Things patient’s wish we would say…

Exposure therapy - not so fast buddy!

From what I’ve posted so far this week, you might think that I would propose exposure therapy be something for all therapists to use with people, but no! I think it’s something that only some people will adopt, and it’s only useful for some people. Although all of us can incorporate some aspects of it in our practice, I don’t think everyone is suited to actually doing this type of work.

Some of my colleagues (and probably my kids too!!) would say that I’m ideally suited to doing this type of therapy - I don’t have any qualms about asking someone to do something that may (read usually…!) increase their distress and often their pain. Just hand me a whip and I’ll use it (no, not really!).
But if you are not like this, and do feel a little worried about possibly causing harm, or at least increasing someone’s pain, then don’t feel you have to do it. The reason for this is simple: if you inadvertently suggest, through nonverbal or verbal means, that they do have a good reason to fear doing the activity, then you may well inadvertently reinforce their anxiety.

It’s true that we as health providers are often as fear-avoidant as the people we work with! What I mean is, we tend to be ‘nicer’ and less assertive in our requirements than when we allow people with pain to set goals for themselves and others. Vlaeyen & Linton (2006), and others have identified that treatment providers who have fear-avoidant beliefs themselves are more likely to suggest passive treatments than those who are not. Some years ago it Hazard (1996) found that people who are given no activity restrictions when they return to work actually return to work more quickly than those who are provided with selected activities.

I’ve observed too, that once the exposure process is underway, progress quickly gains pace. So the first few steps on the hierarchy are quite slow, but provided that the person is generalising their skill, they start to set their own goals and these are often quite a lot higher up the hierarchy than I would have put the target!

So, bringing together some of the factors identified in the Craske, et al. (200 article I referred to yesterday, here are some thoughts about ways to make exposure therapy effective.

1. Practicing exposure in different contexts, with and without ‘warning’, and maintaining this exposure over time
2. Encouraging tolerance to experiencing anxiety - it’s OK to not feel entirely comfortable with a movement that has been uncomfortable in the past, it’s just not OK to avoid it!
3. Practicing in different situations with or without feedback and encouragement - it seems that too much verbal feedback can ’seduce’ the person into believing that they have their fear conquered, but this can be a temporary effect that can disappear quite quickly. It seems to be more effective to have a delay between sessions during which the person practices alone than to have multiple practices with support.
4. Avoid the use of ’safety behaviours’ - especially ’special’ movements such as a special ’safe lifting’ technique, but also the presence of another person (especially you!), or special preparations such as counting or breathing or using equipment. Although you may start with this, in the end it’s important that the person learns to do the movement without any props or rituals.
5. Generalising the exposure into the ‘real’ world needs to happen throughout and after the therapy. Integrating the new learning into life is the aim of therapy, but needs to be structured to actually occur. A plan to make this learning happen should be developed and monitored, as well as a ‘relapse’ plan.

I hope you’ve enjoyed this tour through exposure therapy and the pain-related anxiety and avoidance model. I’ll keep you posted on progress with my client - today he made it into the hydrotherapy pool, so here’s hoping he’ll be well on his way to returning to a normal level of activity in the next few months.

Learning to ‘feel the fear and do it anyway’

If ever there was an over-used quote from a pop-psychology book the ‘feel the fear’ quote has to be a prime contender! However, in exposure therapy for kinesiophobia, this is exactly what we are doing. If we don’t activate the feeling of anxiety just a teeny tiny bit, then we are not going to achieve an awful lot!

So, the steps from yesterday are to identify a range of activities that the person doesn’t feel they can do (and therefore avoids doing), get the person to rank them in order from ‘least bothersome’ to ‘most bothersome’ (or whatever scale you want to call it - some people call it the ‘yukkiness’ scale!).

Then it’s time to find out exactly what the person really fears about the movement. To do this, I ask the person ‘what goes through your mind when you think of yourself doing this movement?’ - it can be an image, a phrase, or some sort of prediction. It’s this prediction, or hypothesis, that is being tested in our ‘behavioural experiments’.

