Methods We used qualitative and quantitative data from 148 intervention logs documenting the follow-up provided to each participant, recordings of 18 intervention sessions and minutes from 20 meetings with the physiotherapists. The log data were analysed with descriptive statistics. A qualitative content analysis was performed of the recordings, and we identified facilitators and barriers for implementation from the minutes. Results Of 170 participants randomised to the SVAI 152 (89%) received the intervention and 148 logs were completed. According to the logs, 131 participants received the correct number of sessions (all by telephone) and 146 action plans were developed. The physiotherapists did not attend any workplace meetings but contacted stakeholders in 37 cases. The main themes from the recorded sessions were: 'symptom burden', 'managing symptoms', 'relations with the workplace' and 'fear of not being able to manage work'. The physiotherapists felt they were able to build rapport with most participants. However, case management was hindered by the restricted number of sessions permitted according to the protocol. Conclusion Overall, the SVAI was delivered in accordance with the protocol and is therefore likely to be implementable in primary care if it is effective in reducing sick leave.

Behavioral Medicine Physiotherapy in the Context of Return to Work for Chronic Pain: A Single-Case Experimental Design Study

Effective interventions are needed for return-to-work (RTW) for individuals with chronic pain on long-term sick leave. In this study, a behavioral medicine physiotherapy protocol was systematically replicated and added to workplace components. The intervention was evaluated for fidelity and effects on target activities and work ability. A single-case experimental design was used with five participants. Daily and weekly ratings of personalized target activities at work as well as work ability were carried out throughout the study period of 26–28 weeks. Effects of the behavioral medicine physiotherapy intervention were evaluated for each individual using visual analysis of displayed graphs and quantitative non-overlap methods. Goal achievement for target activities was reviewed. Three participants completed the intervention. The results indicated an effect from the behavioral medicine physiotherapy intervention on task-specific self-efficacy for target activities, but no consistent effect on experience of target activities or work ability. All three participants had increased function in target activities in line with pre-defined goals. Fidelity to the intervention manual was good. Behavioral medicine physiotherapy can be successfully adapted to work disability and was here replicated in an RTW context for individuals with chronic pain. The intervention protocol should be further evaluated in large-scale studies.

Systematic Review of the Impact on Return to Work of Return-to-Work Coordinators

Purpose We conducted a systematic review to understand the impact that return-to-work coordinators (RTWCs) have on return to work (RTW) outcomes for sick/injured workers. Methods MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Science, and ABI Inform were searched from January 1, 2000 to September 16, 2020. Of 2,927 retrieved and screened citations, 14 quantitative articles fulfilled the eligibility and quality criteria. Quality assessment, data extraction, and evidence synthesis followed article screening. Results We focused on the impact of RTWCs for outcomes of work absence, RTW rates, quality of life, and cost-benefit. Our final synthesis included 14 articles. We found strong evidence that work absence duration was reduced when workers had face-to-face contact with a RTWC. As well, there was strong evidence linking face-to-face RTWC interventions with higher RTW rates and moderate evidence that this reduced intervention costs. RTWC interventions involving the identification of barriers and facilitators to RTW also showed promising results. However, only limited evidence was found that RTWCs improved quality of life for workers. Conclusions Our synthesis identifies key features of RTW interventions that improve RTW outcomes. Future high-quality research should measure long-term outcomes of RTWC interventions to evaluate sustainability and consider the nature of work. They should also focus on RTWC impact on worker quality of life assessments and for older workers and workers with chronic health conditions.

What is meant by case management for the return-to-work of workers with musculoskeletal disorders? A scoping review

BACKGROUND

Case management interventions have shown to be effective to prevent musculoskeletal pain and disability, but a single definition has not been achieved, nor an agreed profile for case managers.

OBJECTIVE

To describe the elements that define case management and case managers tasks for return-to-work of workers with musculoskeletal disorders (MSDs).

METHODS

A comprehensive computerized search of articles published in English until February 16, 2021 was carried out in several bibliographic databases. Grey literature was obtained through a search of 13 key websites. A peer-review screening of titles and abstracts was carried out. Full text in-depth analysis of the selected articles was performed for data extraction and synthesis of results.

RESULTS

We identified 2,422 documents. After full-text screening 31 documents were included for analysis. These were mostly European and North American and had an experimental design. Fifteen documents were published between 2010 to 2021 and of these 7 studies were published from 2015. Fifteen elements were identified being the commonest "return-to-work programme" (44.4%) and "multidisciplinary assessment/interdisciplinary intervention" (44.4%). Of 18 tasks found, the most frequent was "establishing goals and planning return-to-work rehabilitation" (57.7%). Eighteen referral services were identified.

CONCLUSIONS

Despite there were several elements frequently reported, some elements with scientific evidence of their importance to deal with MSDs (e.g. early return-to-work) were almost not mentioned. This study proposes key points for the description of case management and case managers tasks.

Workplace improvements to support safe and sustained return to work: Suggestions from a survey of workers with permanent impairments

BACKGROUND

Roughly 10% of occupational injuries result in permanent impairment. After initial return to work (RTW), many workers with permanent impairments face RTW interruption due to reinjury, unstable health, disability, and layoff. This study used open-ended survey data to: (1) explore workplace factors identified by workers as important levers for change, some of which may previously have been unrecognized; and (2) summarize workers' suggestions for workplace improvements to promote sustained RTW and prevent reinjury.

METHODS

This study included data from workers' compensation claims and telephone surveys of 582 Washington State workers who had RTW after a work-related injury involving permanent impairment. The survey was conducted in 2019, about a year after claim closure. We used qualitative content analysis methods to inductively code open-ended survey responses.

