Returning to work, good or bad?- a very complex question

One of the main reasons returning to work is a priority in many healthcare systems is simply that compensation and off-work benefits is the most costly portion of the bill for people with ill health. This naturally leads to a strong emphasis in most rehabilitation, especially musculoskeletal rehabilitation in New Zealand, to help people return to work as soon as practicable. At times the process can be brutal. In my own case, after 18 months of working part-time due to post-concussion symptoms after a “mild” traumatic brain injury, I had the hard word put on me to get back to my job or I’d be sent to work back on the wards (after having spent most of my clinical career working in pain management). Not quite the supportive approach I needed when I was having to sleep for at least an hour every afternoon!

I can well remember the pressure of trying to maintain my work output to the satisfaction of my manager, keep my home responsibilities going (I had teenaged children at the time), manage all the paperwork required just to be part of a rehabilitation system, maintain my relationship which was strained just because I had no energy to play or have fun the way I used to. Oh and I had weekly rehabilitation appointments to top it all off! Not easy to keep your cool when everything seems balanced on a knife-edge.

Yet, despite the challenges of going back to work, most accounts of recovery from musculoskeletal pain find that returning to work forms a crucial element in maintaining long-term gains. The study that sparked this post is a good example: Michael Sullivan and colleagues, set in Montreal, Canada, found that returning to work helps to maintain treatment gains in people with whiplash injury. Of the 110 people enrolled in this study, 73 participants returned to work by the end of one year, while the remaining 37 remained off work. Using regression analysis, the researchers found that the relationship  between return to work and maintaining treatment goals remained significant even when confounds such as pain severity, reduced range of movement, depression and thinking the worst (catastrophising) were controlled. What this means is that something about those who returned to work seemed to help them achieve this, and it wasn’t the usual suspects of low mood or that the injury was more severe. What is even more striking is that those who didn’t return to work actually reported worsening symptoms.

There are plenty of arguments against this finding: could it be that those who didn’t return to work just didn’t respond as well to the treatment in the first place? Well – the authors argue no, because they controlled for the things that should have responded to treatment (eg range of movement, mood). Participants in the study returned to work 2 months on average after completing their treatment, and final measurement was on average 10 months later suggesting that it was something to do with being at work that made a difference.

In their discussion, the authors suggest that perhaps those who didn’t return to work were overall less physically active than those who did, compromising their recovery potential. They also note that being out of work is known to be associated with poorer mental health, so perhaps that explains the difference at the end of the trial period. In addition, they point out that perhaps ongoing stress related to having to handle disability claims processes, perhaps even the financial stress of being unable to work might have been influential.

It’s this last point that I think is interesting. There is no doubt that people who encounter the disability systems that fund their treatment and replace their income feel like their autonomy and independence has gone. They feel their world is being manipulated at the whim of case managers, treatment providers, assessing doctors, and even their family.  A sense of injustice can be detrimental to outcomes for people with whiplash, as Sullivan and colleagues showed some years ago (Sullivan, Thibault, Simmonds, Milioto et al 2009), and we know also that social judgements made about people who experience persistent pain are often negative and exert an influence on the experience of pain itself (Bliss, 2016; Schneider et al, 2016).

Working is really important to people – even in a job you don’t especially enjoy, there are important reasons you keep going (even if it’s only for the money! Money in the hand means food for you and yours, power for the lighting and heating, and even a little bit left over for jam on your bread!). In addition to the money, the most commonly asked question when you’re introduced to someone is “and what do you do for a job?” It’s a way of categorising a person, as much as we hate that idea. Work gives us social contact, routine, purpose and allows us a way to demonstrate competence. Without the anchor of working, many people who live with persistent pain feel the burden of social judgement “who are you?”, of ongoing bureaucracy (filling in paperwork), of repeated assessments to justify not being at work, of constantly being asked to attend appointments, of never feeling like time is their own. Balancing the demands of a system that judges you negatively because you are “unfit” against the demands of family and your own needs is an incredibly difficult process – but then again, so is the process of returning to a job where you fear you’ll fail and experience That Pain Again, and where, if you fail, you could lose that job entirely.

I don’t have an answer to how we can make this process easier. I do know that early return to work can be positive if handled well – but handled poorly, can be an extremely unpleasant and stressful process. Vocational rehabilitation providers need to understand both acute and persistent pain. They also need to carefully assess the psychosocial aspects of a job, not just the biomechanical demands. And someone needs to represent the needs of the person living with persistent pain and help them balance these demands carefully.

 

Bliss, Tim VP, et al. (2016)”Synaptic plasticity in the anterior cingulate cortex in acute and chronic pain.” Nature Reviews Neuroscience .

De Ruddere, Lies, et al. (2016)”Patients are socially excluded when their pain has no medical explanation.” The Journal of Pain 17.9 : 1028-1035.

McParland, J. L., & Eccleston, C. (2013). “It’s not fair”: Social justice appraisals in the context of chronic pain. Current Directions in Psychological Science, 22(6), 484-489.

Schneider, Peggy, et al. “Adolescent social rejection alters pain processing in a CB1 receptor dependent manner.” European Neuropsychopharmacology 26.7 (2016): 1201-1212.

Sullivan, M. J., Thibault, P., Simmonds, M. J., Milioto, M., Cantin, A. P., Velly, A. M., . . . Velly, A. M. (2009). Pain, perceived injustice and the persistence of post-traumatic stress symptoms during the course of rehabilitation for whiplash injuries. Pain, 145(3), 325-331.

Sullivan, M., Adams, H., Thibault, P., Moore, E., Carriere, J. S., & Larivière, C. (2017). Return to work helps maintain treatment gains in the rehabilitation of whiplash injury. Pain, 158(5), 980-987. doi:10.1097/j.pain.0000000000000871

How does chronic pain management work? A self concept hypothesis

In my previous post looking at how chronic pain management works, I put forward the hypothesis that

“What DOES change is [people’s] self efficacy or belief that they CAN do what’s important in their lives – by hook or by crook. And even more importantly, they have something to DO that’s important to them. Maybe something that hasn’t been studied in sufficient detail is what a person wants to be able to do, what’s their motivation, what are their valued occupations? That’s a hypothesis about therapeutic change I think we need to ponder.”

Later in the comments I mentioned the idea of renegotiating self concept – that part of learning to live well with chronic pain is the process of integrating the reality of on-going pain and associated limitations within their “understanding of how he or she responds in situations and the roles he or she expects to fulfil” (Baumeister, 1997; Christiansen, 1999).  Self-concept is a predictive process where the knowledge a person has about his or her personality traits, roles, and relationships guides their actions so that they present consistently across social and private contexts.