By exposing the person to the opportunity to test their belief that something ‘horrible’ or ‘awful’ will happen if they carry out the movement, several things happen:

1. their anxiety level increases initially
2. they get the opportunity to see that their feared consequence either doesn’t happen, or if it does, it is something they can tolerate
3. their elevated anxiety subsides (we simply can’t maintain high levels of anxiety for very long)

It’s important to work out exactly what the person is concerned about.

• Is it that they think some damage will occur? - how will they tell it has?
• Is it that they think their pain will inevitably increase - and more importantly, that this will be ‘horrible’? - what does ‘horrible’ look like or mean?
• Is it that they can see themselves falling, being looked at, being laughed at? - what does this mean to them, or about them?

We can then run through several different ways of addressing their underlying beliefs.

• We can using cognitive therapy to work with their automatic thought, and evaluate the probability that the negative event will happen.

• We can use cognitive therapy to probe more deeply to find out what it means for this event to happen, and perhaps uncover a more significant belief or attitude that can be worked on in therapy.

• We can also find out what the worst possible consequence could be, and why it might be so awful. Or what the most likely consequence could be, and whether they could cope with that.

Having done this, we can then start to ask the person if they’re prepared to see what happens if they try one of the movements that bothers them. This is the ‘behavioural’ part of this process and it’s critical to include this as well as the cognitive aspects indicated above.

Reassuring the person that we are certain that they can handle the situation (that they have the skills not to freak out!), or that we are clear that the harm they think will happen won’t occur gives the person a sense of your confidence in their skills. I always make sure that they do have skills to reduce their physiological arousal - usually using diaphragmatic breathing, and calming self statements - before starting this process. I also make sure that we start low enough on the hierarchy so that their anxiety is only just increased so they don’t refuse altogether.

The activities in the PHODA are daily activities that almost everyone has to do in life. For this reason it’s usually not too hard to get the person to agree that the activity is something they think is important to learn to do. If the person starts to balk, it may be because the activity isn’t that important to them, or that they really lack confidence that they can do it successfully. If this is happening, it’s time to return to exploring importance, and increasing confidence using motivational interviewing strategies. Moving down the hierarchy gives the message to the person that they don’t have the skills to cope, and that they have every right to be afraid, and that you’re not confident that it will be OK.

Then the process is reasonably straightforward.
Demonstrate the movement using efficient biomechanics. Note that I’m not suggesting ’safe’ movements, or ‘proper’ movements - because this suggests that if and only if the person uses the right technique they will be safe. This is a form of safety behaviour that reduces the anxiety that we really want to have present. What safety behaviours do is act as a sort of lucky charm, and when the lucky charm isn’t present, the avoidance that has maintained the fear returns. Nothing is actually learned!

Then ask the person to rate how much concern they have right now about doing the movement.
Continue with asking the person to then rate how strongly they believe that their hypothesis will come true if they do the movement.

Then it’s their turn to do it. I move quite swiftly into this phase, because it’s the anticipation of doing the movement that generates the anxiety. The longer you delay, the more anxiety, the less likely they are to be able to settle their anxiety level down after the movement.

Once they’ve carried the movement out using efficient biomechanics, it’s time to ask them to re-rate their concern about doing the movement, then re-rate the probability that their feared consequence will occur if they do it again. Most times the rating has reduced, but sometimes it hasn’t gone down by much.

If their rating of the probability hasn’t changed, you can ask ‘how often do you think you need to do this to change your rating?’ You can use logic (How many times have you seen people actually fall over when they bend forward? How many times have you fallen over when you bend forward?) or you use other cognitive strategies to help them re-evaluate their belief, then re-test using the behavioural experiment again. You can also ask the person to develop a new experiment that might be a better test of their belief (to make it more likely that their feared outcome occurs).

For a really good article reviewing models of inhibitory learning in exposure therapy, Craske et al. (200 have written ‘Optimizing inhibitory learning during exposure therapy’ for Behaviour Research and Therapy. Worth a read, even if you’re inclined to go glassy-eyed at loads of psychological stuff. But if you’re reading this, you’re probably quite happy to read psychological stuff, so head on over to it!

More tomorrow on exposure therapy - so y’all come back now!