RESULTS

The most frequent themes were: safety precautions/safer workplace (18.1%), adequate staffing/appropriate task distribution (16.2%), and safety climate (14.1%). Other frequent themes included ergonomics, rest breaks, job strain, predictability and flexibility in work scheduling practices, employer response to injury, social support, communication, and respect. Many workers reported that they were not listened to, or that their input was not sought or valued. Workers often linked communication deficiencies to preventable deficiencies in safety practices, safety climate, and RTW practices, and also to lack of respect or distrust. In counterpoint, nearly one-third of respondents reported that no change was needed to their workplace.

CONCLUSIONS

Policies and interventions targeting worker-suggested workplace improvements may promote safe and sustained RTW, which is essential for worker health and economic stability.

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.

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.

Workplace Organizational and Psychosocial Factors Associated with Return-to-Work Interruption and Reinjury Among Workers with Permanent Impairment

OBJECTIVES

Roughly 10% of occupational injuries result in permanent impairment and a permanent partial disability (PPD) award. After initial return to work (RTW) following a work injury, many workers with permanent impairment face RTW interruption (breaks in ongoing employment due to reinjury, poor health, disability, lay-off, etc.). Most RTW and reinjury research has focused on worker-level risk factors, and less is known about contextual factors that may be amenable to workplace or workers' compensation (WC)-based interventions. The aim of this study was to identify modifiable organizational and psychosocial workplace factors associated with (i) RTW interruption and (ii) reinjury among workers with a permanent impairment.

METHODS

This retrospective cohort study included WC claims data and survey data for 567 injured workers who RTW at least briefly after a work-related injury that resulted in permanent impairment. Workers were interviewed once by phone, 11-15 months after WC claim closure with a PPD award. Logistic regression models were used to estimate associations between each workplace factor of interest and each outcome, controlling for whole body impairment percentage, gender, age, nativity, educational level, State Fund versus self-insured WC coverage, employer size, union membership, industry sector, and employment duration of current/most recent job.

RESULTS

Twelve percent of workers had been reinjured in their current or most recent job, 12% of workers were no longer working at the time of interview, and <1% of workers reported both outcomes. The most frequently reported reason for RTW interruption was impairment, disability, and/or pain from the previous work injury. Lower reported levels of safety climate, supervisor support, and ability to take time off work for personal/family matters were significantly associated with both RTW interruption and reinjury. Inadequate employer/health care provider communication, perceived stigmatization from supervisors and/or coworkers, and lower levels of coworker support were significantly associated with RTW interruption but not with reinjury. Discomfort with reporting an unsafe situation at work, absence of a health and safety committee, and higher job strain were significantly associated with reinjury, but not with RTW interruption. Inadequate safety training and lack of needed job accommodations were not significantly associated with either outcome. There were no notable or statistically significant interactions between workplace factors and degree of impairment, and no consistent direction of association.

CONCLUSIONS

This study provides evidence that several potentially modifiable organizational and psychosocial factors are associated with safe and sustained RTW among injured workers with work-related permanent impairment. The lack of interaction between any of these workplace factors and degree of impairment suggests that these findings may be generalizable to all workers, and further suggests that workplace interventions based on these findings might be useful for both primary and secondary prevention. Though primary prevention is key, secondary prevention efforts to sustain RTW and prevent reinjury may reduce the considerable health, economic, and social burden of occupational injury and illness.

A bibliometric analysis of occupational low back pain studies from 2000 to 2020

This study aimed to explore the evolution tracks of occupational low back pain (OLBP) studies during 2000 ∼ 2020 through strict and systematic bibliometric analysis. The analysis began with data retrieval in Web of Science using defined search terms associated with OLBP. Bibliometric tools, including BibExcel and CiteSpace, were employed to conduct performance analysis and co-citation network analysis. Totally, 4,127 documents were identified from 2000 to 2020. The United States contributed the most publications. The leading journals mainly focused on medicine and ergonomics. The co-citation analysis illuminated the development of OLBP studies and the top three published keywords were musculoskeletal disorder, risk factors, and fear avoidance. This paper can help researchers have a broader and deeper understanding of OLBP studies, provide a general insight into aggregate performance in the OLBP field, and find further research directions.

Role and Responsibilities of Supervisors in the Sustainable Return to Work of Workers Following a Work-Related Musculoskeletal Disorder

Purpose Supervisors play an important role during the return to work (RTW) of injured workers. Yet little research has been done on the actions associated with this role or the contexts in which they are taken. The purpose of this study was to develop courses of action to promote supervisors' involvement in the process aimed at achieving sustainable RTW for workers following a work-related musculoskeletal disorder (MSD), and to verify their pertinence, feasibility, and applicability in practice. Methods A two-phase qualitative method was used. (1) Secondary content analysis of 46 interviews of 14 workers post-MSD and 32 other actors in the RTW process, conducted during a prior case study, yielded proposals for courses of action composed of specific actions for supervisors. (2) The pertinence, feasibility, and applicability of these courses of action and specific actions were explored, first, through a self-administered questionnaire to initiate individual reflection, and later in greater depth through focus groups to identify the different contexts in which they might be applicable. Thematic analysis was performed for each phase. Results Eight proposed courses of action, including specific concrete actions and conditions influencing supervisors' involvement, were developed by the researchers and generally perceived as pertinent and feasible by the participants. Several aspects of the organizational context appeared to influence implementation of these courses of action within the organizations. Conclusion Organizational context appears to influence the application of these courses of action, as do the conditions under which they are implemented.

The Prevalence and Determinants of Being Offered and Accepting Operational Management Services-A Cohort Study

In Germany, employers are obliged to offer “operational integration management” (OIM) services to employees returning from long-term sick leave. OIM aims to improve employees’ workability and to prevent future sick leave or early retirement. This study examined (i) to what extent OIM services are offered to eligible employees, (ii) to what extent offers are accepted and (iii) the determinants of both outcomes. We used data from a cohort of employees eligible for OIM. Thirty-four potential determinants were assessed in 2013 (i.e., the baseline) using participant reports. In 2015 (i.e., the follow-up), participants were asked (a) whether they had ever been offered OIM services by their employer, and (b) whether they had accepted that offer (i.e., the outcomes). We estimated relative risks by multivariable binomial regression to identify predictors based on backward elimination. In total, 36.0% of the participants were offered OIM services and 77.2% of them accepted that offer. The likelihood of an OIM offer at follow-up was elevated in participants with mental impairment, cancer or long-term absenteeism and increased with organizational justice, neuroticism, and company size. The likelihood of accepting that OIM offer was positively associated with mental impairment and decreased with increasing company size.