So self concept is “the person I am”. Several authors have described chronic pain as a “biographical disruption” that forces individuals to reconsider their past, present and future, often creating a discrepancy between the self-concept before pain and the current self (Asbring, 2001; Richardson, Ong, & Sim, 2006; Wilson, 2007). To accommodate chronic pain within the self concept means people need to incorporate an understanding of the new current self in a way that can retain as much of the past self as possible, without placing unsustainable demands on the future self. People who cope well with pain develop a self-concept in which the effect of pain is assimilated without compromising critical values in their lives, even though it may influence how these are enacted.

What this means is that people who cope well with pain identify the important values they hold (parts of self), let go of old parts of themselves they can’t continue to achieve, and find ways of ensuring the parts of themselves that they do value very highly can still be done.

John Quintner suggested that programmes that help people cope with their pain provide people with hope. I agree. I think that by helping people see that they can still retain essential parts of their concept of who they are, they can begin to see that life CAN continue to have some of the good things they really value.

Some of the mechanisms that I think might be involved in helping people renegotiate their self concept are:

• engaging in occupations (activities, roles that are individual and unique to them) as part of learning to make sense of their pain
• this helps to make their pain less threatening, more predictable
• and thus they’re more able to account for the effects of pain on what they want to do

People don’t only learn by doing things themselves, they also learn by seeing other people do things. This means that when people see a famous athlete or actor identifying with something like depression, for example, people with depression can gain hope that they too can still achieve despite their depression. In chronic pain management, people attending a group programme watch one another do things that they have also struggled with – and this provides both a model as to how this can be done, but also something to aspire to. This increases self efficacy because instead of seeing how “experts” (ie professionals) suggest they do things, they see people “like me” doing things.

If learning to live well with pain is partly about developing a new sense of self, then acceptance also involves letting go of things that can no longer be sustained (the past self) while holding onto important aspects of this self that can continue in a sustainable way into the future. This is something we all need to learn to do as we grow older. Usually it’s a gradual process, and most of us are sad to recognise that we’re aging, but also positive in that we’re moving towards new things that continue to add to our self concept. For people who develop chronic pain, it can be a profound change.

Letting go of the desire to “go back to normal” is incredibly hard. It won’t happen if a new opportunity to “go back to normal” keeps on being offered. And this is the tragedy of repeated attempts to find a complete cure, because it stops people being able to let go of things that may be unsustainable, keeps them in a sort of stasis while their life is focused on pain. And for many types of pain, there is no complete cure – even very successful interventions rarely completely abolish pain.

Hope, for people with chronic pain, involves more than taking all the pain away. It needs also to restore their confidence that they can be the person they want to be, to fit their self concept.  This is why return to work for people with chronic pain needs to address issues of the person feeling unreliable (“how can I go to work if I can’t go every day because of my pain?” “who would employ me when I can’t work the way I used to?”), of being able to present themselves as an asset to an employer, where chronic pain isn’t a liability but can be an asset. Because most people want to be seen as competent, reliable, and contributing within a work environment – and until they can see how these things can be achieved despite their pain, it’s going to be hard for them to convince an employer.

I think that learning to be flexible in terms of how to go about achieving something important might be the biggest factor in how chronic pain management programmes work. And I think the process is about renegotiating a self concept that allows this flexibility to occur, and maybe by helping people identify the values that underpin important occupations we might be able to support them to find new ways to express those values.

Asbring, Pia. (2001). Chronic illness – a disruption in life: identity-transformation among women with chronic fatigue syndrome and fibromyalgia. Journal of Advanced Nursing, 34(3), 312-319. doi: 10.1046/j.1365-2648.2001.01767.x

Baumeister, Roy F. (1997). Identity, self-concept, and self-esteem: The self lost and found. Hogan, Robert [Ed], 681-710.

Christiansen, C. H. (1999). Defining lives: occupation as identity: an essay on competence, coherence, and the creation of meaning. British Journal of Occupational Therapy, 53(6), 547-558.

Richardson, Jane C., Ong, Bie Nio, & Sim, Julius. (2006). Is chronic widespread pain biographically disruptive? Social Science & Medicine, 63(6), 1573-1585. doi: http://dx.doi.org/10.1016/j.socscimed.2006.03.040

Wilson, S. (2007). ‘When you have children, you’re obliged to live’1: motherhood, chronic illness and biographical disruption Sociology of Health & Illness, 29 (4), 610-626 DOI: 10.1111/j.1467-9566.2007.01008.x

Pain management and the political

There are only a few more weeks before a general election in New Zealand. This means the usual rounds of promises, muck-racking, hoardings and defaced hoardings. As I browse the research into chronic pain, and bemoan the lack of attention to the SOCIAL of the biopsychosocial model, I find myself looking at factors that almost entirely depend on a political solution. Let me explain.

Social. What is meant to fit into this part of Engel’s model? Drawing from one of his earlier works, Engel stated in his Cartwright Lecture at Columbia University College of Physicians and Surgeons (1977), that

“Health restored is not the former state of health but represents a different intersystemic harmony than existed before the illness, with characteristics based on all the system changes incurred during the illness. By virtue of the illness not only is the individual changed as a person, but so too may be changed others in relationship to him, in the family as well as the community…”

I interpret this segments of Engel’s work, and in particular the diagram he included in the published version of this speech, as a clear indication that while a biomedical model looks at the levels from quarks to systems, a biopsychosocial systems approach looks beyond this and into the person right up to society and nation.

And this is where it gets political. While individuals reappraise their self worth, learn new skills, develop new living patterns (well within the contributions of most allied health including occupational therapists), Governments and economic policy have a direct influence on what occurs in the interaction between what the individual does and the effect on the family, community, culture and subculture (however you define this), and ultimately society-nation.

Here’s some recent research illustrating how these factors interact.

When a person develops chronic pain, clinicians are likely to ask “How did it begin? What happened?” The person will probably talk about an event in the last few months or years that may have triggered the most relevant experience of pain. What clinicians may not think to ask about, and the person with pain may not even consider, is what happened in early life.

Goosby (2013) looked at socioeconomic disadvantage and maternal depression in individuals during their teenaged years, and found that the probability of chronic pain increases in magnitude over life in those adults who had parents with less education, and in those who had mothers who were depressed. She points out that mothers who live in low-income households (e.g. single mothers on a benefit?) are “especially vulnerable to psychological distress and disorders such as depression” (p. 77). She calls this “intergenerational transmission”, and goes on to describe “risk amplification” that occurs for children with low socioeconomic status who continue to experience deprivation as they become adults, while those who are not disadvantaged continue to maintain their health and wellbeing at least in part because of economic stability.

She continues by describing that childhood disadvantage increases the risk of depression and pain in adulthood and that adult socioeconomic status is a key factor through which adult health and wellbeing emerge. Interestingly, she found that adult depression is influenced by fewer factors than adult chronic pain – in fact, she found that all indicators of childhood socioeconomic status had significant interactions with the RR of adult chronic pain relative to no conditions, and particularly for those who had mothers who were depressed.