CRASKE, M., KIRCANSKI, K., ZELIKOWSKY, M., MYSTKOWSKI, J., CHOWDHURY, N., BAKER, A. (2008). Optimizing inhibitory learning during exposure therapy. Behaviour Research and Therapy, 46(1), 5-27. DOI: 10.1016/j.brat.2007.10.003

Working with a kinesiophobic person

One of the biggest challenges when working with someone who is fearful of pain and avoids movement is that although it’s very much like any sort of phobia, it differs on one essential point: people who are spider phobic, socially phobic, fearful of flying or heights or whatever are usually aware at some level that their fear is out of proportion to the ‘real’ risk. People who are kinesiophobic (kinesio - movement, phobic - fearful) are much more likely to believe that their fear is realistic and to have their concerns about moving despite pain reinforced both inadvertently and deliberately by others (including health professionals!).

So, to introduce the idea of beginning to move despite fear of pain or harm requires a bit of a delicate touch!

Some people advocate ‘just tell them’, and spend a good deal of time going through a psychoeducational approach about the difference between hurt and harm until they believe they have convinced the person that it’s OK to move. And sometimes this does reduce the ‘threat value’ of pain.
But just as the spider phobic person (and I was one!) is not reassured by the knowledge that in New Zealand we have very few poisonous spiders, and the one or two we do have are quite rare, the person who is afraid of moving when they are sore can remain unconvinced and continue to avoid moving despite the best ‘information’ or education available.

So, what can you do?
Well, let me tell you how I’ve started working with my current client. The man I’m working with is in his late 20’s, he has a slight disc bulge in his lumbar spine, with little evidence of nerve compression, and he has a 12 month history of low back pain.

His back pain started after he lifted some timber at work, and tripped, falling onto his side with the wood on top of him. He has had a very thorough orthopaedic examination, been seen by a neurosurgeon who doesn’t want to pursue surgery because of the somewhat equivocal findings both neurologically and on imaging studies. He’s now being seen by me and a physiotherapist, and having his low mood treated with pharmacology. He uses paracetamol for pain relief but no other medications.

Functionally, he still has good power in his lower limbs, has no neurological findings, but his activity level and movement patterns are extremely limited. He sits for about 3 - 5 minutes before getting up and slowly stretching. He walks (albeit slowly) to keep comfortable, and can stand for only a few minutes before leaning or stretching.

He has completed a set of questionnaires, including the short version of the Tampa Kinesiophobia Scale, and his score on this questionnaire was well above the cut-off we use to identify those a risk of kinesiophobia.

When I completed the 99 picture PHODA with him, he indicated he would not attempt nearly 70 of the pictures, including any pictures of bending forward, twisting his trunk, jarring (eg going up and down stairs, or riding a bike over a kerb or using a mini-trampoline), carrying anything, or reaching above his head. In his daily activities, he is not working, he makes his bed (he has a duvet only), carries out his personal activities of daily living, but is otherwise either inactive (lying down to rest), or he walks.

He is living with family who are doing all of the household activities, so his responsibilities are very low. In addition, he is quite depressed although starting to look more future-oriented, he has an unsupportive family who are quite critical of his limitations despite carrying out his household responsibilities, and he has broken up from a long-term relationship about six months ago.

I started with using a motivational interviewing approach, and suggested we review some of the areas that other people often find helpful when they are thinking about managing pain. Using a menu of options, he identified sleep, medication use, relationships and work as his main concerns.

I asked him what he had found useful about previous therapies, and also what he had found not so helpful about those approaches. My aim was to help him identify that his previous attempts to control his pain by avoiding activities had not reduced his pain, and had increased the difficulties he faced living his life according to the values he holds.

I asked him whether he thought his movement patterns were helping him or whether there were some not so good features about the way he moved. He agreed that although sometimes it meant that he could avoid doing a movement that he thought increased his pain, for much of the time his pain remained and he had to keep on being ‘careful’ of any movements he did, and this was exhausting!

I then asked him how important it was to him to be able to return to normal activities even if it meant he needed to bring his pain along as well - and he indicated that it was very important. Using the ’scaling questions’ (Why do you think it’s so important to you? Why give it a 9/10 and not a 6/10?), he told me that he thought his life was becoming very restricted, he wasn’t able to work, and he didn’t think there was going to be a medical way to reduce his pain.