Higher daily pain severity after emergency department visits is associated with lower return-to-work rates

BACKGROUND

Pain can impair functional status, including a patient's ability to return to work. The purpose of this study was to determine whether there was an association between pain levels and return-to-work status during the first 4 days post-ED discharge in ED patients seen for undifferentiated acute pain.

METHODS

This secondary analysis of data from the Acute Management of Pain from the Emergency Department (AMPED) registry included patients who reported working either full-time or part-time. We used Cox regression models to examine the association between daily self-reported minimum and maximum pain scores and first return to work. We used repeated measures logistic regression models to examine the association between daily minimum and maximum pain scores and daily return-to-work status.

RESULTS

Of the 610 employed patients, 481 (78.9%) were employed full-time and 129 (21.1%) part-time. The average delay in returning to work after ED visit was 2.4 days. For all models, higher minimum and maximum daily pain scores predicted lower daily return-to-work rates in the first four days post-ED discharge. The adjusted hazards ratios for first return to work were 0.91 (0.87, 0.96) and 0.93 (0.89, 0.97), while the adjusted odds ratios for daily return-to-work status were 0.80 (0.75, 0.85) and 0.88 (0.83, 0.93) for every one-point increase in minimum and maximum pain scores, respectively.

CONCLUSION

Higher daily pain severity is associated with decreased return-to-work after ED visits for acute pain, highlighting the importance of adequate discharge pain management from the ED.

Exploring expected and perceived facilitators and barriers of an indicated prevention strategy to prevent future long-term sickness absence; a qualitative study among employers and employees

BACKGROUND

An indicated prevention strategy (IPS), consisting of a screening questionnaire and early treatment, was found to be effective for the prevention of future long-term sickness absence (LTSA) in two large Dutch RCT's. This IPS aims to detect employees who have a high risk to become absent, and subsequently offer them early treatment. Despite the overall effectiveness, only a few companies have implemented this strategy so far. This suggests that companies may not be convinced of the (cost) effectiveness of this strategy yet. In companies where IPS has been implemented, screenings uptake and adherence to early treatment appeared to be moderate, indicating that both employees and employers might perceive barriers.

METHODS

The aim of this qualitative study was to explore the expected and perceived facilitators and barriers for the implementation of the IPS. Semi-structured interviews were conducted with 9 employers and 11 employees (acquainted and unacquainted with IPS) from large companies. Purposive sampling was used to recruit participants. All interviews were transcribed and analyzed thematically.

RESULTS

The employers believed they were primarily responsible for psychological and work-related health complaints and SA, while the employees felt responsible for health complaints related to their lifestyle. According to the employees, the responsibility of the employer was solely related to work-related health. This finding exposed a relation with the health culture, which was solely based on creating a safe work environment, omitting psychological health issues. The efficacy of this IPS regarding reducing SA was estimated positive, however, the efficacy regarding LTSA was questioned. Fear of a privacy breach was often mentioned by the respondents as an important barrier.

CONCLUSIONS

This study showed that the health culture within a company may be important for the perceived responsibility towards SA and health. A health culture which primarily focuses on physical complaints may raise barriers for the adoption and implementation of this preventive strategy. Participant' perceptions of the nature of LTSA and the fact that not all participants were familiar with the exact content and phasing of IPS may have doubted the efficacy regarding LTSA. This study provides important clues for future and improved implementation of IPS.

Work disability negotiations between supervisors and occupational health services: factors that support supervisors in work disability management

PURPOSE

A work disability negotiation takes place between a supervisor, the disabled employee and the occupational health service (OHS) to support the disabled employee in returning to their work, often with temporary work accommodation. The objective of this study was to define the factors of a work disability negotiation with OHS that supported or hindered supervisors in their task/role in work disability management.

METHODS

The study setting comprised two parts: the creation of survey questions and the actual survey of supervisors (N = 254) from six public and private organizations in Finland. Of these, 133 (52%) had participated in one or more work disability negotiations. The responses covered about 240 work disability cases and considerably more negotiations.

RESULTS

The study identified four key elements that the supervisors expressed as major success factors in the negotiations. First, it was crucial that the supervisors learned about the employee's health restrictions and understood the issues relating to their work disability. Second, the parties should aim for common solutions and conclusions through collaboration. Third, active participation of all the negotiation parties is important. The supervisors gave a high rating to OHS taking their views seriously. Last, the supervisors appreciated collaboration in a constructive atmosphere.

CONCLUSION

In order for a negotiation to help supervisors in their challenges, it should reach solutions, conclusions and a restructured comprehension of the work disability problem in a constructive atmosphere and with active communication between stakeholders.

Managing the Intervention Costs of Musculoskeletal Disorders in the Hospital Workplace

OCCUPATIONAL APPLICATIONSThis study demonstrates the applicability of multicriteria tools to solve occupational health and safety (OSH) problems related to cost management in the healthcare sector. To the best of our knowledge, this is the first work in which linear programming and established methods for risk assessment of work-related musculoskeletal disorders (i.e., the Key Item Method) have been combined with the knowledge and experience of the corresponding safety engineer (or OSH auditor or consultant). The ease of implementation of the whole process facilitates its future utilization in working practice without adding an undue burden on existing OSH practices.

The Association Between Early Postoperative Leg Pain Intensity and Disability at 1-Year and 2-Year Follow-Up After First-Time Lumbar Discectomy

STUDY DESIGN

Longitudinal cohort study.