A similar finding was made by Lacey, Belcher, & Croft (2013) in a study looking at life-course socioeconomic position influencing chronic pain in older adults.

It doesn’t take a rocket scientist to see that this is political. In a climate where single parents (most often women) are told they are “welfare dependent”, receive a tiny sum of money or are asked to return to work when the child is 5 years old, often to work that is poorly paid (because more senior and well-paid positions rarely allow workers time to attend to children’s needs, mind you neither are poorly paid jobs), life is stressful and anyone vulnerable to depression and/or chronic pain is at high risk.

A sense of injustice can exist where individuals feel that circumstances are not fair, and that they are the victims of an injustice. In New Zealand there is a mitigating factor in that all accidental injuries are covered by the state-owned and tax-payer funded Accident Compensation Corporation. BUT, and this is a big one, there are incentives for those case managers to encourage and support people to return to work, while those who are injured while not working may receive far fewer entitlements and will not receive rehabilitation to return to work. This shouldn’t matter because access to rehabilitation is available to all – but in practice, does it?

McParland & Eccleston (2013) found that a sense of injustice can affect emotions, cognitions and behaviours. A particular point they raise is that when there is inequality between two people in a relationship, ie where one has money but the other does not (one is working, while the other is unwell with chronic pain) there may be adverse responses between the individuals. In New Zealand, if one person in a longterm relationship becomes unwell, while the other person is employed there is very little if any financial support for the couple. If the earner is only receiving a minimum wage, this presents a huge obstacle even to attending treatment.

My final review today (and believe me, there are SO many more than I’ve touched on!) comes from Antao, Shaw, Ollson, Reen and colleagues (2013).  They looked at intermittent work incapacity and how this influenced the way we can support people to sustainably remain working despite having times where their chronic pain interferes with this ability.  They draw on Bronfenbrenners Ecological Systems Theory which views child development within a context of social and interpersonal environments. Antao and colleagues used the environmental framework to analyse the workplace: .Micro level issues are defined as issues within the individual and personal realm and include factors such as cognitive deficits. Meso level issues are related to the workplace, such as workplace policies and accommodations. Finally,macro level issues are related to socio-cultural or political issues, such as benefits and insurances. (p. 13).

What these researchers found was there is considerable literature discussing micro-level support for people with pain. These are things like the individual learning about his or her condition, maintaining physical fitness, working on routines that can maintain or support work. Education, for example, focused on giving individuals information about worker’s rights, how to maintain quality of life through coping changes.

Meso-level strategies were rather more scarce in the literature, but they were present – things like educating employers and supervisors, modifying tasks or workstations, ensuring people are aware of the benefits of working on the individual and so on. I guess some of these fit into the “ergonomics” category.

Macro-level strategies were even less often presented, but included using flexible work practices (shifts, glide time, sharing tasks), providing timely financial support during times when an individual is unable to work, anti-discrimination laws and similar.

Meso- and Macro-level strategies are about social change and political will.

Where does this leave me?

When I consider the influence socioeconomic deprivation has on people, right from childhood through to the flow-on effects in adults, I worry about the effects of policy on people in New Zealand. There is an increasing disparity between those earning above $100,000 per annum, and those on the minimum wages of $14.50 or so. Worse for those on a benefit who are also labelled “benefit dependent”.

I’m worried that very often there is an outcry if a policy is introduced to support the situation of workers – employers complain that this is unsustainable, that they won’t remain in business and there will be economic fall-out because of this. I’m concerned at labelling that occurs if a person is on a benefit. Being on a benefit is not a life of luxury, yet benefit fraud is pursued more vigorously than so-called “white collar” crime, and in research conducted by Victoria University in 2011 “22 per cent of tax offenders received a custodial sentence” while “approximately 60 per cent of welfare fraud offenders received a custodial sentence.” Sophie Rule, Report Writer, Youth Parliament 2013, Ministry of Youth Development.

I am unhappy that the “trickle down” of economic growth hasn’t trickled, and that people who have few resources in so many ways are in a very real situation of social injustice. It’s a brave person who challenges an employer who decides to fire a worker who, having been in the same job for 20 years, has a heart attack and needs three months time off work. True story. Or a woman who, since the business she works for has moved from town to Rolleston, now has to travel by bus for an hour, then cycle for another 30 minutes to work in a job that pays minimum wage. And do the same again in the evening, despite her chronic obstructive pulmonary disease. In Christchurch. In winter. Oh and she lives with the man who had the heart attack. She doesn’t get paid when she needs a week or two off work because of her COPD as happened recently.

The social is largely, I think, a political matter. And chronic pain affects one in six New Zealanders. And they all vote.

 

Antao, Lilian, Shaw, Lynn, Ollson, Kaitlyn, Reen, Kavleen, To, Flora, Bossers, Ann, & Cooper, Lynn. (2013). Chronic pain in episodic illness and its influence on work occupations: A scoping review. Work: Journal of Prevention, Assessment & Rehabilitation, 44(1), 11-36.

Goosby, Bridget J. (2013). Early life course pathways of adult depression and chronic pain. Journal of Health and Social Behavior, 54(1), 75-91. Goosby, Bridget J. (2013). Early life course pathways of adult depression and chronic pain. Journal of Health and Social Behavior, 54(1), 75-91.

Lacey, Rosie J., Belcher, John, & Croft, Peter R. (2013). Does life course socio-economic position influence chronic disabling pain in older adults? A general population study. European Journal of Public Health, 23(4), 534-540.

McParland, Joanna L., & Eccleston, Christopher. (2013). “It’s not fair”: Social justice appraisals in the context of chronic pain. Current Directions in Psychological Science, 22(6), 484-489.

Rebuilding work identity

I love helping people return to work.  It’s got to be one of the most rewarding parts of pain management for me because not only is work important for health, it’s a major part of our day, and it’s a whole lot about individual identity.  So helping people reconstruct their sense of self to the point where they can go to an employer and say ‘I can do this for you’ with confidence is an enormous challenge.

To feel confident enough to put yourself on the line to an employer despite chronic pain is a challenge.  It involves at least some of the following (and yes, this is mostly from my experience on this post!):

1. Good self efficacy for managing pain – to the point where fluctuations in pain intensity can be taken with equanimity
2. Strong knowledge of what you can do
3. A sense of yourself as OK despite limitations (reconstructed identity as a worker)
4. Ability to communicate effectively, especially when it comes to doing things differently so as to accommodate functional limitations
5. Underlying routines and habits that can maintain optimal functioning in a work environment

I’m going to put myself out here – I think that although some of this work is considered within pain management contracts for ACC (our national accident insurer), I think much is missing.

