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

More discussion on Functional Capacity Evaluations

Some years ago I wrote about Functional Capacity Evaluations and the lack of evidence supporting their use, particularly their use as predictive tools for establishing work “fitness”. 

I’ve received some sharp criticism in the past for my stance on FCE, and I continue to look for evidence that FCE are valid and reliable.  I haven’t found anything recently, and I’m still concerned that FCE are used inappropriately for people with chronic pain.  There is nothing like the demand characteristics of a testing situation for a person with chronic pain to either push themselves – and have a flare-up for some days afterwards but get a “good” report suggesting they have put in “full effort” and that they can manage a full time job of a certain MET demand; or to pace themselves, using pain management strategies – and avoid a flare-up but receive a “bad” report, suggesting they haven’t put in “full effort” and despite this, they can manage a full time job of a certain MET demand.

I can’t understand why FCE providers don’t work alongside people with chronic pain and their vocational counsellors, to help them define their sustainable level of physical demand, and systematically help them to gain confidence that they can find suitable work without exacerbating their pain. 

For the record, I’m not against establishing functional abilities.  And I think having a systematic approach to doing this.  I am against FCE’s being touted as a way to reliably determine work capacity, or to being able to determine “effort” through “consistency”. There simply isn’t published evidence to support these claims.  If someone can provide me with evidence, I’ll gladly change my mind because if there is one thing scientific training teaches, it’s that it’s OK to change your mind – if there’s evidence to do so.

This doesn’t mean that FCE’s would then be fine and dandy – because, as I’ve seen far too many times – HOW they’re used goes often well beyond what any FCE can possibly do, and very often is used as a blunt instrument when some good motivational interviewing and careful vocational counselling would achieve the same.

Here’s my original post, and some very good references are at the end of it.

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!

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

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

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

RTW and ACC in New Zealand – RTW Matters Analysis

This just in from RTW Matters – Dr Mary Wyatt analyses the New Zealand RTW Monitor results and makes her predictions about whether, in the light of financial pressures and declining RTW rates, NZ  is in for a RTW thaw or a snap freeze.  It’s available only for subscribers, but here’s a brief summary… (oh and subscription isn’t much in financial terms but packs a punch in information terms!)

• RTW rates are declining in both New Zealand and Australia

• ACC indicates that this is because of ‘a number of factors, including the ageing population, the increasing complexity of claims, and claims management inefficiencies. The resulting impact has meant that clients are staying on the Scheme longer and costing more.’

As an aside, I wonder how it can be that claims are becoming more complex?  Can someone enlighten me?  Certainly I don’t see this in pain management: people with chronic pain are, almost by definition, complex, and this has not changed on iota in the 20 years I’ve been working in pain mangement.  The only significant changes I’ve seen are that fewer people are attending for pain management with multiple surgeries, and more people are referred slightly earlier than the previous pain duration of 3.5 years.

• The focus of the Government for ACC is cost containment

• The ACC has taken the common scheme approach of dealing with financial problems by trying to moving long-term claimants out of the scheme.  Long term claimants are the most costly part of any scheme, and removing them is the most cost-effective ways to deal with cost blowouts.

• Mary Wyatt points out that one strategy used by ACC to do this is the increasing use of FCE to ‘predict’ whether someone can return to work.  As she says, ‘As a tool to define a person is having a work capacity and therefore no longer being eligible for scheme payments, they may be an effective, however this does not mean they are valid.  Moving people on from the system after a few years is basically declaring a failure of rehabilitation.  If they are capable of returning to the workforce at that point, why haven’t they done so earlier?’

I’d mitigate this last statement by saying that because of legislation, economy and fear, amongst other reasons, people who are ‘fit to work’ in some capacity may not always obtain employment, hence the ‘work testing’ or ‘vocational independence assessment’ that ACC conducts in New Zealand.  The intention of the legislation is not ‘return to work’ but ‘return to work readiness’.  The end of rehabilitation assessment is a slightly different approach from some areas of the world and consists of:

(1) a review of the assessment recommendations that have been made over the course of the claim to establish whether all rehabilitative efforts have been completed

(2) a vocational assessment that details the work options a person may be able to do given ‘education, training and experience’ – without considering functional ability

(3) a medical assessment that reviews the medical status of the person and, in collaboration with the person reviews the various work options to establish whether he or she can sustain ’35 hours or more’ in any of them

For those unfamiliar with New Zealand legislation, there is no ability to litigate for personal physical injury, as ACC provides 24 hour ‘no-fault’ cover forpersonal physical injury for all people whether working or not, funded by levies from employers, employees and various other taxes.  It was first introduced to New Zealand in 1974, and has continued to be a model for many commentators on accident compensation.