OBJECTIVES

To investigate whether a cutoff point in leg pain intensity measured preoperatively or at early follow-up could identify patients at risk of poor outcomes in terms of disability at 1-year and 2-year follow-up after first-time lumbar discectomy, and to identify the characteristics associated with early postoperative leg pain intensity.

METHODS

From 2010 to 2013, 556 patients underwent lumbar discectomy. Leg pain intensity was measured preoperatively and at early postoperative follow-up and dichotomized according to an established cutoff point on a 0 to 100 visual analogue scale (mild <30, moderate/severe ≥30). The outcome measurement was Oswestry Disability Index (ODI). Generalized estimating equations modelling established the association between leg pain intensity and ODI. Characteristics associated with early postoperative leg pain intensity were identified using common hypothesis tests.

RESULTS

Moderate/severe leg pain intensity at early follow-up showed a statistically significant association with higher ODI at 1-year and 2-year follow-up compared to mild leg pain intensity (median [interquartile range]: 24 [26] and 26 [26] versus 12 [18] and 10 [20], respectively). Patients reporting moderate/severe leg pain intensity were more often smokers, were more prone to receive social benefits, and were more prone to have chronic back pain. The preoperative measurement of leg pain intensity showed inferior associations.

CONCLUSION

The proposed cutoff point in leg pain intensity at early follow-up can identify patients at risk of disability at both 1-year and 2-year follow-up after first-time discectomy. Future research should be undertaken to investigate whether patients with moderate/severe leg pain intensity at early postoperative follow-up could benefit from additional or more intensive postoperative interventions.

Return on Investment (ROI) and Development of a Workplace Disability Management Program in a Hospital-A Pilot Evaluation Study

The progressive ageing of the working population and the increase in related chronic diseases tend to affect working capacity. The aim of this study was to evaluate a Workplace Disability Management Program (WDMP) within a pediatric hospital. Absenteeism due to healthcare workers’ (HCWs) pre- and post- WDMP and the related costs were used for the program evaluation. The Return on Investment (ROI), the Break-Even Analysis (BEA) and the value of the average annual productivity of HCWs who took advantage of the Disability Management (DM) interventions to assess the economic impact of the program, were also used. The HCWs enrolled in the program were 131 (approximately 4% of hospital staff), of which 89.7% females and with an average age of 50.4 years (SD ± 8.99). Sick leave days of the HCWs involved decreased by 66.6% in the year following the end of WDMP compared to the previous one (p < 0.001). The total estimated cost reduction of absenteeism is 427,896€ over a year. ROI was equal to 27.66€. BEA indicated that the break-even point was reached by implementing the program on 3.27 HCWs. The program evaluation demonstrated the particular effectiveness of the implemented WDMP model, acting positively on the variables that affect productivity and the limitation to work.

Occupational advice to help people return to work following lower limb arthroplasty: the OPAL intervention mapping study

BACKGROUND

Hip and knee replacements are regularly carried out for patients who work. There is little evidence about these patients' needs and the factors influencing their return to work. There is a paucity of guidance to help patients return to work after surgery and a need for structured occupational advice to enable them to return to work safely and effectively.

OBJECTIVES

To develop an occupational advice intervention to support early recovery to usual activities including work that is tailored to the requirements of patients undergoing hip or knee replacements. To test the acceptability, practicality and feasibility of this intervention within current care frameworks.

DESIGN

An intervention mapping approach was used to develop the intervention. The research methods employed were rapid evidence synthesis, qualitative interviews with patients and stakeholders, a prospective cohort study, a survey of clinical practice and a modified Delphi consensus process. The developed intervention was implemented and assessed during the final feasibility stage of the intervention mapping process.

SETTING

Orthopaedic departments in NHS secondary care.

PARTICIPANTS

Patients who were in work and intending to return to work following primary elective hip or knee replacement surgery, health-care professionals and employers.

INTERVENTIONS

Occupational advice intervention.

MAIN OUTCOME MEASURES

Development of an occupational advice intervention, fidelity of the developed intervention when delivered in a clinical setting, patient and clinician perspectives of the intervention and preliminary assessments of intervention effectiveness and cost.

RESULTS

A cohort study (154 patients), 110 stakeholder interviews, a survey of practice (152 respondents) and evidence synthesis provided the necessary information to develop the intervention. The intervention included information resources, a personalised return-to-work plan and co-ordination from the health-care team to support the delivery of 13 patient and 20 staff performance objectives. To support delivery, a range of tools (e.g. occupational checklists, patient workbooks and employer information), roles (e.g. return-to-work co-ordinator) and training resources were created. Feasibility was assessed for 21 of the 26 patients recruited from three NHS trusts. Adherence to the defined performance objectives was 75% for patient performance objectives and 74% for staff performance objectives. The intervention was generally well received, although the short time frame available for implementation and concurrent research evaluation led to some confusion among patients and those delivering the intervention regarding its purpose and the roles and responsibilities of key staff.

LIMITATIONS

Implementation and uptake of the intervention was not standardised and was limited by the study time frame. Evaluation of the intervention involved a small number of patients, which limited the ability to assess it.

CONCLUSIONS

The developed occupational advice intervention supports best practice. Evaluation demonstrated good rates of adherence against defined performance objectives. However, a number of operational and implementation issues require further attention.

FUTURE WORK

The intervention warrants a randomised controlled trial to assess its clinical effectiveness and cost-effectiveness to improve rates and timing of sustained return to work after surgery. This research should include the development of a robust implementation strategy to ensure that adoption is sustained.

STUDY REGISTRATION

Current Controlled Trials ISRCTN27426982 and PROSPERO CRD42016045235.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 45. See the NIHR Journals Library website for further project information.