There are some assumptions held by people about work.  Sort of a Calvinist view that everyone ‘should’ work, that work ‘should’ be done dutifully albeit not really enjoyably, and that everyone ‘should’ know what kind of work they can do – or be grateful for the chance to go to work so be happy with whatever is provided.

This somewhat simplistic view of ‘work ethic’ ignores some really significant issues – and as a result, the programmes for returning to work for people with chronic pain, along with the pain management programmes, don’t seem to address them.

A couple of vignettes might help illustrate the problems:

• Angus is 58, a truck driver, he has long-standing low back pain, what he calls a ‘crook’ heart, and a recent seriously sprained ankle that is still niggling.  He knows he can’t manage a full working day, but his job has gone and he is getting pressure from his case manager to return to work.  Functionally he is able – but he needs to change the way he does activities AND cope with ongoing pain that he gets worried about, and this is difficult for him.
• Caroline is a very busy teacher.  She loves teaching but is finding it very difficult to communicate to the Principal that she can’t keep up with the out-of-school activities that are expected from her.  She’s struggling because she knows what she used to expect from herself is not appropriate now, but finding it difficult to negotiate changes and help people adjust their expectations.
• Kevin is bitterly unhappy that his last employer was never prosecuted for the accident in which he hurt his hand.  He has always been a very fit person and had moved up ‘through the ranks’ at work to become a production manager, so had no paper qualifications.  Now he is not confident that he can either maintain the hours he used to do (and that he sees as normal), or that he can honestly tell an employer that he will be reliable.  He doesn’t know what kind of job to go back to because his previous work involved using both hands all the time in skilled movements (making furniture).

Each of these people has had pain management – but not specifically targeting the things that are important for them for returning to work.  While they have all been workers and obtained jobs in the past, it’s difficult doing the same thing now.  They have different work habits, restricted functional abilities, and need to change from ‘tried and true’ ways of living life and responding to pressures than they’ve needed to before.

How often are these problems directly addressed in a pain management programme?

I’m struck by the blithe way in which some people are told ‘You can’t go back to your old job, you probably need to look for something else.’  And while many vocational providers are good at eliciting transferable skills – they don’t appear to readily address altered worker identity.  Neither do they appear to recognise the need for people to both be honest with an employer and openly discuss their pain and how they manage it.  It’s not OK to tell someone to lie about their health at a job interview!

There are some fundamental factors that clinicians can ask about to help someone identify their concerns about returning to work:

How much do you believe the following statements:

• I may do damage to my body
• I may put other people at risk of harm because I may not do my job well
• I am not reliable and I might let my employer down
• My medications make it difficult for me to concentrate, or they are not allowed in my workplace
• I need to get my pain under control before I start thinking about returning to work
• I look as though I am well, and people may misunderstand how much I can actually do
• I can’t return to my previous job, and I don’t know what else I can do
• If I go to work, the rest of my life outside of work suffers
• I don’t know how to talk about my health problems to people at work
• While I can manage my pain at home, I don’t think I can manage it at work

If we can help people feel confident to be unconcerned about these things, we may be able to help people move from pain management at home to living life well and working.  And yes, occupational therapists (among others) can help with this!

How did that happen? Stories of returning to work

Yesterday I started to talk about returning to work with chronic pain. I mentioned that it’s often not the degree of importance an individual places on returning to work that engenders resistance – it’s more likely the lack of confidence the person has towards the process, the fear that this won’t work out and they will fail…

A story or two might help detail some of the issues that people I work with encounter when they’re returning to work. Now I recognize that the people I see are possibly at the more complex end of the spectrum than many, so these stories might well be more extreme than what many clinicians see, but at the same time they illustrate where things go wrong.

A note: vignettes used in this blog are composites of people I’ve worked with, so their confidentiality is respected.

Bill is a man in his late 50’s, a bluff bloke with a long career (about 30 years) as a sheet metal worker. He developed back pain in his mid-30’s but managed to remain at work for about 10 years by pushing himself during the day and ‘collapsing’ at night. He did stop work after his GP advised him that his work was ‘not doing you any good’, suggesting to Bill that he should take time off to ‘give your back a rest’ and maybe consider a new job.

Bill is a man who has limited reading and writing skills. He doesn’t like being around people very much, his beard is impressive – and he hasn’t cut it for many years! He loves working with his hands and not only has he been a sheet metal worker, he has a green thumb and grows his own veggies, has a garage workshop and a partially restored classic car in it, and he likes to go fishing and bushwalking.

He doesn’t like bending. He is quite afraid to bend forward, sideways, to reach up or down, or to carry heavy objects. While he can walk for hours on flat ground he’s not comfortable walking over rough ground or slopes. He believes that his back is fragile and that his pain means that there is ongoing damage. His GP has reinforced this by telling him that he needs to be ‘very careful’ with his back – or else (but didn’t elaborate on what the ‘or else’ means).

When Bill looked at returning to work, he was sent to a local vocational provider who promptly told Bill to get rid of his beard because ‘no employer wants to see you looking all bushy and scruffy’, advised him to ‘dolly up’ his CV (although Bill saw that as lying to prospective employers), and asked him to go door-knocking to get interviews.

Needless to say, Bill ran a mile. He had worked in an industry where his personal appearance was quite appropriate. He had never had a CV. He had few skills and a lot of anxiety about being around people let alone asking for an interview, and finally – he had no idea about what kind of work he could do.

But worse than that: he was fearful of bending, his GP reinforced this, and his past work experience and limited literacy meant that the only work he thought he could do was well beyond him.

If you think that’s sad, can I say Bill’s case is not isolated. He’s one of many people who get conflicting messages, hear advice that isn’t tailored to individual needs and doesn’t address individual concerns – and the likelihood of Bill returning to work without effective support is minimal.

Here’s another case, with a different ending.
Max has been a farmer all his working life, a shepherd with a leasehold farm. He hurt his back and for three years was given three-monthly blockades for pain relief. About six months before we saw him, he was told that these wouldn’t continue and he would now need to ‘learn to live with’ his pain. Unfortunately Max had learned to be very afraid of having pain, feeling overwhelmed by it, and, like Bill, avoiding all movements that made his pain worse. This meant he didn’t sit, he avoided bending to put even his sock and boots on, he spent hours lying down because this was more comfortable than any other position and he told us he was experiencing ‘death by DVD’.

Max had been through two attempts to return to work. He had decided that farming was out of the question, so his case manager referred him to a vocational provider who found a work trial in an agricultural company. The first work trial failed after a week because Max couldn’t manage the drive to work and the four hours he was expected to do in the warehouse (which involved lifting and bending to pack orders). The second failed when he was given ‘stocktaking’ to do as a task – this consisted of counting screws and bolts for the four hours he was expected to be there. Needless to say, he hated it and he stopped after about a month.