It’s difficult to establish why rehabilitation ‘performance’ appears to be less effective than previously.  I can only observe that management of claims is often fragmented, that multiple treatment providers are often involved with quite contradictory aims, that contracts for services to claimants appears very prescriptive and often clumsy, and that case management can be quite different depending on the individual case manager working on a claim.  Perhaps one factor could be the increased use of ‘multidisciplinary’ pain management but using teams of clinicians who rarely meet, may not have any specific education, training or experience in pain management, and who’s membership changes often, and within a programme framework that may be ‘pain management lite’ – or less than the recommended 50 – 100 hours of consolidated input (Main, Sullivan & Watson, 2008).

Back to RTW matters – as a taster, take a look at the free information available, and make your own mind up about its value.

Main, C., Sullivan, M.,  & Watson, P.  (2008). Pain Management: practical applications of the biopsychosocial perspective in clinical and occupational settings. 2nd Ed. Churchill Livingstone, Elsevier, Philadelphia.

Back to the basics: Cognitive-Behavioral Therapy and Psychosocial Factors in Low Back Pain

In New Zealand, the national accident insurer, Accident Compensation Corporation, has been reviewing its pain management service contracts. The latest message from both the Government and ACC is the need to reduce costs (not that I’ve ever heard anyone say ‘let’s go for broke, let’s spend all we can!’) and one way to do this is to look at how to reduce the risk of long-term disability associated with chronic pain. So, in their pursuit of ways to do this, ACC has consulted with providers and reviewed opinions about services provided to claimants under the various pain services contracts and come up with some pretty sensible options.

Some of the findings from examining current services simply do not surprise me – amongst two of the most common services, pain interventions (ie nerve blocks and infusions etc), and ‘functional reactivation’ programmes (ie let’s get fit in a gym), the providers rarely use a biopsychosocial model – apparently, these services are provided within a biomedical model, and those factors that are so well known to complicate recovery are simply not addressed. Now I’ve mentioned before in this blog that some interventional doctors actually believe that if they can abolish the pain the person’s problems will simply disappear and they’ll return to normal – and this is an opinion that now ACC is fully aware of, and hopefully will reconsider! The evidence from empirical studies just does not support the idea that pain and disability are linked in a nice tidy causal relationship. In fact, for a really lovely illustration of this in another health condition, angina, by Gill Furze, I think you’ll enjoy it.

So, from my somewhat cursory reading of the recommendations from ACC, it looks like a ‘stepped care’ approach is being adopted.  In this, ‘low risk’ people are provided with fairly simply input – advice from a GP, maybe a DVD or pamphlet advising people that it’s OK to move, that returning to work is good, and to simply get on with it.  ‘Medium risk’ people are provided with ‘reactivation’ but with some attention to psychosocial factors, and a comprehensive pain assessment is less likely to be on the cards for them.  Finally, ‘high risk’ people will be able to access ‘the whole works’ including comprehensive pain assessment, multidisciplinary and interdisciplinary pain management, and with a strong emphasis on attending to the psychosocial factors that are known to influence recovery.  Good ideas. With one catch – how ‘risk’ is identified is not yet clear.

In New Zealand we’ve used the Orebro Musculoskeletal Screening Questionnaire in some form since 1997 or so.  Unfortunately, this wonderful tool is often either not interpreted, or the ‘warning signs’ are not addressed, and for some people, a high score can almost be a flag for a case manager to be especially punitive in terms of ‘lets get this person back to work any way we can’ rather than using it as an indication that this person requires more support.  If this tool is used to screen for risk, and used well – then there could be some excellent results, and hopefully ‘low risk’ people won’t be over-serviced, while ‘high risk’ people will receive that help that they need.  But it will need case managers and other service providers to really come to grips with what the biopsychosocial model actually is, and how to truly address psychosocial factors in a systematic way.

