Return to Work

It’s hard work researching teamwork
After writing about teams and models and the distinct possibility of talking past each other, I had a very quick search for a paper on teamwork and models this morning, and came across this one by a group of Canadian researchers. It is, like many of these pieces of research into the messy and complex area of decision-making and teams, a qualitative piece of work. It examines process and identifies underlying values within a team.

Values are interesting things – they’re the often unspoken ‘things we think are important’, and possibly represent the very things that we both share in common with each other – and at the same time, can be the very things that underlie our major differences of opinion with each other too.

In this study by Loisel, Falardeau, Baril, José-Durand, Langley, Sauvé, & Gervais, (hereafter ‘the authors’), they observed a single team discussing the cases of 22 workers off work due to musculoskeletal pain.  They painstakingly transcribed then analysed the discussions (338 meetings, 75 hours of discussion transcribed!)…

The team consisted of : general practitioner, occupational therapist, kinesiologist, psychologist, ergonomist, and team coordinator.  They held weekly team meetings to decide on progress, messages to give to employer and participant (an investment in meetings that I don’t see happening on a regular basis in many pain management settings today).

Data analysis is modelled after Glaser & Strauss, although thankfully they acknowledge they are not using grounded theory – instead, they coded, wrote memo’s, created flowcharts and looked for similarities and differences between each coded category until they came up with explanatory hypotheses that cohered to form a theoretical explanation for how the teams worked.  For a full description of the types of grounded theory (so you can see how this study differed from a methodologically sound grounded theory) you can go to here and here.

The findings identified ‘ten common values and were shown as supporting the team’s decisionmaking process during case management. They repeatedly appeared during interdisciplinary team meetings and were reinforced by team leaders.’ The researchers thought they fell into four main groups: (1) team-related values, (2) stakeholder-related values, (3) worker-related values, and (4) general values influencing the intervention.

Team-related values

Team unity and credibility – this reflected the approach of the team to both arrive at consensus, and then act in consensus so that there were no ‘gaps’ or opportunities for the participant or employer to split the team.

Stakeholder-related values

Collaboration with stakeholders – this represented coordination of care, and the team worked hard to bring participants alongside with the team’s view, so that the person returning to work had consistency of management.

Worker values

Worker’s internal motivation – the team worked hard to strengthen the worker’s internal motivation, so the worker was encouraged to be autonomous and assertive.

Worker’s adherence to the program – the team worked hard to ensure the person returning to work followed the team’s recommendations, seeing this as vital to the success of the programme.  The authors found that it seemed important that the worker and the team were ‘thinking in the same way’, that they became ‘allies’.

Worker’s reactivation – being active = good, being inactive = bad.  All workers were thought to be able to return to work irrespective of their diagnosis.

Delivering a single message – unity and consensus seemed critical to ensure everyone heard the same message and the aim of the programme was achieved.


Worker’s reassurance – that the person was doing no harm to themselves, that they would ‘make it’, and that the team was supporting them.

Stakeholders’ reassurance – to ensure the stakeholders felt comfortable with accepting someone back to work even if they weren’t at full physical capacity.

General values

Interventions should be graded – because workers had been off work for some time, the team agreed that they should be gradually reintroduced to the workplace.

Pain is multidimensional and must be actively controlled – both physical and psychosocial factors were actively addressed throughout the programme, including ensuring the participant knew about the multidimensional nature of pain.

Work is therapeutic – the team supported the idea that being back at work is good in itself.


For me, this study illustrates that even if a team hasn’t clearly or explicitly discussed underlying values or models, they hold them.  It’s probably (and I’m hypothesising here) a more effective team that is open amongst the members about the values or model they have, so that differences of opinion can be openly aired, and especially given that at least in this team, being united was thought to be so important.

I’ve recorded and tracked the discussion patterns across team members, and also looked at roles participants play within a team, but I’ve never examined the underlying values. 

I think it’s an interesting approach to how living teams function, and it begs the question: how long does a team need to be together to cohere values?  What is the effect of introducing a new person to a team? How does a team work to integrate or exclude values brought in by new team members that don’t align with the rest of the team?

It also brings into question the process of selecting a new team participant – maybe it’s much less about what the person knows, and much more about how comfortable that new team member is with the ‘way we do things around here’, or the values and culture of teamwork.