Managing work participation for people with rheumatic and musculoskeletal diseases

Improving work participation for individuals with rheumatic and musculoskeletal diseases (RMDs), has gained increasing interest over the last 10 years. New approaches are based upon increasing adoption of a biopsychosocial approach to improving work participation, incorporating evidence that health professionals within multidisciplinary teams have a key and critical role. In particular, interaction between health professionals and employers, and rehabilitation services that are linked to the workplace are key elements for improving work participation for people with RMDs. This review outlines recent research that underpins approaches for health professionals to develop their role in improving work participation for people with RMDs based on recent research; it outlines how to measure work-related outcomes in clinical practice, models of work participation, and approaches for health professionals to improve work participation outcomes. The potential for developing the role of health professionals in future years is also outlined.

Return to work and recovery time analysis after outpatient endoscopic lumbar transforaminal decompression surgery

BACKGROUND

This study aimed to analyze the return to work (RTW) and recovery time (RT) to narcotic independence following outpatient endoscopic decompression for contained lumbar herniated disc causing sciatica-type low back and leg pain.

METHODS

A retrospective study of 442 patients with symptomatic contained lumbar herniated disc was treated with the transforaminal endoscopic decompression surgery. The mean follow-up was 33.5 months, ranging from 24 to 85 months. The patients' age ranged from 30 to 85 years, with a mean age of 40.9 years. Statistical analysis of pre- and postoperative VAS, Macnab outcomes, improvement of postoperative walking endurance was performed. RTW rates were correlated with the type of work as classified according to energy consumption per minute (Kcal/min) as Light, Medium, and Heavy using guidelines adopted from the U.S. Department of Labor. Kaplan-Meier (KM) survival tables were calculated, and curves were plotted using IBM SPSS 25.0 to graphically illustrate the diverse RTW and RT dynamic when analyzed by the clinical outcome and the type of work performed by the patient preoperatively.

RESULTS

Excellent (237/442) and Good (133/442) results were obtained in 83.7% (370/442) of patients. Fair results were reported by 43 patients (9.7%), and Poor results by 29 (6.6%), respectively. The mean preoperative VAS was 8.08. The mean postoperative VAS was significantly reduced to 2.55 (P<0.0001). The overall RTW rate was 92.5% (409/442). Patients performing Heavy (RTW rate =87.5%) and Medium (RTW rate =86.0%) work had a lower RTW rate than patients who were performing Light jobs (370/442; RTW rate =95.8%). Preoperatively, only 31.7% (140/442) had unlimited walking endurance. Postoperative walking endurance was unlimited in 77.4% (342/442; P<0.0001). Another 20.4% (90/442) of patients had pain-free walking endurance up to one mile. K-M analysis showed an estimated median RTW of 6 days for Excellent, 9 days for Good, 17 days for Fair, and 18 days for Poor Macnab outcomes. RTW analysis by the type of work showed estimated median RTW of 20 days for patients in the Heavy, 13 days in the Medium, and 6 days in the Light workgroup. The mean RT was 33.52 days in the Heavy, 19.17 days in the Medium, and 9.86 days in the Light workgroup (P<0.0001). The mean RTW was 22.27 days (P=0.008) in the Heavy, 13.97 days (P=0.004) in the Medium, and 7.58 days (P=0.004) in the Light workgroup. Postoperative irritation of the dorsal root ganglion (DRG) occurred in 68 of the 442 study patients (15.38%). DRG irritation delayed RTW to a mean of 18.94 days (P<0.0001) and RT to 15.31 days (P<0.001).

CONCLUSIONS

Patient RTW and RT data are "real-world" economic indicators of successful clinical outcomes with the lumbar endoscopic transforaminal decompression procedure and compare favorably to previously reported benchmarks for other types of translaminar surgeries. These median postoperative RTW and RT times with narcotic independence were on the order of 10 days or less in the vast majority of patients Excellent and Good outcomes (83.7%). The most relevant surgical predictor of delayed RTW and RT is a postoperative DRG irritation which predominantly affected patients adversely in the Medium and Heavy workgroups. These RTW and RT data may assist in the management of return-to-work expectations with the spinal endoscopy procedure.

Temporary Disability Pension, RTW-Intentions, and RTW-Behavior: Expectations and Experiences of Disability Pensioners over 17 Months

Purpose: Individuals receiving a temporary disability pension (TDP) should get the opportunity to return to work (RTW). The current study aims to determine the factors contributing to RTW. Methods: 453 individuals on TDP were interviewed at three measurement points (T1, T2 = T1 + approximately 7 months, T3 = T1 + approximately 17 months). Socio-demographics, psychological predictors, and current work status (maintained TDP, permanent disability pension, old-age pension, employed, or receipt of other benefits) were assessed. Results: Throughout the duration of the study, only four of the former temporary disability pensioners returned to work, and an additional seven made themselves available to the labor market. These were individuals who were younger, in TDP for a shorter period of time, and reported a higher RTW-intention. Higher RTW-intention was cross-sectionally associated with younger age, shorter TDP duration, and more positive outcome expectancies. Additionally, study participants who expected that medical rehabilitation would help them RTW were more motivated to RTW. An increase in RTW-intention over 17 months was related to younger age and better health. Conclusion: Personal factors such as self-efficacy and job-related variables appear less important for RTW than age and subjective health status. The observed RTW rates call for early support and tailored medical rehabilitation interventions that help individuals prevent functional limitations, overcome disability, and facilitate RTW.

Sustainable Return to Work: A Systematic Review Focusing on Personal and Social Factors

Purpose A systematic review was conducted to evaluate the impact of important personal and social factors on sustainable return to work (RTW) after ill-health due musculoskeletal disorders (MSDs) and common mental disorders (CMDs) and to compare the effects of these personal and social factors across both conditions. Sustainable RTW is defined as a stable full-time or part-time RTW to either original or modified job for a period of at least 3 months without relapse or sickness absence re-occurrence. Methods A literature search was conducted in 13 databases and 79 studies were selected for the review, of which the methodological design was graded as very high, high and low quality. Results The most consistent evidence for achieving sustainable RTW for both MSDs and CMDs was from support from line managers or supervisors and co-workers, positive attitude, self-efficacy, young age and higher education levels. Job crafting, economic status, length of absence and job contract/security showed promising results, but too few studies exist to draw definite conclusions. Results regarding gender were inconsistent. Conclusions This review demonstrates that a variety of personal and social factors have positive and negative influences on sustainable RTW. We suggest that the social environment and how it interrelates with personal factors like attitudes and self-efficacy should be studied in more detail in the future as the inter-relationship between these factors appears to impact positively on sustainable RTW outcomes. Areas for future research include more high-quality studies on job crafting, economic status/income, length of absence, job contract/security and gender.

