Work conditioning, work hardening and functional restoration for workers with back and neck pain

In New Zealand most people who have been off work with chronic pain, and receive compensation from ACC, will have been a participant in some sort of fitness programme.  It’s almost a rite of passage for people to have a programme of functional restoration before or during an attempted return to work once the person has been off work for around 3 – 6 months.

There are a lot of different types of programme available:

  • two of the Prof Mick Sullivan’Goal attainment’ programmes for sub-acute pain,
  • Functional restoration programme – for sub-acute pain, involving activity with some ‘education’
  • Pain management psychological services – for psychological strategies for pain management
  • Activity focus programme – for chronic pain, involving activity and cognitive behavioural therapy approach for self management
  • Multidisciplinary programme – a three-week intensive interdisciplinary programme with a cognitive behavioural approach, including reactivation

Given that functional reactivation is integral to all but the psychological services contract, I thought I’d take a quick look at the Cochrane review for the use of work hardening, work conditioning and functional restoration for workers.  Now while it was first published in 2003, at least at first glance the state of play doesn’t seem to have changed significantly since then in terms of the studies and outcomes.  So I’m going with this version even if it may be slightly old.

The authors of this review, Schonstein, Kenny, Keating and Koes, grouped together all the programmes variously called work hardening, work conditioning and functional restoration and called them ‘physical conditioning’ programmes.  Whether this is appropriate I can’t comment – but they do all have in common the use of graded reactivation through gradually increasing physical activity using simulated work tasks and other physical activities in a supervised setting.

For this review, the objectives were

To compare the effectiveness of physical conditioning programs
with management strategies that do not include physical conditioning
programs (e.g. standard medical care, non- exercise-based
physiotherapy treatment, education or no intervention), or other
strategies, in reducing time lost from work and in increasing functional
status of workers with back and neck pain

As usual for a Cochrane review, RCT’s were included and others were excluded, this left them with 18 studies meeting the criteria. These studies were contrasted with 23 studies using other approaches such as GP care, combined CBT and exercise, work site assessments. Challenges the authors faced, again as usual, were the lack of definitions for work conditioning, work hardening, and functional restoration.

Cutting to the chase, the outcome of this review found that ‘physical conditioning programs that include a cognitive-behavioural approach can reduce the number of sick days lost at 12 months follow-up by an average of 45 days, when compared to general practitioner usual care or advice, for workers with chronic back pain.’ For work-related outcomes, there was equivocal evidence that specific exercises without a cognitive behavioural approach made any difference to outcome. There was no evidence this approach was supported for people with acute low back pain.

So, it seems pretty important to not just simply provide exercise without at the same time ensuring the programme has a cognitive behavioural approach incorporated in it.
This begs the questions: what exactly is included in ‘a cognitive behavioural approach’?
From a quick scan of the descriptions of the C-B components, these ranged from motivational sessions, to ‘education’ about chronic pain, to behavioural cues, to relaxation training, to ‘work difficulties being discussed’. I wasn’t clear how these components were delivered, nor whether they were provided by physiotherapists or other members of the team. This is a real problem in research about cognitive behavioural approaches in pain management – so much is included in the ‘black box’ of this approach, it’s hard to determine which elements are effective.

It was also interesting that these studies typically didn’t include participants who no longer had a job – I’m guessing that people who do have a job to return to would be much more likely to go back to work, while those who have lost jobs, or cannot return to their original job, would be much less likely to return to work. The problem of seeking work is completely different from the problem of simply not being able to tolerate the physical demands of a job. Sadly, there is very little research about the processes used by people who no longer consider themselves to be workers to return to work.

Several studies included graded return to the workplace – and some had specific attention to workplace factors (not simply ‘ergonomic’ advice). Again I’d love to see whether this aspect of functional restoration made a difference either way (extending work disability or shortening it).

Why do we use exercise?
Well, it seems to work, sometimes. Why does it work? Well now, that’s another question indeed. It’s an area of real complexity – movement generally feels good (try sitting still for an hour and see what I mean!), there’s some evidence it helps with mood, it certainly helps with weight maintenance, it does reduce fear of harm, it’s a ‘normal’ activity that can help people re-engage with their ‘normal’ life. It doesn’t seem, from these studies, that any specific exercise works any better than any other – so hula hoop anyone? I do bellydance, maybe that could be a new therapy? Once again, it’s an area for more study!

Work conditioning, work hardening and functional restoration
for workers with back and neck pain (Review)
Schonstein E, Kenny DT, Keating J, Koes BW
The Cochrane Library
2008, Issue 3

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