Loisel, P., Falardeau, M., Baril, R., José-Durand, M., Langley, A., Sauvé, S., & Gervais, J. (2005). The values underlying team decision-making in work rehabilitation for musculoskeletal disorders Disability & Rehabilitation, 27 (10), 561-569 DOI: 10.1080/09638280400018502

Functional capacity evaluations – my take on them!

Functional capacity evaluations

There are many forms of functional assessment available.  These range from a series of structured activities carried out in the home or work environment over a period of days or weeks to those that are carried out in a very precise manner in a clinic and often under the supervision of an occupational therapist or physiotherapist.  Both commercial (ie standardised and franchised) ‘Functional capacity evaluations’ (FCE) are available, as well as semi-structured or individualised assessments.

The term functional capacity evaluation has been criticised, because it can suggest that it is able to assess ‘capacity’ or ‘can do’, while most commentators believe that functional assessments can only assess what a person ‘will do’ (e.g. Battie & May, 2001).

One of the major criticisms of FCE is that few studies of reliability or validity have been published in peer reviewed journals.  This means most FCE have not been subject to the degree of scrutiny that is usually employed when developing assessment tools.  The relatively few studies that are available suggest that ‘only limited aspects of FCE reliability have been studied’ (Battie & May, 2001), and predictive validity, or the ability of the FCE to predict whether someone can or will return to work, is not strong (e.g. Gross, Battie & Cassidy, 2004)..

Reliability refers to whether two different people can conduct the FCE and obtain the same results (e.g. inter-rater reliability).  Intra- and interrater reliability for most FCE methodologies  have not been established.  There is some evidence that interrater reliability for establishing between ‘light’ and ‘heavy’ exertion, and whether a lift is performed safely, but mixed findings have been obtained for identifying the level that would ‘constitute safe, maximal lifting’ (Battie & May, 2001).  This means that when reviewing the findings of FCE, it is uncertain whether the same results would be achieved a second time, or by a different assessor.

Validity refers to whether an assessment is measuring the dimension it says it is measuring.  There are several different types of validity – content validity refers to whether the items used in the assessment ‘look like’ and agree with other ways of measuring a similar area – for example, do the items in the FCE measure the same sort of areas that disability questionnaires measure?  If they do, there should be a degree of similarity between the scores on both type of assessment if they’re completed by the same person.

Reneman et al. (2002) found little to moderate correlation between the self-report and performance-based measures, while Gouttebarge et al. (2009) found poor construct validity of lifting tests, discriminative validity was not statistically established, and convergent validity with self-reported pain intensity and disability was poor.

One of the most important aspects of validity is whether the results from an assessment can be used to predict behaviour in the ‘real world’ – this is predictive validity.  Gross and Battie (2005), found that FCE did not predict function at 12 months, and stated in a further paper that ‘The validity of Functional Capacity Evaluation’s purported ability to identify claimants who are “safe” to return to work is suspect.’ (Gross, Battie & Cassidy, 2004).  A very recent study demonstrated that while FCE was related to return to work the predictive efficiency is poor, with the findings contributing only 5% to the overall model (Striebelt, et al.2009).

Strong and colleagues provide recommendations as to how FCEs should be requested, undertaken, reported and particularly applied to reduce work disability among injured workers and this paper, in part, describes my approach with clients when discussing the relevance and limitations of FCE results (Strong et al. 2004).

FCE can provide some helpful information to both client and health provider when used as a ‘pre and post’ assessment, to monitor functional improvement, and to assist a client to develop an awareness of the areas of functional performance he or she may need to improve on (such as improving grip strength, manual handling technique or cardiovascular fitness).  At the same time, FCE is a measure of volitional behaviour at one time in a clinical setting, as opposed to a ‘real world’ setting where consistent performance is necessary.  As I have indicated above, the predictive validity of FCE is not strong, and FCE should not be relied upon to determine ability to carry out activities over the course of a day or week.

Gouttebarge, V., Wind, H., Kuijer, P. P., Sluiter, J. K., Frings-Dresen, M. H., Gouttebarge, V., et al. (2009). Construct validity of functional capacity evaluation lifting tests in construction workers on sick leave as a result of musculoskeletal disorders. Archives of Physical Medicine & Rehabilitation, 90(2), 302-308.

Gross, D. P., & Battie, M. C. (2006). Functional Capacity Evaluation Performance Does Not Predict Sustained Return to Work in Claimants With Chronic Back Pain. Journal of Occupational Rehabilitation, 15(3), 285-294.