I then went through his confidence that he would be able to carry out normal activities despite his pain, and he told me it was 3/10. Once again, using ’scaling questions’, I asked him what it would take to help him move his confidence up a little, had he ever successfully made a change in his life despite it being quite hard, and he was able to talk about how he had worked his way up in the workplace despite not being a proficient reader, and that he knew he could make changes because if he took things one step at a time, he could see progress.

I then went through the PHODA pictures, and asked him which of the images he thought were most important for him to be able to do. He indicated that bending forward (eg to do dishes and clean teeth) was important, and also to put on shoes and pick things up from the floor.

I suggested to him that we weren’t sure why he thought he shouldn’t do these things, and asked him what went through his mind when he thought of himself doing these activities. He told me immediately that as he looked at photographs of people bending he could see himself falling forward and hitting the ground, or he could see his vertebrae grinding ‘bone on bone’ and see himself clutching his back because of the pain saying ‘I couldn’t cope with that sort of pain’.

Three things to note here:

1. the catastrophic image which generates an emotional response,
2. the misbelief that his vertebrae had no ‘padding’ so they were ‘grinding’ when he moved, and
3. the belief that he ‘couldn’t cope’ with high levels of pain

Each of these automatic thoughts/images are open to reappraisal, but unless they’re paired with actual movement, they are not likely to help him actually do things.

So - tomorrow I’ll discuss the next step in his programme: working towards ‘exposure’

Fear/anxiety, pain and movement…

The best way to start this week’s series of posts is by quoting Simmonds, Moseley & Vlaeyen (200 who said: ‘Chronic pain and its often associated movement dysfunction are pervasive, intriguing and complex problems … conceptualisation of pain and movement dysfunction has increased our understanding of both…that conceptualisation remains incomplete until it also includes the mind.’

For many years, ‘reactivation’ has been the watchword for chronic pain management ‘functional’ programmes. This was predicated upon the belief that people with chronic pain became ‘deactivated’ or lost physical conditioning due to low levels of activity, and that if they were encouraged to get fitter they would return to normal function. An alternative option was to use the behavioural school of therapy, where positive health behaviour (to normalise activity level) was reinforced, mainly through therapist encouragement and self-monitoring, and by doing this the individual would return to normal function.

Problem was (and still is), a certain proportion of people just don’t engage in this type of programme, often becoming highly distressed, convinced they had been harmed because their pain increased (often with a raft of new symptoms developing also), and without another alternative, these people were either left without any reactivation or referred for ‘talk therapy’.

In the mid-1990’s, research into the model of pain-related anxiety and avoidance (commonly called the ‘fear-avoidance model’) was initiated, and the growing literature into this model since then has confirmed its value in working with people who develop high levels of avoidance.

Essentially, the model describes the two approaches an individual can take when experiencing pain - either avoidance, with subsequent loss of activity and engagement in life roles; or approach, with increasing re-engagement in activities despite short-term fluctuations in pain. Research has confirmed that it is not just the pain that is the problem, it is the fear and avoidance of pain (or to be quite pedantic, it is the anxiety about pain - fear is quite specific (Rachman, 1998), while anxiety is generalised, future-oriented and the ’source of threat is more elusive without a clear focus’ (Leeuw et al. 2008)).

Further development of the model has identified some of the underlying thinking patterns that may influence the development of avoidance in response to pain - particularly health anxiety and negative affectivity. Health anxiety refers to the tendency to have catastrophic thinking patterns in response to threats of loss of body integrity, while negative affectivity is the tendency to see the glass half empty rather than half full.

For an excellent recent review of the ‘fear-avoidance’ model, Leeuw, Goossens, Linton, Crombez, Boersma & Vlaeyen (2007) have written in the Journal of Behavioural Medicine (30:1), February 2007.

My interest in posting on this model this week is to review the application of one of the treatment options suggested as a result of this model: exposure therapy. I’ve referred to this approach a couple of times before, in CRPS, in a pain management programme , in whether we are afraid to push our patients, and so on.

My interest currently is because I’m working with a young man who presents with extensive deactivation and loss of roles, depression and difficulty coping who identified almost 70 photographs from my set of 99 PHODA photographs as activities he would not do for fear of either increased pain or potential harm.