Early occupational intervention for people with low back pain in physically demanding jobs: A randomized clinical trial

BACKGROUND

Occupational medicine seeks to reduce sick leave; however, evidence for an add-on effect to usual care is sparse. The objective of the GOBACK trial was to test whether people with low back pain (LBP) in physically demanding jobs and at risk of sick leave gain additional benefit from a 3-month complex intervention that involves occupational medicine consultations, a work-related evaluation and workplace intervention plan, an optional workplace visit, and a physical activity program, over a single hospital consultation and an MRI.

METHODS AND FINDINGS

We enrolled people from the capital region of Denmark to an open-label, parallel-group randomized controlled trial with a superiority design from March 2014 through December 2015. In a hospital setting 305 participants (99 women) with LBP and in physically demanding jobs were randomized to occupational intervention (n = 153) or no additional intervention (control group; n = 152) added to a single hospital consultation giving a thorough explanation of the pain (i.e., clinical examination and MRI) and instructions to stay active and continue working. Primary outcome was accumulated sick leave days due to LBP during 6 months. Secondary outcomes were changes in neuropathic pain (painDETECT questionnaire [PDQ]), pain 0-10 numerical rating scale (NRS), Fear-Avoidance Beliefs Questionnaire (FABQ), Roland-Morris Disability Questionnaire (RMDQ), Short Form Health Survey (SF-36) for physical and mental health-related quality of life (HRQoL), and self-assessed ability to continue working (range 0-10). An intention-to-treat analysis of sick leave at 6 months showed no significant difference between groups (mean difference in days suggestively in favor of no additional intervention: 3.50 [95% CI -5.08 to 12.07], P = 0.42). Both groups showed significant improvements in average pain score (NRS), disability (RMDQ), fear-avoidance beliefs about physical activities and work (FABQ), and physical HRQoL (SF-36 physical component summary); there were no significant differences between the groups in any secondary outcome. There was no statistically significant improvement in neuropathic pain (PDQ score), mental HRQoL (SF-36 mental component summary), and self-assessed ability to stay in job. Four participants could not complete the MRI or the intervention due to a claustrophobic attack or accentuated back pain. Workplace visits may be an important element in the occupational intervention, although not always needed. A per-protocol analysis that included the 40 participants in the intervention arm who received a workplace visit as part of the additional occupational intervention did not show an add-on benefit in terms of sick leave (available cases after 6 months, mean difference: -0.43 days [95% CI -12.8 to 11.94], P = 0.945). The main limitations were the small number of sick leave days taken and that the comprehensive use of MRI may limit generalization of the findings to other settings, for example, general practice.

CONCLUSIONS

When given a single hospital consultation and MRI, people in physically demanding jobs at risk of sick leave due to LBP did not benefit from a complex additional occupational intervention. Occupational interventions aimed at limiting biopsychological obstacles (e.g., fear-avoidance beliefs and behaviors), barriers in the workplace, and system barriers seem essential to reduce sick leave in patients with LBP. This study indicates that these obstacles and barriers may be addressed by thorough usual care.

TRIAL REGISTRATION

Clinical Trials.gov: NCT02015572.

Acceptability and Feasibility of a Shared Decision-Making Model in Work Rehabilitation: A Mixed-Methods Study of Stakeholders' Perspectives

Purpose To establish the acceptability and feasibility of implementing a shared decision-making (SDM) model in work rehabilitation. Methods We used a sequential mixed-methods design with diverse stakeholder groups (representatives of private and public employers, insurers, and unions, as well as workers having participated in a work rehabilitation program). First, a survey using a self-administered questionnaire enabled stakeholders to rate their level of agreement with the model's acceptability and feasibility and propose modifications, if necessary. Second, eight focus groups representing key stakeholders (n = 34) and four one-on-one interviews with workers were conducted, based on the questionnaire results. For each stakeholder group, we computed the percentage of agreement with the model's acceptability and feasibility and performed thematic analyses of the transcripts. Results Less than 50% of each stakeholder group initially agreed with the overall acceptability and feasibility of the model. Stakeholders proposed 37 modifications to the objectives, 17 to the activities, and 39 to improve the model's feasibility. Based on in-depth analysis of the transcripts, indicators were added to one objective, an interview guide was added as proposed by insurers to ensure compliance of the SDM process with insurance contract requirements, and one objective was reformulated. Conclusion Despite initially low agreement with the model's acceptability on the survey, subsequent discussions led to three minor changes and contributed to the model's ultimate acceptability and feasibility. Later steps will involve assessing the extent of implementation of the model in real rehabilitation settings to see if other modifications are necessary before assessing its impact.

Structured physiotherapy including a work place intervention for patients with neck and/or back pain in primary care: an economic evaluation

A cluster-randomized controlled trial, WorkUp, was conducted for working-aged patients at risk of sick leave or on short-term sick leave due to acute/subacute neck and/or back pain in Sweden. The purpose of WorkUp was to facilitate participants to stay at work or in case of sick leave, return-to-work. The aim of this study was to study whether the WorkUp trial was cost-effective. Patients in the intervention and reference group received structured evidence-based physiotherapy, while patients in the intervention group also received a work place dialogue with the employer as an add-on. The participants, 352 in total, were recruited from 20 physiotherapeutic units in primary healthcare in southern Sweden. The economic evaluation was performed both from a healthcare and a societal perspective with a 12-month time frame with extensive univariate sensitivity analyses. Results were presented as incremental cost-effectiveness ratios (ICER) with outcomes measured as quality-adjusted life-years (QALY) and proportion working for at least 4 weeks in a row without reported sick leave at 12-month follow-up. From the healthcare perspective, the ICER was €23,606 (2013 price year) per QALY gain. From the societal perspective the intervention was dominating, i.e.. less costly and more effective than reference care. Bootstrap analysis showed that the probability of the intervention to be cost-effective at €50,000 willingness-to-pay per QALY was 85% from the societal perspective. Structured evidence-based physiotherapeutic care together with workplace dialogue is a cost-effective alternative from both a societal and a healthcare perspective for acute/subacute neck and/or back pain patients.Trial registration ClinicalTrials.gov: NCT02609750.