Gross, D., Battie, M., & Cassidy, J. (2004). The prognostic value of functional capacity evaluation in patients with chronic low back pain: part 1: timely return to work. Spine, 29(8), 914-919.

Gross, D. P., Battie, M. C., Gross, D. P., & Battie, M. C. (2004). The prognostic value of functional capacity evaluation in patients with chronic low back pain: part 2: sustained recovery Spine, 29(8), 920-924.

Reneman, M. F., Jorritsma, W., Schellekens, J. M., & Goeken, L. N. (2002). Concurrent validity of questionnaire and performance-based disability measurements in patients with chronic nonspecific low back pain. Journal of Occupational Rehabilitation Vol 12(3) Sep 2002, 119-129.

Soer, R., Groothoff, J. W., Geertzen, J. H. B., Cp, Reesink, D. D., & Reneman, M. F. (2008). Pain response of healthy workers following a functional capacity evaluation and implications for clinical interpretation. Journal of Occupational Rehabilitation, 18(3), 290-298.

Streibelt, M., Blume, C., Thren, K., Reneman, M. F., & Mueller-Fahrnow, W. (2009). Value of functional capacity evaluation information in a clinical setting for predicting return to work. Archives of Physical Medicine & Rehabilitation, 90(3), 429-434.

Strong, S., Baptiste, S., Clarke, J., Cole, D., & Costa, M. (2004). Use of functional capacity evaluations in workplaces and the compensation system: A report on workers’ and report users’ perceptions. Work, 23(1), 67-77.

Seeing people progress

A quick post this morning before I search for some Friday funnies!
I saw a few patients this week after having had just over a fortnight off work – and you know how sometimes working in pain management can seem unrewarding, progress can be incredibly slow, one step forward, two sideways… Well here are some progress reports from some of the people I’ve been seeing (names and details changed to protect identities).

Hypnosis for intermittent phantom pain
First up is a man with a 10 year history of below knee amputation. He wears a prosthesis, is fit and active, and until late last year was working full time. Over the latter half of last year he developed intermittent severe stabbing phantom pain (prior to this he had phantom sensation with some stump pain but never phantom pain). He initially tried to fight against the pain, holding his breath and tensing up – but as the length of the pain episode could be up to four or five hours, he found he couldn’t maintain his work, so has stopped. He’s been working with me and the rest of the team off and on over the past six months, and although he’s tried just about all the medications available, his pain hasn’t changed one iota.

He’s someone who readily took to using mirror therapy, but found that after a couple of months the effectiveness of this wore off, and the illusion that the reflected leg was his own wasn’t as strong. He’s adopted going ‘with’ the pain and breathing through it rather than fighting it, and he’s developed an effective visual imagery strategy that he finds really helpful provided that he’s lying down to achieve it. That kind of gets in the way of the rest of his activities – swimming, going to the gym, cycling and generally living life!

We’re now working on some cued hypnosis, so that while his pain may not be reduced, he may be able to ‘distance’ himself from it, and be able to do this in a range of settings so he won’t need to stop what he’s doing to ‘deal with’ the pain. He is continuing with two more medication trials, but if they don’t change his pain he’s told me he will be no worse off than he is now. Once he’s got his hypnosis ‘portable’ he intends to start looking at his work options.

My reasoning for using hypnosis lies with his strong ability to visualise and imagine his limb, his well-developed relaxation response, the intermittent nature of his pain meaning he needs something he can draw on as required, and that he is looking for something ‘portable’. I’ve started with deep relaxation, moved onto visualisation, then to quick inductions, and now we’re working on strengthing a physical cue while he’s deeply relaxed (pressing finger and thumb together while increasing the suggestion that he’s feeling really relaxed and that while he is aware of things, ‘nothing is bothering him’). The next step is to do what I call ‘porpoising’ which is where we dip in and out of a deeply relaxed state to full awareness, pairing the ‘awareness’ state with the physical cue.

Working on self efficacy for return to work
The next person I’ve caught up with is a man who’s been off work with nonspecific low back pain for about 2 years. When he first came to see us he was very fearful of moving, he thought there was ‘something wrong’ with his back that meant he shouldn’t bend, and he was very deactivated. He used a stick, and walked unsteadily and very, very slowly. As a previously very fit man with a history of competitive team sports and having been in the military, this was an incredibly frustrating experience for him.