I was excited to find that the shortened electronic version of PHODA is available for free download, and I reported recently on a cervical spine version of the PHODA that has been published just a short while ago.

I’m also keen to see how I can integrate some of the work that has been carried out on mindfulness as it is applied to anxiety (eg Forsyth & Eifert, 2007) and whether this can be applied when helping people work through a hierarchy of feared activities.

So…an interesting week ahead!
BTW the three favourite (in terms of number of hits at least!) topics on this blog to date are: mindfulness, malingering and the CBT worksheet - so expect more soon!

Leeuw, M., Goossens, M.E., Linton, S.J., Crombez, G., Boersma, K., Vlaeyen, J.W. (2007). The Fear-Avoidance Model of Musculoskeletal Pain: Current State of Scientific Evidence. Journal of Behavioral Medicine, 30(1), 77-94. DOI: 10.1007/s10865-006-9085-0

Rachman, S. (2004). Fear and courage: A psychological perspective. Sociological Research., 71, 149-176.

Simmonds, M. J., Moseley, G., & Vlaeyen, J. W. Pain, Mind, and Movement: An Expanded, Updated, and Integrated Conceptualization. Clinical Journal of Pain May 2008;24(4):279-280.

World Bellydance Day!

If you have ever recommended ‘core stability’ for back pain, here’s a way to really work on it while having loads of fun!
OK, while core stability HASN’T proven to be the ‘cure’ for back pain, belly dance is still a great way to have fun and work the core muscles…

It’s for men and women, although more women than men dance (but that’s probably true of most dance forms!), the music is very catchy and has great rhythm, and it’s pretty low impact while toning and improving posture, body awareness and adding to your 30 minutes a day exercise routine. Oh and it doesn’t take up much room to practice, in fact you need no equipment at all! (apart from some music)

If you want to learn more, take a look at Kashmir’s site , she’s based in Christchurch and is my teacher.
Or if you’re looking for information on World Bellydance Day - go here
For information on styles (OK it refers to the US, but in NZ we probably have the same range) go to Shira’s website
And for some great video’s, YouTube has plenty, but to find them can be a leeeetle bit difficult, so take a look at Oriental Dancer’s video section.
And for a taste of what real dancing can look like? Take a look below…

Orit Maftsir is a dancer originally from Israel, but dancing all around the world - and she’s been to NZ, and danced for us! I wish I’d seen her live, she really enjoys her dance and represents to me what dancing is all about.

Friday funny! or ‘Look how far we’ve come’

If you ever think that things in our world haven’t improved a bit, take a look at this advertisement!

See? Hopefully we won’t see anything like that again - there are a few other adverts I’d like to see the back of too, like the ‘magnetic woollen underlay to relieve pain’ and the ‘back brace’. Until they go, we’ll just have to be satisfied with this.

Return to work: Clinical judgements and evidence-based decisions

Followingon from yesterdays post - qualitative analysis of comments that rehabilitation providers made about factors they thought important and modifiable in helping an individual return to work.

For each factor that was analysed, the participants were asked ‘how and why is this factor important?’ Using ‘Leximancer’, a text analysis software, the relationships between various terms were mapped as shown above. For example, the three main words used were ‘Return’, ‘Work’, and ‘Injury’. The frequency of each word in relation to other words such as ‘Return’ and ‘Motivation, duties, help, impact’; ‘Workplace’ and ’support, worker, injured’; and ‘Injury’ and ‘injured, employer, person’.

The authors describe the concept cluster of ‘Return’ which they interpret as reflecting ‘motivation to overcome difficult circumstances (as depicted by the concept terms ‘motivation, ‘negative’, ‘impact’) in returning to work (as depicted by the concept terms ‘job’, ‘return’, ‘person’), and the need to receive assistance to do so (as depicted by the concept term ‘help’). They suggest that this cluster of concepts was defined as ‘a process that was dependent upon the notion of engagement, supporting the injured worker to return to a more positive position through motivating relationships.’

The ‘Workplace’ cluster represented the need for a supportive workplace setting, or context, (‘workplace’, ‘worker’, ‘support’) and workplace involvement (‘time, ‘process’,‘employer’). This cluster of concepts was defined as a process that focussed on context, in that the workplace was a central point for rehabilitation and that a successful return-to-work would involve support for both worker and employer.