Max became very depressed, and his confidence for working was at an all-time low. He attended a pain management programme, but things only got worse immediately after it, partly because we emphasized that his pain was likely to remain the way it was. He was bitterly upset at the loss of his role, that his masculine sense of self was being eroded, and he couldn’t do all the things that he knew were ‘his’ jobs to do around the home.

It was a long, hard six months of work with us. We used CBT for mood management, graded exposure for his movements, and a lot of work to help Max identify the skills he still had and could use in the workplace.

He finally said that if we were right that he wouldn’t damage his back, then why couldn’t he consider returning to farming? I couldn’t think of any reason why (although he wasn’t physically able at this point), but from then on he started to really work hard on his movements and fitness. We arranged for another work trial, this time in an outdoors recreational area where Max was able to try out a range of activities like moving irrigation, checking fence lines, and planting. After a few flare-ups that resulted in Max feeling rather afraid but eventually managing to remain at work (with the support of his GP, our team and the local vocational team), Max has now returned to full time work. He’s been there for six months now, and does all the tasks involved including cutting down trees, operating heavy machinery, repairs to fencing, irrigation and so on.

The best thing? Max sent us a photograph recently of him holding a large opossum (they’re a pest in NZ) at arms length after having shot it in the bush when out hunting.

Returning to work for Bill and Max is a lengthy process. It involves commitment by all the team members and particularly commitment to the same message – that it’s possible to go back to work, that it’s healthy to do so, that pain doesn’t mean damage, that it’s possible to cope with even high levels of pain and carry out very heavy work, and that we as a team have confidence in the person’s ability to make it. It also means acknowledging that one size does not fit all. It’s not always necessary to conform to ‘white, middleclass’ dress code or presentation. It’s entirely feasible to return to really heavy work provided the person is confident that he or she is not doing damage. That choosing ‘the wrong kind of work’ that doesn’t suit the person’s skills, preferences or experience does not work.

We ALL have a role in instilling confidence that people with chronic pain can manage normal activities. I can’t say that it’s easy, and it’s certainly not quick. It does rely on really good teamwork and a consistent approach. It take hours of coordination via phone, email, face-to-face, letter. But to see Max’s face with that huge possum held at arms’ length, and to hear from him that he still has pain but he can manage it – that’s why we do it!

Working and chronic pain

If there is one aspect of chronic pain management that has received more attention than returning to work, I don’t know it! In 1995 when I started working at my current workplace, work was almost a dirty word. I was accused at one time of being a ‘Siberian workcamp’ Commandante because some people thought it was cruel to ‘force’ people with chronic pain into the workplace. Thankfully this attitude has changed over the years, and most people recognise that working when you have chronic pain, while difficult, is achievable and good for health. At the same time, returning to work with pain has never been especially easy and there are numerous issues to work through.

Today is the first day I will discuss the practical aspects of returning to work with the current group of people participating in the three week pain management programme. We’ve already discussed what work is (something to organise your day, social role, productive activity, source of income and self esteem, identity, social contact – that list goes on!), and each participant has looked at how important returning to work or being at work is, and how confident each individual is to achieve that goal. Each person has looked at the ‘stages of change’ cycle (Prochaska and diClemente) and identified where he or she sits on that model.

The findings in this group are pretty typical of most groups that I’ve worked with. Most people indicate that work, however they conceive it, is pretty high in importance. At the same time, most people also indicate that their confidence to achieve their goals in work is lower than the importance – and some cannot even rate their confidence above 0/10. Many of the participants indicate that they’re ambivalent about returning to work – probably in the ‘contemplation’ or ‘preparation’ stage in the stages of change model.

What are the issues?
Amongst the issues, one is prime: the ability to attend work consistently, to be reliable as an employee. This is a real challenge for many of the participants in this programme, and I don’t see that they are very different from most people with long-standing chronic pain.  Until being in the programme, these patients have often relied on pain intensity as their guide to activity level – and this has often lead to a saw-tooth pattern of ‘boom and bust’, or a gradual reduction in activity level to the point where they are quite deactivated.

Another critical issue is the difficulty talking about their pain and any functional limitations – or even the ‘work-arounds’ that people have developed to manage their pain – with employers.  The belief is that if chronic pain is mentioned, ‘no employer will have me’.

And yet another issue is the difficulty translating generic pain management strategies into the workplace. Things like activity management (aka ‘pacing’) or regular stretch breaks or relaxation are not thought to be acceptable in a workplace, and communicating about the value of doing these things is, as I’ve mentioned above, incredibly difficult.

This is an area of pain management that I think has been omitted.  In the rush to ‘get people fit enough’ to return to work, or to ensure they have ‘pain management’ often delivered in a clinic setting, I think the core problem has been either ignored or glossed over.  And the core problem IMHO is that people with chronic pain need to feel confident that they will succeed if they attempt to return to work.

To feel confident, people need to have their individual concerns addressed, and to develop strategies to help them work through the challenges of applying pain management in the work environment.  Because, like it or not, the work environment is different from a clinic, the home, or even within a family.  We ignore this at our peril.

I am not an advocate of dividing the delivery of pain management and vocational management.  The two need to go hand-in-hand.  So often return to work is seen as separated from healthcare.  It’s not – it’s as integral to people’s wellbeing as being able to use the toilet or have a bath, to be able to walk to the shops, to manage the household tasks, or to budget and do the grocery shopping.  At the same time as we consider functional movements, we also must consider work activities.

This paper by Cost-Black, Loisel, Anema and Pransky elaborates on the current state of play with respect to helping people return to work.  I’ll be discussing more of this tomorrow – and the day after!  But, I do believe that this paper omits a crucial aspect of returning to work, and that is the issue of self efficacy for returning to work and managing pain.  The ‘how’ of returning to work is more than accessing selected duties, or becoming fit enough, or even coordinating the process with all the various providers involved in the process.  It is all of these things, but if we fail to help the people we are trying to assist to feel more confident, it is unlikely to work.

And we face enormous challenges in this work – economy, conflicting advice from various providers, a sense of urgency to ‘move quickly’ by insurers (often too soon and ill-coordinated), clumsy administrative systems, lengthy time off work (in this group of people one person has had 30 years away from the paid workforce), and loads of anxiety and fear of failing.

I don’t see the problem of return to work as one of motivation on the part of the individual – motivation is often about how important an activity is, and how confident the person is that he or she can do it.  At least in the people that I see, it’s the latter that creates the resistance to move on.  Working can be SO important that to fail would be devastating, so people just don’t attempt it.  This is maybe what we need to focus on.

Costa-Black, K., Loisel, P., Anema, J., & Pransky, G. (2010). Back pain and work Best Practice & Research Clinical Rheumatology, 24 (2), 227-240 DOI: 10.1016/j.berh.2009.11.007

Information is to behaviour change as spaghetti is to a brick

I’m a great fan of books like ‘Explain Pain’.
This delightful publication by David Butler and Lorimer Moseley gives accurate information about pain, particularly chronic pain, in an accessible format for both patients and clinicians, and I’ve used it often with people I’m seeing. I’m also a fan of helping people to understand what we do (and don’t) know about pain to give them more awareness of their ability to influence their own body.