As a family, he’d moved from being an earner to being quite settled in the caregiving role for their young child. His wife worked full time but also carried out most of the household activities – including mowing the lawns, cleaning the car, doing the laundry.

This man had no confidence at all in his ability to return to work – he thought his medication would interfere with functioning (and it probably did – he was very drowsy after using meds ‘as needed’), he was fearful of telling anyone about his back pain, and he thought he had no skills for work given that he wasn’t even able to carry out a full day’s household activity. His past employment was physically demanding and he thought he wouldn’t be able to study because of his medication. After completing a self efficacy measure for returning to work, where 1 = ‘not at all confident’ and 10 = ‘completely confident’, over the three domains of ‘managing pain’, ‘asking for help’, and ‘fulfilling job demands’, his average score was just 2.5.

I should add that this man has attended the three week interdisciplinary CHOICES pain management programme, and also had a 12 week individualised programme with myself, physiotherapy and clinical psychology – so he’s had the full house of pain management over about six months.

The part I’ve played has been to review his coping strategies, and identify the ‘obstacles’ to using these at work. We’ve looked at his beliefs about the various coping skills and why he thought he couldn’t use them at work, and identified those that he can and those that are better used when he gets home. We’ve worked on effective communication. We’ve discussed ACC and the process case managers need to follow. We’ve set goals and developed a daily routine. We’ve reviewed setbacks and flare-ups and looked into the chain of events leading to ‘high risk situations’ in which he’s chosen to revert to old habits. We’ve tweaked his suite of coping strategies so that he has lots of options for ‘what to do’ in the event of pain fluctuations. He’s minimised his use of ‘as needed’ medication which has reduced the side effects that do interfere with his functioning. He’s studied and achieved a very good pass in his exams for his chosen field of work – and used the studying as an opportunity to practice active coping, persisting with activities despite fluctuations in pain, and working with his slightly reduced concentration and memory.

Yesterday he turned up in suit, shirt and tie, looking absolutely spiffing. He’s got brochures introducing himself to potential clients. He’s reorganised his life so he and his wife share child care. He’s fit and working towards a specific fitness goal (to play in the Masters tournament). He’s coped with several setbacks – successfully! He’s even participated in a functional capacity evaluation that he knew would temporarily increase his pain – and managed this without reverting to ‘old habits’. On a re-test of his self efficacy for return to work, over the three domains, his mean score is now 9.8.

You know, someone once told me that people with pain are often ‘losers’, or ‘non-copers’. While there are some people who are certainly much more vulnerable to life’s misfortunes, and perhaps haven’t had the advantages I have, the two people I’ve just described are amongst the strongest, most resilient people I’ve met. Maybe their experience with coping with chronic pain has been their opportunity to transform their lives, and maybe I, along with the rest of the team, have been a small part of that transformation. All I can say is that it’s an incredible privilege to work with people like this – and see their progress.

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

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

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

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

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

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

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

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

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

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

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

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

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

More pain sites over time = greater risk of work disability
It struck me today, as I spent a little time with two people who have been returned to Pain Management Centre for a review of their progress, that something we don’t do very well is help people distinguish between an acute or new problem and what might be a flare-up of the old chronic problem. And by ‘we’ I mean all health providers.

Ok, so that the problem is there is not really so surprising – after all, helping clinicians work out that chronic pain doesn’t respond to acute pain management is quite a change of focus (from short-term cure to long-term management), but I guess I hadn’t really thought through how to help people deal with new pain problems as they arise.

Let me illustrate what I mean. Gary (not his real name, and other details are also disguised to protect privacy) has returned to work after nearly five years since his injury. The original injury was a crush injury to his foot and he was left with a complex regional pain syndrome. For at least the first three years he believed, because he was told by surgeons, that surgery would ‘fix’ the problem – and it was a case of him simply waiting for the surgeons to decide what the best surgical option would be. Unfortunately, his foot pain didn’t respond to surgery and he’s ended up with an arthrodesed ankle and chronic pain. The pain is not resolving – but he is feeling quite confident about how to manage it after completing a pain management programme and with some individual input to help with his mood and return to work planning.

Unfortunately, he’s hurt his knee now. He came off a ladder and landed awkwardly on his knee about five months ago. Initially his GP suggested that he simply wait for it to settle, but Gary had learned from his foot problem that it’s better to get on with moving it – and he didn’t want to risk his return to work planning. So he got a knee brace, had some physiotherapy, and carried on. After about two months, he saw a surgeon who said his knee didn’t need surgery right now although it was a little ‘sloppy’ in the ligaments, so Gary should keep on with his exercises, be ‘careful’ and wait for a while before considering a surgical review.