Early workplace dialogue in physiotherapy practice improved work ability at 1-year follow-up-WorkUp, a randomised controlled trial in primary care

Workplace involvement in rehabilitation for patients with musculoskeletal pain may improve work ability. Convergence Dialogue Meeting (CDM) is a model aimed at helping the patient, the care giver, and the employer to support work ability and return-to-work. Our aim was to study the effect on work ability when adding a workplace dialogue according to CDM in physiotherapy practice for patients with pain in ordinary primary care. We conducted a prospective pairwise cluster randomised controlled trial (ClinicalTrials.gov ID: NCT02609750) in primary care involving 20 primary care rehabilitation units with 1-year follow-up. Adult patients with acute/subacute neck and back pain, worked ≥4 weeks past year and not currently on sick leave or no more than 60 days of sick leave and considered at-risk of sick leave were included (n = 352). All patients received structured physiotherapy and the intervention was the addition of CDM, delivered by the treating physiotherapist. The main confirmatory outcome, work ability (defined as working at least 4 consecutive weeks at follow-up), was assessed by a weekly short text message question on number of sick leave days past week. Work ability was reached by significantly more patients in the intervention group (108/127, 85%) compared with the reference group (127/171, 74%) (P = 0.02). The intervention increased the odds of having work ability at 1-year follow-up, also after adjustment for baseline health-related quality of life (odds ratio 1.85, confidence interval 1.01-3.38). We conclude that an early workplace dialogue in addition to structured physiotherapy improved work ability significantly.

Can the STarT Back Tool predict health-related quality of life and work ability after an acute/subacute episode with back or neck pain? A psychometric validation study in primary care

OBJECTIVES

The predictive ability of the STarT Back Tool (SBT) has not yet been examined among acute/subacute back and/or neck pain in a primary care setting in respect to health-related quality of life (HRQoL) and work ability outcomes. The aim of this study was to evaluate the SBT's predictive validity for HRQoL and work ability outcomes at long-term follow-up in a population with acute/subacute back and/or neck pain.

SETTING

Prospective data from 35 primary care centres in south Sweden during 2013.

PARTICIPANTS

Patients (n=329) with acute/subacute back and/or neck pain, aged 18-67 years, not on sick leave or <60 days of sick leave completed the SBT when applying for physiotherapy treatment. Long-term follow-up measures (median 13 months, range 11-27 months) of HRQoL (EQ-5D) and work ability (Work Ability Score) was completed by 238 patients (72%).

OUTCOMES

The predictive ability of the SBT for HRQoL and work ability outcomes was examined using Kruskal-Wallis test, logistic regression and area under the curve (AUC).

RESULTS

Based on SBT risk group stratification, 103 (43%), 107 (45%) and 28 (12%) patients were considered as low, medium and at high risk, respectively. There were statistically significant differences in HRQoL (p<0.001) and work ability (p<0.001) at follow-up between all three SBT risk groups. Patients in the high risk group had a significantly increased risk of having poor HRQoL (OR 6.16, 95% CI 1.50 to 25.26) and poor work ability (OR 5.08, 95% CI 1.75 to 14.71) vs the low risk group at follow-up. The AUC was 0.73 (95% CI 0.61 to 0.84) for HRQoL and 0.68 (95% CI 0.61 to 0.76) for work ability.

CONCLUSIONS

The SBT is an appropriate tool for identifying patients with a poor long-term HRQoL and/or work ability outcome in a population with acute/subacute back and/or neck pain, and maybe a useful adjunct to primary care physiotherapy assessment and practice.

TRIAL REGISTRATION NUMBER

NCT02609750; Results.

Low back pain

Low back pain affects individuals of all ages and is a leading contributor to disease burden worldwide. Despite advancements in assessment and treatment methods, the management of low back pain remains a challenge for researchers and clinicians alike. One reason for the limited success in identifying effective treatments is the large variation in the manifestations, possible causes, precipitating and maintaining factors, course, prognosis and consequences in terms of activity interference and quality of life. However, despite these challenges, steady progress has been achieved in the understanding of back pain, and important steps in the understanding of the psychological and social risk factors, genetics and brain mechanisms of low back pain have been made. These new findings have given impetus to the development of new diagnostic procedures, evidence-based screening methods and more targeted interventions, which underscore the need for a multidisciplinary approach to the management of low back pain that integrates biological, psychological and social aspects.

Image and perception of physicians as barriers to inter-disciplinary cooperation? - the example of German occupational health physicians in the rehabilitation process: a qualitative study

BACKGROUND

In the German rehabilitation system, primary care physicians (PCPs), occupational health physicians (OPs), and rehabilitation physicians (RPs) fulfill different distinct functions and roles. While effective cooperation can improve outcomes of rehabilitation, the cooperation between these groups of stakeholders has been criticized as lacking or insufficient. This article proposes an approach to understand the low levels of cooperation by examining the role of group perception and group identity in intra-professional cooperation as a barrier to cooperation between physicians in different roles. Group perception was evaluated in terms of (1) negative views about another group of medical specialists and (2) differences between the perception of members and non-members of a medical specialty group. To examine this issue, we focused on the role of OPs in the German rehabilitation process.

