Hi ho! Hi Ho! It’s off to work we go!

I know, it’s Monday and such cheer about work should be reserved for people with no life – but helping people return to work has been and still is one of my favourite parts of pain management. A pity that work rehabilitation has become somewhat far removed from pain management as it is practiced in New Zealand.

This paper by a group of Canadian researchers takes the basic steps to returning to work, and maps them onto relevant theory associated with both managing low back pain and changing behaviour. It is one of a very few papers I’ve read that demonstrate the reasoning behind how an effective work rehabilitation programme is established.

The focus of this paper is on describing how a work rehabilitation programme can work by “having trained personnel coordinate the RTW process, identifying and ranking barriers and solutions to RTW from the perspective of all important stakeholders, mediating practical solutions at the workplace and, empowering the injured worker in RTW decision-making.” I hope by now we’re all aware of the need to help people remain in work despite their pain, and if they do stop working, using the workplace as the setting for functional restoration as well as the best place to learn to manage pain.

The process used to generate the five step work rehabilitation programme involved six steps.  Step 1 consists of a needs assessment; steps 2, 3 and 4 involve the initial development of the intervention; step 5 consists of planning for implementation; and step 6 involves evaluation and refinement of the intervention.  At each step in the ‘intervention mapping’, core processes are developed, and involve brain-storming among a selected group of individuals (known as the intervention mapping team made up of researchers, content experts and stakeholders), who come up with provisional solutions to the specific tasks and questions.  A consensus process was used amongst the participants following a review of the literature for the best available evidence and theories around RTW and the management of occupational LBP, and combining this with the practical experiences of stakeholders.

The sort of questions asked during this process were things that clinicians who help people return to work ask themselves – what does a work supervisor have to do to facilitate RTW in a
worker with LBP? What are the determinants that will impact the supervisor’s ability to facilitate successful RTW? What needs to change at the level of the supervisor in order to facilitate
successful RTW? NB: this set of questions is about supervisors, but can be about the individual, the case manager, the clinician etc.

A ‘Matrix’ describing the skills the individual worker needs in order to return to work is given – this illustrates for me some of the key areas for intervention.  Things like “keeps active despite pain” needs an attitude of “being confident that moving is good” and may require, from the clinician, help to “ensure understanding that hurt does not equal harm”.  Specific skills needed to maintain activity are, therefore, “active coping strategies”, and the expected outcome should be “activity despite pain, reduced pain behaviours”.

I could argue the toss a little about some of the ideas in this matrix, because I believe it over-simplifies some of the quite difficult aspects of pain management and self efficacy in the work setting – for example, under ‘communicates concerns at work’, the belief required is ‘belief that worker has a say in RTW process, and that employer will listen and understand concerns and be supportive’, this is followed by knowledge of ‘how to make workplace safe’ and requires skills to ‘develop a sense of control, can adapt work tasks’ to finally manage to ‘return to work before 100%’.  The focus in this aspect of communication doesn’t seem to acknowledge that for many workers it’s not the physical aspects of the work that are difficult to manage – it’s the attitudes and behaviours of other people at work.  While an employer at one level of the organisation can be supportive, down on the workfloor, it can be a whole other ball game!

By following this process of generating ideas about the core processes at each stage of returning to work, then developing a consensus approach from both literature and practice experience from the people that are involved in work rehabilitation, these authors developed a five step process for work rehabilitation in a local institution.  the five steps are useful to review because they look readily transferable to other settings.

Step one: The first task of the RTW program is to identify potential barriers to RTW from the perspective of all stakeholders who can impact on return to work.  The person with work disability completes a set of questionnaires (mainly the usual psychometrics for pain management from what I could see); and barriers to RTW are assessed from the point of view of the
injured worker.  The return to work coordinator also assesses psychosocial barriers to returning to work such as concern about injury, relationships with others in the workplace and practical barriers like transport to and from the workplace.  In turn, the funder, the health care provider and the workplace are interviewed about aspects of this person’s return to work, to identify possible obstacles and facilitators for the person to rehabilitate successfully.

Step two: Meeting at the workplace which is facilitated by the return to work coordinator, and includes a tour of the workplace and sharing concerns and solutions to issues each of the stakeholders has raised.

Step thre: An agreed return to work plan is documented, and appropriate interventions such as psychosocial management or cognitive behavioural therapy is instituted.

Step four: Implementation of the plan with the return to work coordinator maintaining close supervision of the whole programme and includes discussion with all stakeholders.  This part of the process continues until discharge.

Step five: Usually omitted at least in my experience(!) is a review of the whole programme by all the stakeholders.  All the solutions used in the process are documented, and a final progress report is documented.

Now this process is not rocket science.  I have seen it used, and used it myself, for many years – what is different about this is the documentation and prior planning of what the needs are for each stakeholder throughout the entire process.  It’s nice to see the communication being facilitated and supported by all stakeholders. It’s great that not only practical nouce but also information from the literature is combined to arrive at expected concerns and appropriate strategies for each person in the process.

The parts that I’d love to see carried out far more often are the aspects about what the person returning to work needs to know about how to manage pain, communicate effectively and obtain support; and the final review of the programme along with the solutions used – this provides the whole team of people with a documented learning opportunity, and should help them the next time someone needs to return to a similar situation.

Long live work rehabilitation that uses a cognitive behavioural approach and has great communication!

Ammendolia, C., Cassidy, D., Steensta, I., Soklaridis, S., Boyle, E., Eng, S., Howard, H., Bhupinder, B., & Côté, P. (2009). Designing a workplace return-to-work program for occupational low back pain: an intervention mapping approach BMC Musculoskeletal Disorders, 10 (1) DOI: 10.1186/1471-2474-10-65


  1. The program sounds all encompassing, but reality… the program isn’t what happens in the real world, especially in the States. Worker gets injured… worker goes to worker compensation physician… worker may have referral to physical therapist… physical therapist treats patient… physical therapist communicates with case manager… case manager provides the “work duties” the injured employee needs to perform and communicates corporate policy. Physical therapist does not communicate with supervisor at work environment. Focus is generally always on knowing work duties and meeting corporate policy. Some policies are an “all or none”.. .meaning – injured worker will only be allowed to return to work when has ability to successfully perform 100% of duties. Nice, huh?

    Maybe if the system did change to allow some research/evidence to be injected into the process, maybe our society could save some money by having less long-term disability claims and return people to work faster. (Okay.. not *all* companies are like the above… but in my area, there are many with policies like that. Policies that aren’t good for the injured and aren’t good for the company.)

    1. What you describe sounds like what can happen here in NZ in the early stages of RTW for some people. Comprehensive RTW programmes do happen in some places in NZ, but often it’s a haphazard process with poor coordination and limited communication between the various providers. However, it is great to see that in some parts of the world, and in some organisations, this well-defined approach does work – and the evidence shows that it is cost effective. A good reference that is available online is Waddell, Burton & Kendall ‘Vocational Rehabilitation: What works for whom and when’, published by The Stationary Office, UK. It is a review of vocational rehabilitation for a range of health conditions, not just musculoskeletal, and has a long list of programmes that have good evidence to support them. Worth a read – just use a good search engine and you’ll find it (published 2008).

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