Now the point of this is that Gary didn’t know whether his knee pain was something he should worry about, or whether it was something he should treat as he does his foot pain – using pain management strategies. I’m picking that he found it hard to know whether he was going to do further damage by using his knee normally (ie what are the risks from using a ‘sloppy’ knee), given that he knows that his foot pain is no longer related to damage.

It seems likely that if someone has a central sensitisation problem, for example, they develop a CRPS, the chance of their nervous system responding similarly to another trauma is quite high. A similar case might be someone who has fibromyalgia, with widespread body pain, and a sensitive nervous system – a person in this situation may also be quite likely to take a long time for post-traumatic aches and pains to settle down.

BUT I don’t think I routinely mention this to people I’ve worked with.

What might the implications be for someone who has a chronic pain problem, and then develops a new, acute pain? Well, given the difficulty we find with treatment providers switching from acute management to chronic management, I think the same old problems are likely to rise. Lots of investigations to work out why the pain isn’t settling as it ‘should’ (and as it would if there wasn’t an underlying central nervous system sensitivity), and lots of passive treatments to reduce the pain – but if the pain isn’t directly related to the acute tissue disruption, then it’s unlikely to respond to these treatments – and I’m sure yet more investigations and treatments are tried.

Let’s take a step back and look at whether there are differences between acute management and chronic management.

  1. In acute management, for the majority of problems (and I’m racking my brain to think of one actually) we ask people to start doing things normally as soon as possible – pain doesn’t have to be completely gone before we encourage people to get moving.  In chronic pain management, we ask people to do things despite pain.
  2. In acute management, we encourage a ‘start low and go slow’ approach to increasing activity.  We do the same in chronic pain management.
  3. In chronic pain management, we recognise the pain is a stressor, and that there is a relationship between having pain and physiological arousal.  In acute pain, the same phenomenon occurs.

So is the main difference is in determining the end goal of treatment? – in acute pain management, we are relatively certain that pain will eventually subside.  In chronic pain management, we are relatively sure that pain will persist.    So we are really looking in both cases at encouraging a focus on function – but in acute pain, the ‘end point’ is often reaching when the pain reduces.

I wonder whether we need to focus on using the same cognitive behavioural approach to self managing many acute problems that we use for chronic pain. And maybe we should consider whether we need to advise people who have chronic pain of their susceptibility to pain in other parts of their body and manage that pain accordingly.  It might just save an awful lot of money on treatments for ‘acute on chronic’ low back pain (just what is that, really?), or for ‘acute back pain’ when the low back pain has never really gone away…

I included this study from Norway, because I think it illustrates something that we observe very often.  I call it ‘recycling’, but other people call it ‘frequent fliers’ – people who have pain in more than one part of their body are more likely, at least in this study, to eventually move onto Disability payments, and stop work.

I don’t think this is simply the effect of a person having trouble coping with the additional burden of pain – I think it’s much more about a systems problem.  If the participants in this study engage with the health system each time they develop a new pain site, the chance of their encountering another provider who follows an acute pain management model (with all that can entail when problems fail to resolve) is pretty high. And with each new encounter with a health provider challenging their own belief in their ability to self manage, these people have a real struggle to remain confident that they can do things despite their various pain.

For this week I’m going to focus on follow-up and effective use of the health care system – care to join me on this journey?  If you do, you can subscribe using the RSS feed link above, or you can just bookmark this page and come back.  I do write most days during the week, and I do love comments.  If you don’t want people to read your comments, you can send them to me via the ‘About’ page which gets sent directly to my email, otherwise they’ll appear on here for others to respond to.  I’m looking forward to hearing from you!

Kamaleri, Y., Natvig, B., Ihlebaek, C., & Bruusgaard, D. (2009). Does the number of musculoskeletal pain sites predict work disability? A 14-year prospective study European Journal of Pain, 13 (4), 426-430 DOI: 10.1016/j.ejpain.2008.05.009

Returning to work is a complex business
There have been many studies looking at factors that can be used to predict whether a person will return to work after developing pain. Many, quite naturally, look at factors relevant to acute and subacute pain problems, aiming to reduce the number of people eventually progressing to longterm disability. Some people will slip through these interventions – for many reasons – and the news for returning to work is not good for those who do have extended periods of time away from the workforce.