I think this would reflect most of our experience - and interestingly, this is an area not much studied in empirical studies. I expect that this is because of the complexity of the setting, and also the process focus rather than outcome focus of this aspect of intervention.

Two concepts that intersect all three clusters were ‘processes’, and ‘relationships’. This suggests that in all three areas, the way that people work together, and especially the need to follow through a series of actions to achieve the outcome. Again, neither processes nor relationships are often examined in detail in much rehabilitation research which focuses on ‘did the person return to work’?

Finally, this study analysed the ways in which the different participants classified predictors.
The following table illustrates some of the comments participants made: and agreement was not particularly high (Kappa 0.37), suggesting that different vocational rehabilitation professionals view various factors quite differently from each other.

My take on the lack of agreement between professionals is that we don’t really have a common model of work disability and rehabilitation, and commonly it seems that biomedical factors receive more attention than workplace factors, and employers are often left without significant guidance for them to achieve the level of support for the injured worker that is required.

I found this study to be very interesting - and apart from my criticisms that a larger group of participants from a wider range of backgrounds would have been helpful, and the thought that it would have been great to have had the opinions of people who have been through the process, both workers and employers, it helps develop the knowledge base in an area of rehabilitation that still seems somewhat under-developed.

Of course, another criticism is that this doesn’t reflect some of the changes that occur in dynamics between injured workers and their rehabilitation and employer relationships over time - especially if their return to work is delayed, or is taking longer than anticipated. But perhaps that’s a topic for a future study.

Muenchberger, H., Kendall, E., Grimbeek, P., Gee, T. (2007). Clinical Utility of Predictors of Return-to-work Outcome Following Work-related Musculoskeletal Injury. Journal of Occupational Rehabilitation DOI: 10.1007/s10926-007-9113-0

Return to work: Clinical judgements and evidence-based decisions

It’s not often that we find an article that draws on clinical knowledge rather than directly from experimental findings, but when we do, it can add something really helpful as in this article by Heidi Muenchberger, Elizabeth Kendall, Peter Grimbeek and Travis Gee.

Now I’m definitely a proponent of evidence-based management - but in very complex situations such as the return to work setting, the insights gained from our clinical experience can be very helpful.

What these researchers did was review the literature on factors known to be associated with returning to work for people experiencing musculoskeletal injury. From an initial group of over 1000 articles, only 55 met their inclusion criteria, which is surprising in some ways, and could suggest that perhaps they were rather too restrictive in their choices. Despite this, 38 unique predictors were identified, which were expanded by a group of researchers to a total of 85. Some of the predictors that were expanded included: Dependents, Occupation, Employment status, Nature of injury etc.

The authors of this report commented that, as in many meta-analytic studies, many of the terms used were rather loosely defined and could cover a multitude of factors. For example, ‘rehabilitation intervention’ ranged from medical treatment, physical rehabilitation, educational rehabilitation, multidisciplinary rehabilitation, vocational rehabilitation… ahh do you get the picture?!

A separate group of rehabilitation practitioners were then brought in to participate in the clinical examination of the relevant factors. From a large number of individuals, only 12 participants completed the study, and sadly there were no occupational therapists (in New Zealand, occupational therapists and physiotherapists appear roughly in equal numbers providing vocational rehabilitation).

This groups’ job was to rate each of the 85 predictors using three scales according to importance, modifiability and categorisation. Importance and modifiability were rated using a three-point scale, while they were asked to classify each predictor according to a seven-point nominal scale, with ‘each value representing one of seven categories of the typology proposed by Krause and colleagues’
1 = Individual Worker Factors,
2 = Injury Factors,
3 = Medical and Vocational Rehabilitation Factors,
4 = Job Factors,
5 = Organisational Factors,
6 = Insurer Factors
7 = System Factors
The most useful aspect of this study probably also took the most time: ‘practitioners were asked to provide a written rationale for each of their 85 ratings of importance. Specifically, participants were asked to describe why each predictor was important for rehabilitation and how it influenced return-to-work. This qualitative data was analysed separately to the survey results.’