METHODS

We implemented a qualitative study design with eight focus group discussions with PCPs, OPs, RPs, and patients (two focus group discussions per stakeholder group; 4-10 participants) and qualitative content analysis. We used the Social Identity Approach by Tajfel and Turner as a theoretical underpinning.

RESULTS

While all protagonists reported a positive perception of their own professional group, we found numerous negative perceptions about other groups, especially regarding OPs. Negative perceptions of OPs included 1) apparent conflict of interest between employer and employee, 2) lack of commitment to patient outcomes, 3) lack of useful specialized knowledge which could have a bearing on rehabilitation outcomes, and 4) distrust on the part of their patients. We also found divergent perceptions regarding roles, responsibilities, and capabilities among the specialist groups. Both negative and conflicting perceptions about roles were characterized as barriers to cooperation by study participants.

CONCLUSION

This example of cooperation between RPs, OPs, and PCPs suggests that negative and diverging perceptions about an out-group could create barriers in intra-professional and inter-disciplinary cooperation between physicians. These perspectives might also be useful in explaining problems at intersections between different specialties. We suggest examining the inter-group dimension of perception-based barriers to cooperation in future interventions to overcome problems caused by intra-professional and inter-disciplinary conflicts in addition to other barriers (i.e. organizational hurdles).

Nationwide implementation of a national policy for evidence-based rehabilitation with focus on facilitating return to work: a survey of perceived use, facilitators, and barriers

Aim: The aim is to assess whether the national policy for evidence-based rehabilitation with a focus on facilitating return-to-work is being implemented in health-care units in Sweden and which factors influence its implementation.Methods: A survey design was used to investigate the implementation. Data were collected at county council management level (process leaders) and clinical level (clinicians in primary and secondary care) using web surveys. Data were analyzed using SPSS, presented as descriptive statistics.Results: The response rate among the process leaders was 88% (n = 30). Twenty-eight percent reported that they had already introduced workplace interventions. A majority of the county councils' process leaders responded that the national policy was not clearly defined. The response rate among clinicians was 72% (n = 580). Few clinicians working with patients with common mental disorders or musculoskeletal disorders responded that they were in contact with a patient's employer, the occupational health services or the employment office (9-18%). Nearly, all clinicians responded that they often/always discuss work-related problems with their patients.Conclusions: The policy had been implemented or was to be implemented before the end of 2015. Lack of clearly stated goals, training, and guidelines were, however, barriers to implementation. Implications for rehabilitationClinicians' positive attitudes and willingness to discuss workplace interventions with their patients were important facilitators related to the implementation of a nationwide policy for workplace interventions/rehabilitation.A lack of clearly stated goals, training, and guidelines were barriers related to the implementation.The development of evidence-based policies regarding rehabilitation and its implementation has to rely on very structured and clear descriptions of what to do, preferably with the help of practice guidelines.Nationwide implementation of rehabilitation policies has to allow time for preparation including communication of goals and competence assurance in a close collaboration with the end users, namely clinicians and patients. AbbreviationsCBTCognitive behavioral therapyCFIRConsolidated framework for implementation researchCMDCommon mental disordersIPTInterpersonal psychotherapyMMRMultimodal rehabilitationRGRehabilitation guaranteeRTWReturn to workSPSSStatistical package for the social sciences.

A concept of psychological work capacity demands: First evaluation in rehabilitation patients with and without mental disorders

BACKGROUND

Work capacity demands are a concept to describe which psychological capacities are required in a job. Assessing psychological work capacity demands is of specific importance when mental health problems at work endanger work ability. Exploring psychological work capacity demands is the basis for mental hazard analysis or rehabilitative action, e.g. in terms of work adjustmentOBJECTIVE:This is the first study investigating psychological work capacity demands in rehabilitation patients with and without mental disorders.

METHODS

A structured interview on psychological work capacity demands (Mini-ICF-Work; Muschalla, 2015; Linden et al., 2015) was done with 166 rehabilitation patients of working age. All interviews were done by a state-licensed socio-medically trained psychotherapist. Inter-rater-reliability was assessed by determining agreement in independent co-rating in 65 interviews. For discriminant validity purposes, participants filled in the Short Questionnaire for Work Analysis (KFZA, Prümper et al., 1994).

RESULTS

In different professional fields, different psychological work capacity demands were of importance. The Mini-ICF-Work capacity dimensions reflect different aspects than the KFZA. Patients with mental disorders were longer on sick leave and had worse work ability prognosis than patients without mental disorders, although both groups reported similar work capacity demands.

CONCLUSIONS

Psychological work demands - which are highly relevant for work ability prognosis and work adjustment processes - can be explored and differentiated in terms of psychological capacity demands.

Measuring the effectiveness of workplace health management programs: An Australian example

The workplace can provide opportunities to support workers in adopting and sustaining health enhancing behaviours. Health promotion programs based at the workplace need not only to achieve this goal but also the continuing support of the employers. This can best be achieved by demonstrating a return on their investment. The aim of this study therefore was to develop an integrated workplace health management program which could be associated with measurable outcomes related to benefitting the institution's "bottom line". This program was based in a metropolitan surgical hospital in Melbourne, Australia from 2006 to 2010 with a total workforce of 1400 employees aged 18-74 years (86% female 14% male), The program followed two key principles of 1) building safe and familiar support networks in order to build a workplace culture where all the workers felt valued. 2) Providing time for individual workers to focus on themselves as a means to achieve early intervention and management of injuries. Insurance data generated by the Workers Compensation Authority identified the following 'bottom line' benefits over three years: injury management costs reduced by 56%; number of compensation Injury claims dropped by 46%; time to return to work post injury reduced by 68%, and; a reduction. in premiums of 43% achieved over a six-year period. Insurers world-wide calculate workers' compensation insurance premiums on injury claims history. It is concluded that such data as these can offer a reliable and 'persuasive' measure of health and injury outcomes, in workplace interventions of this nature.