The factors that might precipitate stopping work in the acute or subacute stages may not be the same as those involved in maintaining longterm disability. For example, it’s well known now that pain-related fear and avoidance can influence people’s initial disability (see Prkachin, Schultz,& Hughes, 2007), but studies looking at whether interventions to reduce avoidance behaviour through psychosocial methods haven’t been entirely positive (e.g.Frost, Haahr,& Andersen, 2007).

Marois and Durand describe a descriptive correlational study of over 200 people with work disability who participated in the Canadian ‘Previcap’ work rehabilitation programme.

This programme is a roughly 12 week interdisciplinary programme based on the ‘Sherbrooke’ model (go here for a nice powerpoint by Patrick Loisel on this programme).  The programme has three components –

  1. Work disability diagnostic interview, which is intended to ‘rule out a serious medical diagnosis and to formulate a diagnosis based on one or more factors explaining long term work disability of musculoskeletal origin.’
  2. Preparation for Therapeutic Return to Work – clinic-based interdisciplinary rehabilitation
  3. Therapeutic Return to Work – graded exposure to a real work environment

Participants in this study had been enrolled in these programmes and included in this study if they had persistent musculoskeletal pain, an existing employment relationship (i.e. had a job to return to), and had been completely off work for a minimum of 12 weeks.

Data was collected twice during the participants progress through the Previcap Programme – once at the initial assessment, and again at completion of the programme.  I’m not going to go through the method or measures, suffice to say that 83 different factors were measured, and the authors state that ‘these variables … include most of the factors identified in the literature as being associated with long-term work disability during the sub-acute phase’.  Several additional factors were added by a committee of clinicians.

Work status was measured at the end of the programme in terms of ‘back at work’ full time or part-time, or ‘able to go back to work’ but had no job available or had non-musculoskeletal problem reasons for not returning.  The final group were ‘unable to return to work’ related to their musculoskeletal problem.

I don’t want to go into any detail with regard to the analysis undertaken – suffice to say that it involved a lot of logistic regression both multivariate and univariate!  The full details are described in the article itself.  What is interesting are the characteristics of the people in the programme, and the findings themselves.  What is even more interesting are the implications.

Cutting to the chase: the participants were around 40 years old, had an average time off work of 31 weeks, particpated in the Previcap Programme for about 15 weeks or so, and mainly, returned to work – more women than men did so, however.

The factors that ended up predicting return to work were different for men and for women, and three different models of return to work were developed.  Out of the original 65 factors measured, only 17 were retained – and these were mainly work related and psychosocial.

So, what were they?

The key ones from this study for the ‘general’ model were:

  • diagnostic labelling
  • fear of aggravating symptoms
  • no light duties
  • awkward postures needed at work
  • static work postures needed
  • longer time on the Previcap Programme

For the men’s model:

  • diagnostic labelling
  • absence of musculoskeletal history requiring time away from work
  • longer time away from work
  • no light duties
  • longer time on the Previcap Programme

For the women’s model:

  • higher psychological distress
  • fear of aggravating symptoms
  • presence of recent personal events
  • presence of work equipment that is unsuitable

Of lower odds ratio, a common factor for all models was the person’s perception that treatment had failed.

These models were able to predict between 84 – 96% of those who returned to work, but were less successful at identifying those who didn’t do so (37 – 48%).

So, where does that leave us?

Now first of all, some interesting things to ponder.

At least in New Zealand, people who still have an employment relationship are more likely to return to paid employment than those who don’t. Three months isn’t a long time in the rehabilitation game, but it is to an employer who needs to have someone on deck to keep the wheels of industry turning.  In another roughly three months, (six months total time away from work) some estimates suggest that the chances of returning to work are around 50% (see Waddell, 2004 for example), while by 12 months, the chances have reduced to around 10% or less.  So my best guess is these people were slightly different from those in New Zealand – after roughly 30 weeks off work, I’m not sure that as many NZers would still have jobs to return to.

Another point to consider is the way ‘able to return to work’ is measured. I can readily understand those who do return to their original job (either in suitably selected or reduced hours), but when someone is judged ‘able’ to return to work in the absence of actually testing it in the real workplace, I’m suspicious.  Read here for a great discussion of ‘designated guessers‘ by Dr Jennifer Christian.