And the findings?
Well, I was interested in just how much agreement there was between practitioners - and it came out as ‘fair’ (Kendall tau = 0.27). Curiously, the authors suggest that this is ‘acceptable’, but in my mind it’s probably a little low…Despite this, the results of internal reliability testing at the individual predictor level showed that practitioners were in agreement for importance of predictor. Only four predictors were considered the most important to rehabilitation and return-to-work by almost all practitioners (over 90%). These were:

• timeliness of rehabilitation,
• clear return-to-work goals,
• communication between GPs and injured workers and
• rehabilitation in the workplace

‘Predictors that were considered least important to rehabilitation included gender, cultural background and whether the person was a member of the union. Interestingly, some of these predictors (e.g., gender, cultural background) are among those represented most frequently in the return-to-work literature.’

What can we make of this discrepancy? Well with the small reference group, not a lot really. What would be interesting would be to see what other groups such as employers or people undergoing rehabilitation would say!

Two predictors, namely ergonomic strategies within the workplace and timeliness of rehabilitation,
were agreed by most (at least 80%) practitioners as having the greatest possibility for modification.
I’m not sure that the first, ergonomic strategies, is particularly helpful especially for the long term management of a musculoskeletal problem, however, it’s nice to know that practitioners acknowledge that they’re relatively easy to modify - perhaps that ease of modification (and the visibility of modifications) is why they get done, while other aspects such as timeliness and communication do not.

Judgements of clinical utility were made using ratings of importance and modifiability (is that even a word?!). Nine factors were identified as having sufficient agreement:

• Rehabilitation in the workplace
• GP and injured worker communication
• Clear return-to-work goals
• Timeliness of rehabilitation
• Proactive response by employer
• Workplace accommodations
• Elimination of risk factor from workplace
• Modified work
• Intensity of rehabilitation

Cultural factors were commented upon by the research group: ‘‘injured workers from
non-English speaking backgrounds often have cultural pressures on them not to complain or to keep
working even if injured’’, and, ‘‘some cultures have a particularly strong work ethic and other cultures (on the whole) cope less well with the change an injury brings, which deeply affects their pride and their ability to be the breadwinner’’.

To accommodate this, the authors state that ‘culture was more likely to be inherently considered in the design of intervention rather than as a single predictor of outcome.’

I’m not entirely sure how this was determined from this piece of research - and indeed, I’m not sure whether it is well considered. Perhaps this is yet another area for research from the patient’s perspective.

I’m going to continue commenting on this study tomorrow - the qualitative comments provide some interesting findings, and deserve more space than I can give today!
So, come on back tomorrow for more!!

Muenchberger, H., Kendall, E., Grimbeek, P., Gee, T. (2007). Clinical Utility of Predictors of Return-to-work Outcome Following Work-related Musculoskeletal Injury. Journal of Occupational Rehabilitation DOI: 10.1007/s10926-007-9113-0

Krause N, Frank JW, Dasinger LK, Sullivan TJ, Sinclair
SJ. Determinants of duration of disability and returnto-
work after work-related injury and illness: Challenges
for future research. Am J Ind Med 2001;40(4):464–84.

Return to work and chronic pain

Again this post is a bit of a reflective one, but also refers to the literature a wee bit too…

I’ve posted before about the importance of support in the workplace for people returning to work…and of the value of work to people living with chronic pain.

How about some of the wider issues that may influence work disability.
First of all, I think it’s important to consider whether pain is getting the blame, when actually a lot of other things are influencing the work disability. Let me be a bit pedantic here for a moment: disability is limitation in ability to perform normal activities; while pain is an unpleasant sensory experience. It’s entirely possible to have pain, even persistent pain, and even pain that is quite intense, and have no disability. It’s also highly possible that pain intensity can be quite low, while disability or limitation in ability to perform normal activities, is quite high. This is why focusing purely on reducing reported pain intensity just doesn’t see the whole picture (or touch the whole problem).

Factors such as fear of harm, kinesiophobia (fear of movement), punishing responses from other people, low mood, high anxiety about managing activities to the standard the person normally expects from him or herself will influence disability.

In return to work situations, factors such as having an unsupportive work environment, having very poor expectations of success, feeling constantly critiqued or monitored, not enjoying the job anyway, along with heavy physical demands and working alone or in shift work - these will all make returning to work difficult.