But as anyone who has worked in chronic pain management knows, telling someone something doesn’t always make an enormous difference – and here’s a case in point.  Before I go on, any cases I refer to on this blog are a compilation of several people and details are altered to protect confidentiality.

Yesterday I met with a person who has had chronic back pain for about four years.  She has had a discectomy for what the notes stated was a ‘large disc prolapse compressing the nerve root with neurological signs’, so a good candidate for this procedure.  The operation was a success four years ago – but, as is common in spinal surgery, she was left with persistent low back pain.  Her surgeon told her to ‘be careful of heavy lifting, twisting and bending’ and she had taken this to mean she shouldn’t do things like carry a full washing basket of clothes to the clothesline, do the vacuum cleaning (I can understand this decision!), load the back of her car up with groceries, mow lawns, or even play golf. Ooops, I’m not sure the surgeon meant ALL of these things, but you never know.

We met with one of the doctors I work with to review her clinical chart and to talk about her back pain because she was very wary of doing any of these movements even under clinical supervision.  The problem being that her surgeon, four years ago, had said she ‘shouldn’t’.

I want to add at this point that she was seeing us because of another, unrelated pain problem that was responding well to input although the pain from this other problem was not resolving.  The other pain problem was in her knee, and it had stopped her from walking comfortably and had also lead to her stopping work.  I also want to add that the doctor she was seeing with me is one of the best physicians I know for explaining medical investigations and treatment in a way that patients understand.

The consultation took about 45 minutes – so definitely not a quick’n’dirty consultation.  Together we reviewed all the clinical information including medical notes from the surgery.  We looked at a model of the spine and my patient was shown exactly what the surgical procedure was – she had no idea of what had actually been done to her vertebra or disc, and had visions of large chunks of bone being removed leaving a weak and vulnerable vertebra and disc that had lost most of its height.

We talked about the risk factors associated with having had one disc prolapse – that the risk of having other prolapses, and particularly another one in that disc, were somewhat higher than before her first disc prolapse.  We talked about the relationship between disc changes and pain (which is not entirely straightforward).  We discussed the signs and symptoms of a return of her original problem, and that her current back pain was quite different from the original leg pain.

And you know what?

Even though we followed best practice and used the kind of information that Lorimer Moseley describes in the paper I’ve linked this post to, and this woman has had this information given to her in several different ways by different clinicians in the Centre I work in, she is not convinced.  To her, having pain in her back inevitably means her surgeon was quite correct to tell her to avoid bending, twisting and lifting, and that unless she is very careful she risks needing the much more significant surgery of a spinal fusion.

The power of a surgeon who, with a few words, has helped this woman become trapped into no longer doing what she used to love.

What’s worse – her GP has said that she should ‘think of doing another job because it’s clear this one isn’t going to be good for your back’ – she’s a taxi driver.  So after the whole of her adult working life in the driving industry, at 52 she believes she needs to think of doing another job – even though she and her husband drive off in their motorhome every weekend, and she loved being a cabbie.

What to do, what to do.  Information alone in these cases doesn’t help this person feel confident enough to contradict the explicit instructions of her surgeon, nor the advice of her GP, nor her behaviour over the past four years.

It was Bill Fordyce who apparently coined the phrase ‘Information is to behaviour change as spaghetti is to a brick’.  While sometimes simply helping people to understand more about their body and what pain is and is not, can be enough for people to take their own steps towards changing their behaviour, for many others – and particularly people who are anxious about their health – it takes more.  That’s because knowing in the ‘I can tell you about it’ way is not the same as knowing in the ‘I really understand it’ way.

At heart, I’m a behaviourist I think.  While I know the value of working with thoughts and beliefs, and I thoroughly enjoy this part of my work, it makes very little difference to someone’s life if, after all our work together, they carry on doing what they’ve always been doing.  That’s one definition of insanity – doing the same thing again and again and hoping for a different result.  Something needs to change.

For me, with this person, I hope to start working using an exposure-based treatment.  Graded exposure, by identifying the movements she’s currently not happy to do, developing a hierarchy of avoided movements, and starting to help her recognise that the relationship between what she thinks is going to happen and what actually does happen is not the same, is one strategy that can help.  Underneath her almost religious adherence to this one surgeon’s advice is a potent fear that (a) she is going to do harm and (b) that she won’t cope with the changes in her pain if she disobeys his instructions.

Trying to convince her or to give her more information – even the very best information along the lines of Lorimer’s paper – isn’t, on its own, going to change her willingness to put her body on the line.  Successfully encountering movements and doing them without the scary consequences is probably the only way to help her gain confidence that she can manage it – and return to her normal work.

A pox on people who work with people who have pain and haven’t yet got up to speed with modern scientific knowledge about pain mechanisms.  And a bouquet to people like Bill Fordyce and Lorimer Moseley and David Butler and Nick Kendall who have, over the years, contributed so much to scientific and clinical knowledge about the biopsychosocial nature of pain and pain management.

Moseley, G. (2007). Reconceptualising pain according to modern pain science Physical Therapy Reviews, 12 (3), 169-178 DOI: 10.1179/108331907X223010

Goals, outcomes, direction & values

Someone asked recently, how do you decide the difficulty level of a goal?  Or words to that effect.  It’s a good question – and like most good questions, there doesn’t seem to be a nice clear-cut answer.  So here’s a ramble on where I’ve got to with goals.

The first thing I remember about goals is that there is a big difference between a goal that I am aiming for and the actions that I can do to achieve the goal.  What I mean by this is it’s pretty easy to set a goal like ‘I want to get a job by March 2011’ – but this goal could well be setting you up for failure.

Why? Not because it’s about working, no, but because it doesn’t depend entirely on your actions – in fact, it depends on an employer deciding that you are worth the money to employ.  So you could be the most motivated person in the world, do all the right things to look for a job, but you may not actually get one in that timeframe.  The outcome of that goal is not up to you – it’s up to the employer. Similarly, someone might want to achieve top in class – but getting top depends on whether there is anyone else in the class who might be able to achieve a higher score.  You can’t be responsible for that other person’s ability, you’re only responsible for your own actions.

So rule number one for me is to make sure goals are about actions, or things that you can do rather than outcomes that might depend on others.

The next thing I’ve been pondering comes from ACT – and it is that goals or actions need to be important, they need to enact a value in some way. The ‘why are you doing this’ part of deciding the direction you want to take.