There are several factors that seem to need to line up for someone to return to work IMHO: they need to believe at some level that they can be successful, they need to believe they won’t harm themselves – and that they have what it takes to cope.  There also need to be suitable work duties and employer support, and the support from a health provider (preferably someone familiar with the workplace).

The factors that were associated with unsuccessful attempts to return to work were quite interesting. I’m not at all surprised by the finding that men with a shorter period of time in employment at that place of work were less likely to re-engage.  For women, attempting to return to work but failing (notably because of increased pain), and ‘wanting’ to return to work were both associated with poorer outcome.

The authors suggest that ‘wanting’ to return to work might be influenced by social desirability in women – I’d suggest there could be a lot of reasons for women to say they want to return to work, but not be able to, including the influence of others (who benefits when a woman doesn’t return to work?) and logistic problems around re-engaging in the work role alongside other occupational demands for women (transport to and from work, integration of grocery shopping, childcare, household management and so on).

Another interesting finding is the relationship between health services factors and return to work – the person’s perception that health care has failed (maybe a mismatch between expectations and results?), and, in men at least, duration of a work rehabilitation programme.  Perhaps this means more time to address the obstacles that are identified by the person, maybe it’s partly the mediating role that health providers can play to liaise between the person and the employer (acting as a buffer to set limits perhaps).

More on return to work and similar things tomorrow – sorry for the length of this post, but returning to work is a complex business!

If you’ve enjoyed this post, and want to continue reading – subscribe using the RSS feed link above, or you can bookmark and return at your leisure.  I post most days during the week, and love comments and discussion.

Marois, E., & Durand, M. (2009). Does participation in interdisciplinary work rehabilitation programme influence return to work obstacles and predictive factors? Disability & Rehabilitation, 31 (12), 994-1007 DOI: 10.1080/09638280802428374
Frost, P., Haahr, J. P., & Andersen, J. H.(2007). Reduction of Pain-Related Disability in Working Populations: A Randomized Intervention Study of the Effects of an Educational Booklet Addressing Psychosocial Risk Factors and Screening Workplaces for Physical Health Hazards. Spine 32(18),1949-54.
Prkachin, K. M., Schultz, I. Z., & Hughes, E. (2007). Pain Behavior and the Development of Pain-related Disability: The Importance of Guarding. Clinical Journal of Pain Vol 23(3) Mar-Apr 2007, 270-277.

The gap between pain management – and returning to work

One of the most satisfying experiences I have in my job is seeing someone who has been off work for ages finally return to work.  It’s like seeing the person open up and bloom again. 

I often see people who have been off work for several years – most of them don’t have jobs to return to, and most of them have experienced a couple of attempts to return to work that have, for some reason or another, failed.  Often pain is given the blame for this, and the remedy is thought to be ‘develop pain management skills’ – and I guess in part that’s true.  But not completely.

There is a difference between using pain management skills at home, where for the most part, activities can be picked up and put down as needed, and at work where other demands are present.  There’s an element of discretion about when and how things are done at home.  People can, if they want to, take it a bit quietly on days when their pain is worse, and fit things in more readily on days when they’re feeling better.  Not so at work!  At work we have to do things to fit into an external timetable – deadlines exist! There are jobs we have to do that are not so forgiving – we have to do them in a certain way, or at a certain time whether we’re feeling great or not.

And therein lies the one of the reasons I think there is a gap between pain management and returning to work.  There’s a whole lot more riding on being able to keep going at work.

Let’s take a case like Allan.  Allan has been off work for three years now.  Before his accident he’d been working for two years as a night supervisor in a food production factory, and before that he’d been the primary caregiver for his wee girl who is now 8 years old.  And before that he’d been a professional athlete.

When he hurt his back he thought it would resolve quickly – but after a series of unsuccessful nerve blocks attempting to ‘find and obliterate the cause’ of his pain, and after two multidisciplinary physical rehabilitation programmes, he finally had to accept that his back pain wasn’t going to just go away.

He lost his job after he tried to return to work for about six weeks on a graduated return to work programme.  Allan had an occupational therapist visit his work place and was advised that he could do X, Y and Z tasks – but this wasn’t practical given the nature of the work, not even as a supernumerary.  Like many employers, his employer didn’t have any ‘selected duties’, and needed to employ someone else to cover Allan’s shift, and eventually told Allan that he couldn’t come back to work until he could manage certain tasks.  Allan’s employer terminated his employment after both of them decided that he wasn’t going to make it back in the next two or three months.

