Another editorial chimes in: Time for a new approach to musculoskeletal problems?


ResearchBlogging.org
For many years, as I started to work in vocational management, I felt like a lonely voice in the wilderness. It seemed that apart from the people I was working with, and perhaps the compensation system, no-one was particularly interested in return to work attempts. Now it’s a slightly different story – but again, the research into HOW people go back to work, and what actually works within a return to work programme is quite slim.
Despite this, yet another esteemed journal has added its editorial voice to the cry of ‘Let them go back to work’!

Ray Armstrong and Ross Wilkie write in the journal Rheumatology that returning to work is a good thing, while remaining away from work is hugely significant. In fact, they say ‘although much attention is given to stress and mental health problems as a cause of absence from work, and although this may account for the majority of time absent from work, musculoskeletal disorders (MSDs) account for a rather higher number of episodes of absence from work’. In New Zealand I’m not sure the absences from mental health and ‘stress’ have reached quite the proportions they seem to have in the UK (probably because we lack any system of support for these problems apart from our struggling mental health system), but we certainly have our numbers of people off work because of musculoskeletal problems.

Boiling the arguments down to bullet points, the main reasons for people to return to work are about

  • reducing the economic cost of time off work to industry and society/community
  • reducing the economic cost of time off work to the individual
  • reducing the personal cost of time off work to the individual, including loss of health status

I’m sure this isn’t news to anyone.  What I thought was a good point in this editorial was the focus on the medical certificate.  New Zealand’s medical certification process for non-accidental time away from work is even more minimal than the UK.  A doctor simply has to complete a certificate stating that a person is unwell, with the dates to start and finish, and that’s that.  No further information is needed.  Thankfully the certificate for ACC people is somewhat more complex – but rarely completed with any more detail than is absolutely essential (name, provisional diagnosis, restrictions on duties).

The employer doesn’t feature at all in the medical certification, there is no obligation to contact the employer, and the word of the employee is taken at face value.

Most of the time this is OK, I mean for most of us, a day or even a week away from work is taken reluctantly (after all, who is going to do the work we do while we’re away? The longer I’m away from my desk, the more piles up on it!).  For some, however, this isn’t the case.  And these people are more likely than you or I to have trouble returning to work in the event of a musculoskeletal pain problem.  Work factors feature quite highly in the ‘yellow flags’ literature.

The problems arise though, when trying to extend our knowledge of what works to help people return to work.  There isn’t actually a lot of effective research available.  ‘Finally, there is a lack of good-quality evidence to guide the preventive, therapeutic and rehabilitative arms of the response to the whole problem of sickness and work’.

While the authors of this editorial point out that the employer has to be an integral part of any return to work attempt, and that modified duties to assist with the transition from fully off work to fully at work, details on any other components of work rehabilitation are scant.  There doesn’t appear to be much evidence about which tasks should be avoided, or how activities should be graded up.  There is limited evidence as to the type of rehabilitation approach that should be used.  There is even less evidence for ‘ergonomic’ approaches to work rehabilitation.

A key component is that a coherent and collaborative team need to work together. ‘A greater emphasis on a ‘joined up’ approach to the sick worker’s problems involving the worker, the multidisciplinary team (e.g. the GP, physiotherapist, occupational therapist, psychologist, occupational health professional and/or employer advisor  and the employer is required.’ (Armstrong & Wilkie, 2009)  I’m pleased to say that for ACC claimants, this can be facilitated.  BUT what about non-ACC people?

My final point comes straight from the editorial: ‘Although it is important to acknowledge the importance of controlling pain and preserving and improving function, continued participation in work should be harnessed as a positive contributor to recovery and rehabilitation rather than being perceived as a barrier.’ Some kind of support needs to be given to employers, especially small employers, who know very little about what to do when someone has a musculoskeletal problem affecting their work.  Health providers need to learn more about the workplace – and the many threads of work-related research to be drawn together to develop a coherent and theory-based approach to return to work rehabilitation.

Is it time for the Ministry of Health, OSH and ACC to pull together to help people with work loss from any kind of health problem access effective and coordinated return to work support?

Armstrong, R., & Wilkie, R. (2009). Musculoskeletal problems and work in the UK–time for a new approach? Rheumatology, 48 (7), 709-710 DOI: 10.1093/rheumatology/kep071

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