What I mean by this is that we know there are multiple ways to live out what is important in life. For example, being a good provider for my family is a value.  It’s not something that can be ticked off a list and then, with a sigh, say ‘I’ve done that’!  It’s something that is lived every day in a series of actions that embody the value I hold of being a good provider.  I could do this by having a wonderful garden and supplying veges to my family, or by preparing great meals, or obtaining a good job, or budgeting carefully, or supporting my partner to go out to work – you can see how many different ways this value can be played out!

For clinicians to help someone decide ‘what to do’ or what kind of goals to set, we need to help people clarify what is important to them and then set actions accordingly, so the goals are contributing to the person being able to live out their values.  If we as clinicians forget this, we could end up dictating a set of activities that are meaningless to the person – and as a result, don’t get carried on when we stop seeing the person.

The actions we establish may not look very much like the values that the person wants to live out, especially in the initial stages.  For example, if the person wants to be more open and honest in relationships, perhaps initially identified a goal of ‘no longer being tied up in my worries when I’m around people’, the first steps towards this might be to simply sit in the same room as other people and be prepared to remain there for 10 minutes, being mindful.  On its own, this action doesn’t look like being open in a relationship – but it’s a step towards being able to allow the worrying thoughts to be present without being acted on, while remaining open to being present in a group of people.

Another example might be for the person who is fearful of walking in busy environments such as a shopping mall or supermarket – maybe because he or she could be bumped and that painful limb or back might get more uncomfortable, or because he or she might be asked ‘and what are you doing for a living right now?’  The first step could be to go to a mall early in the morning when it’s all quiet and have a cup of coffee with a friend.  It’s a first step towards the living the value of being free to walk wherever and whenever.

So while the SMART goalsetting mnemonic certainly has value – after all, it’s been around for a while! It also fails us as clinicians at times.  I think it’s a great way to begin to develop an action plan – or committed actions the person is prepared to do (Specific, measurable, achievable, recorded, timeframed – or whatever variation you’ve learned!). but it’s not enough on its own.  As clinicians we must recognise that SMART actions must be things the person can do, not outcomes.  And SMART actions need to be important to the person in some way – there has to be a reason for doing them beyond pleasing the clinician!

So – is it OK for a person with pain to have very high goals?  Of course!  If someone wants to return to paid employment, it’s a fabulous goal to have, even if I, as a clinician, have no idea what that might look like.  I would ask what is so important about being in paid employment as one of the first steps to fleshing out what the next best step might be.  It might be about finances, it might be about self esteem, contributing to the community, being busy through the day, feeling useful – all of these could be underlying values for returning to paid employment.  I’m likely then to ask about how confident the person is to achieve this goal – and what contributes to this confidence.  Then I’m likely to ask what the person thinks the ‘next best step’ might be.  This could be something like learning more about transferable skills, developing confidence in physical abilities, becoming good at interviewing and presenting skills well, or developing effective pain management strategies that mean activities can be sustained reliably day in and day out.

All of these possibilities can become actions – but the reason the person is doing them is to return to paid employment because of some underlying value.  My job? To help the person identify what the obstacles are and how to work through them, while recognising that the person can only be responsible for his or her own actions.

Ways to ask about sensitive topics

I teach postgraduate courses in pain and pain management.  Many of my students are experienced general practitioners who often ask me “how do I talk to people with pain about psychosocial issues without them thinking I’m telling them their pain is ‘all in the head’?” It can be a pretty sensitive topic for the person with unexplained pain that doesn’t go away because to somehow suggest (a) they’re not coping with their situation or (b) they have some psychological problem can seem uncaring or even that the person’s pain is ‘imaginary’.

The psychosocial ‘yellow flags’ are widely known, but even after a decade or more of exposure to what the ‘yellow flags’ are, there is much confusion and misconception.  Today’s post will hopefully help to clarify things a little.

In 1997, the Acute Low Back Pain Guidelines were published in New Zealand.  As a companion to this publication, the ‘Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain’ was also produced by my then colleague Dr Nicholas Kendall, along with Steve Linton and Chris Main.  It was a very new concept and a little bit revolutionary – for the first time not only were physical risk factors and medical management of acute low back pain detailed, but risk factors for long-term disability and work-loss were included and considered to be of equal importance.

Red flags are risk factors in acute low back pain that indicate the need for urgent medical investigation and management in order to prevent serious harm – things like caudae equinae and tumours and so on need to be identified as soon as possible so that effective management can be instituted.  Yellow flags are described as ‘the analogue’ to these physical risk factors, and are equally likely to lead to long-term disability and ‘serious harm’ from back pain. They are the psychosocial factors (note: not psychological) that need to be identified and managed as early as possible so that people can have the best chance for recovery.

The distinction between psychosocial factors and psychological factors is very clear: psychosocial includes the social – in the original publication, it is described as ‘the interaction between the person and their social environment, and the influences on their behaviour’. (frequent readers of this blog – do you see a theme happening here?!)  This includes family members, friends, people at work, employers, the compensation system and health professionals.  It also includes cultural and community and socioeconomic factors.  All these things can affect how a person views his or her pain, and how they respond behaviourally.

There are seven ‘headings’ or groups of psychosocial factors to explore: Attitudes and beliefs, Behaviours, Compensation issues, Diagnostic/Iatrongenic factors, Emotions, Family and Friends, and Work factors.  (Observant people will note that these translate into the mnemonic ‘ABCDEFand W’)  People can have problems recovering from acute pain because of the presence of a few very striking factors, or multiple, less important factors.  In any event, if psychosocial factors that are known to be associated with the risk of long-term disability are present, they need to be assessed and managed effectively and promptly. And by everyone in the health care team from case manager, GP, practice nurse, physiotherapist, occupational therapist – yes, everyone!And not necessarily by clinical psychologists although they may be helpful with more seriously affected people.

So, how do you raise the questions?

The Yellow flags document (click on the link to go to KendallBurton’s page full of great documents, and including the YF doc from 1997) has some great suggestions about how to phrase the questions:

• Have you had time off work in the past with back pain?
• What do you understand is the cause of your back pain?
• What are you expecting will help you?
• How is your employer responding to your back pain? Your co-workers? Your family?
• What are you doing to cope with back pain?
• Do you think that you will return to work? When?

Here are some more, grouped under the headings.  I’d weave them into your normal history-taking – they are absolutely as relevant as any physical examination.

Attitudes and beliefs

‘Some people think pain like yours is always a sign of damage or harm – what do you think?’
‘What do you think is causing your pain? What do you think should happen to help you recover?’
‘What do you think about starting to do normal activities even while your pain is present?’

Behaviours

‘To help me understand how this pain is affecting you, could you take me through a typical day?’
‘Are there movements or activities that you are worried about doing, or even steer clear of?’
‘How is your sleep at the moment?’

Compensation issues

‘Is there anything going on with your medical/accident claim right now?’
‘How is the process of making a claim affecting you at the moment?’
‘How is your relationship with your case manager?’