How this plays out will be interesting.  Currently a claimant could see several providers concurrently: perhaps a doctor who is completing medical certificates, the physiotherapist providing the ‘reactivation’, an occupational therapist helping with return to work, and maybe an independent psychologist providing ‘CBT’ for pain.  If each of these providers has a slightly different understanding of the risk factors influencing disability in chronic pain, the poor claimant is going to be very confused.

For example, the doctor may be aware of the person’s home situation and certify fitness for work based on his or her knowledge of the overall ‘stress’ level of the person in context.  Without good understanding of how pain can influence function, the doctor could suggest ‘no heavy lifting’ – but fail to indicate how heavy ‘heavy’ is, whether this applies all day every day, whether there is a difference between lifting from the ground or above the head etc.  And the rationale for ‘no heavy lifting’ is fairly limited – what ‘damage’ will actually occur? or is the doctor responding to the person’s distress about ‘having to lift’ and experiencing pain?

The physiotherapist could be focusing on fitness generally, and asking the person to complete a full gym routine, maybe with some ‘core stability’ thrown in for good measure.  If the person is still fearful about his or her pain (because the doctor has said ‘no heavy lifting’), while completing the gym programme may actually be avoiding specific movements like bending because of this.  And be extremely fit – but not actually doing anything at home!  And you canbe very sure that this happens.  A lot.

The occupational therapist, with a really good ‘ergonomic’ approach, may recommend all sorts of wonderful gadgets, seating and break down the work tasks to ones the person ‘can do’, but the actual tasks the person does is really being established on the basis of what the doctor said about ‘no heavy lifting’.  The person feels pressured because there are lots of other movements that increase pain, apart from ‘heavy lifting’ (what about sitting? or twisting? or going up stairs?) but ‘has’ to do these movements because the doctor didn’t say they were ‘banned’, and there really are not that many tasks at work that the person can do!

And finally the psychologist, who is aware that the person isn’t sleeping, is feeling quite anxious and doesn’t have effective communication skills, works on these – but fails to address the confusion that the person has about what this pain actually means.

These situations are so common as to be the norm.  And while each provider is possibly working to ‘clinical standards’, the models they’re using don’t dovetail, and the person’s real concerns are not identified – and worse, the person gets caught in the middle between all these rather earnest providers who are actually talking past each other!

Now it’s not my plan here to lobby for any specific approach – I think plurality and choice is great in pain management.  But – and you knew there would be a but – there does need to be excellent communication and agreement amongst the providers and the claimant/person as to

1. what the problems are
2. what the hypothesised relationships between various factors are
3. a consistent approach to managing specific beliefs and behaviours

Oh and it does need to be evidence-based.  That means ‘favourite’ treatments that individuals like to do (like acupuncture, pilates, adaptive gadgets and even CBT or mindfulness) need to be justified not only from the literature, but also in terms of how they ‘fit’ for this person in this situation at this time.  That means outcomes need to be measured.

I’m still not convinced that primary care, even secondary care, clinicians talk to each other enough in the same language.  If ACC wants to ‘risk profile’ patients, maybe it also needs to ‘risk profile’ providers.  And maybe providers could be given some further training (maybe even training through a tertiary institute like University of Otago’s postgraduate papers in Musculoskeletal Medicine, Pain, Pain Management etc?!), even psychologists who currently don’t receive any specific training in a cognitive behavioural approach in pain management.

Read this paper – it’s an oldie but a goodie.  Even though some of the recommendations have now moved on, the fundamentals remain.  Psychosocial factors continue to be the most important predictor of disability, and need to be managed from the outset.  After all, people with chronic pain had acute pain in the beginning!

Pincus T, Vlaeyen JW, Kendall NA, Von Korff MR, Kalauokalani DA, & Reis S (2002). Cognitive-behavioral therapy and psychosocial factors in low back pain: directions for the future. Spine, 27 (5) PMID: 11880850