Papers such as this one written by Covington (2007) published in Neurologic Clinics do try to provide a biopsychosocial model of pain, so that medical practitioners are exposed to the idea that ‘at some point interminable searching for peripheral pathology that can explain the patient’s status becomes futile and possibly even harmful’, and asks them to consider that although ‘these ideas fly in the face of a health care system that is predicated on eliminating symptoms by identifying and correcting underlying tissue
pathology … they are well supported by experimental findings and the results of treatment.’

Covington goes on to review sources of pain, psychosocial issues, environmental factors (with specific attention to psychosocial factors at work), and notes that ‘progression to chronic pain was more dependent on demographic, psychosocial, and occupational factors than on medical pathology’.

Finally in this section, and very importantly, he reviews the influence of what he calls ‘the system’. This refers to many factors, but Covington pays particular attention to the thought that ‘Workers’ compensation systems may be especially toxic, with long delays in diagnosis and treatment, during which time workers must continually prove how sick they are to obtain care they believe they need.
Physicians and attorneys for each side may take polarized and improbable positions. The result is that patients receiving and applying for workers’ compensation benefits seem to fare worse with virtually all interventions than those not so encumbered.’

The situation in New Zealand is quite different from that referred to by Covington, in that the majority of claims made do not take long to establish cover, and there is no requirement to find ‘fault’ or attribute blame or responsibility to any party.
However, systemic delays in receiving treatment, the ongoing provision of income replacement (especially over prolonged periods, and where it pays more than other benefits such as sickness benefits), and poor or ineffective case management still occurs in our relatively enlightened system.

He continues with a comprehensive review of psychological factors as well as psychiatric disorders - a very useful review that is concise and up-to-date.

When he turns his attention to treatment, his turn of phrase is really quite excellent! He states ‘we must challenge the value of, for example, a month of good relief for a condition that lasts many years. And we must ask whether the answer varies depending on whether we are the payer, the clinician, or the parent of the person suffering.’ When considering the outcomes of treatment, he ponders the question of what should be measured. ‘The obvious answer, that pain reduction is the primary outcome variable, may be wrong. For example, a treatment that enabled a person isolated in bed with a pain level of 7 on a scale of 10 to begin playing golf with the same pain level would clearly be beneficial, perhaps more so than one that only improved the level of pain in bed.’

Covington also reviews a large range of treatments appropriate for back pain. Disappointingly, however, he makes minimal mention of the role of the workplace, or working as a key element in treatment. Given the attention he pays to the various factors known to be involved in the development and maintenance of disability associated with pain, and more critically, the value that individuals place on returning to work, it’s disappointing that so little is covered in his review.

So, I thought I’d put in a couple of thoughts that might make sense to you:
1. All return to work programmes need to be individualised
2. Return to work needs to start early on in rehabilitation, and be considered an essential part of it
3. The key people involved in a return to work programme must communicate well - and throughout the entire return to work period
4. Expectations need to be clear, and reviewed on a regular basis, an in an open forum where all key people are available
5. Functional updates need to be provided at regular review points, so that expectations for the level at which the employee needs to be working are clear
6. Communication needs to be not just spoken, but in written form too, so that they can be available for review throughout the period
7. ‘Performance’ issues need to be deferred until the return to work programme has been completed.
8. Questions of ‘motivation’ and ‘attitude’, and of functional ability need to be answered via medical or health care team reports. The programme needs to adjust according to functional ability, rather than any other factor influence changes in hours or duties. Functional ability can only be assessed by the health care team, and is not part of manager’s role.
9. It’s really important that the individual returning to work has the opportunity to have normal holidays, and to continue to balance outside of paid work responsibilities with paid work responsibilities. This means the person managing the return to work programme should be able to assess the demands overall, rather than just the workplace demands.
10. Progress, any progress, needs to be celebrated to ensure the person returning to work feels like his or her efforts are being recognised and appreciated.

There, that’s my tuppenceworth.

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COVINGTON, E. (2007). Chronic Pain Management in Spine Disorders. Neurologic Clinics, 25(2), 539-566. DOI: 10.1016/j.ncl.2007.01.009