Diagnostic/Iatrogenic issues

‘What is your theory on the cause of your pain?’
‘What have other health providers said about your pain?’
‘What kind of advice have you had from the health people you’ve seen?’

Emotions

‘Can you tell me how you’ve been feeling about your situation?’
‘How has your pain affected your spirits?’
‘Can your mood take a dip? Does it make you feel wound up?’

Family and Friends

‘What lets other people know you’re having a bad day?’
‘How do your family and friends feel about you starting to do everyday activities?’
‘What have your friends and family suggested you do about your pain?’
‘What do your friends and family do or say when they know you’re having a bad day?’

Work issues

‘How have your employers and workmates been about your pain?’
‘Can you take me through a typical work day?’
‘How has your employer been about taking you back at work?’
‘What has your contact with your work been like?’

(Acknowledgement to Dr David Craig, Clinical Psychologist, Greater Glasgow Back Pain Service)

To find some really good suggestions about how to best support a person with acute low back pain – head to the link above, and within the Yellow Flags document is a great section on strategies that ANYONE can suggest or integrate into their clinical practice.

Psychosocial risk factors shouldn’t just be identified – although that’s a first step. They also need to be managed and managed promptly. After reading a medical report yesterday in which a well-known musculoskeletal doctor clearly identified the presence of ‘fear avoidance’ but did not make a single suggestion about this being managed (instead, lots of suggestions about more diagnostics and ‘physical rehabilitation’) – I think I need to post about ‘what to do when you’ve found yellow flags’ tomorrow!

Physical and Organisational Ergonomic Interventions: so far not effective

A million years ago (truly, ask my daughter if I’m that old!) I completed several papers in postgraduate ergonomics, primarily physical and organisational ergonomics rather than cognitive, and for a while there I could recall the NIOSH lifting equation and even discuss biomechanics with some confidence. Sad to say, over the years, my familiarity with those mathematical concepts has rather fallen away, but with an ongoing interest in work and workplaces, I’m still trying to keep up-to-date with the literature on the effectiveness of these interventions.

My frustration with ergonomics grew as I started to realise how limited biomechanical modelling that I used was by comparison with the real work of real people in a real workplace.  All of those ‘reals’ add up to messy variables that don’t conform to the assumptions that are needed to avoid hugely complex mathematics.  Suffice to say, even with computing power as good as we get today, something’s missing!  I think now, of course, that what’s missing is recognition of the variables that are implicated in problems with errors and injury and pain, those messy psychosocial factors.

Anyway, Driessen, Proper, van Tulder and colleagues undertook a comprehensive review of the ergonomic literature – note, not all the ergonomic literature, only physical and organisational ones – and after whittling down the list to include only those that met quite rigorous criteria, wrote a review that was published in Occupational and Environmental Medicine journal very recently.  To give some indication of the scale of the job, the initial list of references two reviewers had to wade through had over 3000 papers!  And after using the methodological criteria they had chosen, this enormous list shrank to … erm… 10.

Inclusion criteria were as follows:
< The study was an RCT.
< The cohort studied was a non-sick listed working population.
< The intervention met the definition of a physical or organisational ergonomic intervention, that is, the intervention is targeted at changing biomechanical exposure at the workplace or at changing the organisation of work.
< The outcome measure included non-specific LBP or neck pain, incidence/prevalence or intensity of pain.Studies on neck/ shoulder pain were considered as neck pain studies

The exclusion criterion was as follows:
< Individual worker interventions.

The reviewers used the  GRADE approach to classify the overall quality of the evidence, and this is briefly described in the article.

Cutting to the chase – what did they find?

“there is low to moderate evidence that ergonomic interventions were no more effective than control interventions on short and long term LBP and neck pain incidence/prevalence, LBP intensity and short term neck pain intensity.”

So, despite the huge investment in time, energy, funding and (often) gadgetry, ergonomic interventions at an organisational level do not have good support.

Does this mean a biomechanical approach is unhelpful?  Well, if it’s applied to individuals, possibly not – there is some evidence from return to work literature that modifying work tasks to enable a person with pain to return to work can be helpful.

Most of the time, modifications in this context mean changing the number of movements, reducing the physical demands somewhat by lightening loads in manual handling, or reducing the length of time the person is exposed to the demands.  So I think there is some support for biomechanical or physical ergonomic approach for individuals.  I also think that if the outcome intended by an ergonomic approach is to reduce or minimise errors, and maximise biomechanical efficiency, then some of the interventions are useful.

But there is a difference between those outcomes, which are useful in industry, don’t forget! and the pain reduction, ‘injury prevention’ outcomes that so often the ‘ergonomic salesperson’ touts  (usually accompanied by a special ‘ergonomic’ gadget or piece of equipment).

Critics of this review suggest that some study designs such as quasi-experimental and qualitative designs should have been included.  The authors of this paper indicate that previous reviews did include study designs that were suspicious for bias (ie, pre–post trials, prospective cohort studies, controlled trials and quasi-experimental trials) and that the purpose of the RCT is to control for most unforeseen factors.  However, interventions conducted in complex environments may be affected by organisational changes, financial problems, lack of management support or other issues and, as a result, study results may be influenced.

They state “In our opinion these factors could hamper evaluation of the potential effects of ergonomic interventions in all types of studies except for those carried out in laboratory settings. These unforeseen factors are in fact an inevitable part of applying ergonomic interventions in real (working) life.”

The authors (and me!) think that a process evaluation should be carried out alongside all ergonomic studies to demonstrate the modifications and fidelity of any real world intervention to the original design.  This would help reviewers and readers of such papers to identify how well biasing factors have been managed, and how much the ‘end-users’ of ergonomic interventions have adopted the strategies.  In the real world, the make or break of any input is how much the people who are meant to use a new approach actually do so.

Where does this leave me?  Well, after a temporary career trying to introduce ‘safe handling’ processes in two busy hospital environments, where I couldn’t put my hand on my heart to say a ‘no lift’ policy would reduce back pain, I am so glad I was both honest enough to say what the outcomes might be (much to the consternation of the management teams in both hospitals!), and sensible enough to ensure that any person returning to work with low back pain had a discussion with me about how to manage their return to work.  While the biomechanical approach did not and could not reduce back pain, the individual advice and reassurance that it’s OK to help patients to move using efficient strategies I think helped increase confidence to return to work.

Note to self: don’t bother trying to recall the NIOSH equations, they don’t look like the real thing!

Driessen, M., Proper, K., van Tulder, M., Anema, J., Bongers, P., & van der Beek, A. (2010). The effectiveness of physical and organisational ergonomic interventions on low back pain and neck pain: a systematic review Occupational and Environmental Medicine, 67 (4), 277-285 DOI: 10.1136/oem.2009.047548