Allan was finally referred for pain management, and attended a three week interdisciplinary pain management programme.  He struggled with many of the concepts, particularly activity regulation (pacing was his least favourite word!), and he experienced panic when trying to use relaxation techniques.  He had been using a walking stick, and although he tried to stop using it during the programme, shortly afterwards he fell, and the stick became an ongoing fixture.  Allan was trying very hard to learn how to do things differently – but needed another twelve week programme of pain management using a cognitive behavioural approach before he could consistently maintain even his normal home activities.

Work was out of the question initially.  Allan’s confidence was shot – he knew he could do ‘some’ pain management, but much of what he did involved minimising fluctuations in pain, and when he did have an increase in pain he’d either push himself very hard to ‘get the job done’, or he’d use medications or rest to get through the tough patch.

Let’s make one thing clear, Allan really wanted to go back to work.  He told me he felt worthless, not a ‘real man’ because he wasn’t providing for his family and he felt trapped in his own home.  His confidence though, was at rock bottom.

The specific issues he saw as obstacles to going back to work were:

  1. Managing his pain without resorting to prn medication
  2. Coping with the side effects of his medication
  3. Confidence to tell an employer that he would be reliable
  4. Confidence he could be reliable and work consistently
  5. Confidence to be assertive and let others know what he could and could not do
  6. Worry that he would increase his pain and the other important aspects of his life would be under strain
  7. Feeling out of touch with the technology and specific skills in the workplace
  8. Not knowing how to present himself positively in a job interview – how would he answer those tricky questions about the time he’s had off work and about his health?
  9. Knowing his own functional abilities – he knew what he couldn’t do, but not what he could rely on doing consistently
  10. Identifying specific job options now that he couldn’t work the way he used to

You can see that the gap is not just about job seeking skills, although that’s certainly a part of it, but it’s also about how to use his skills to be reliable at work – to experience pain but persist and be consistent with his output.

How confusing it would be for Allan to be seen by a vocational provider who had a limited knowledge of chronic pain management.  How scary would it be for Allan to start to return to work after having failed in the past.  How demeaning to feel inadequate about his own skills and lack confidence to ask for help not only with every day work technology, but also with his pain (after all, that’s what lead to his loss of job early on).

The literature on returning to work after illness or injury is clear.  It’s not simply about coping with pain, it’s not simply about coping with disability, it’s not just about finding work, it’s not just about the person with the pain problem.  Vocational management is anything that helps a person remain at work or return to work – and it includes all of us on the team, including the employer.

For the most extensive review on vocational management that has been published recently, go to here for the executive summary of the report into vocational rehabilitation ‘What works for Whom’ by Waddell, Burton & Kendall (2008). 

Go here for a great set of downloadable documents about work and health (Working for Health, UK government)

And of course, RTW Matters  (Australasian) and ACC (New Zealand) Return to Work search page

Fantastic resource

Blatant advertising today! I’m blown away by the content available in RTW Matters.  I occasionally get to write a column for them, so I’ll own up to that right now, but despite my bias – this list of topics is exactly what I’d like everyone in pain management to read (and these ones are free! – there is a subscriber service with more content too)

Take a look at these topics:

Facilitators and Barriers to Return to Work: A Literature Review (Australia – Institute for Primary Care)

On Giving Advice to People Who Are Coping with Disability / Impairment at Home or Work
(US – Webility)

Are People with Disability at Risk at Work – A Review of the Evidence (Australia – Safety and Compensation Council)

But wait – there’s more!

Tools for healthier lives (US – Mayo Clinic)

Glossary of jargon words often used in medicine (UK – Bandolier)

The winter fitness survival guide (Australia – ABC)

Do I need to go on?
I haven’t even started to list the resources for health providers…

Seriously, if we work in the area of chronic pain, we need to know about anything and everything that will help our clients/patients return to work. Working is normal, healthy, and an important part of our lives. Without working, people’s health suffers. Two references to read and ponder if you’re not convinced that working is healthy…(thanks to Dr JA for his links to these two references)

Bamia, C., Trichopoulou, A., Trichopoulos D., (2008). Age at retirement and mortality in a general population sample: the Greek EPIC study. American Journal of Epidemiology, 167, 561-569.

Tsai, SP., Wendt JK., Donnelly, RP., de Jong, G., Ahmed, FS. (2005). Age at retirement and long term survival of an industrial population: prospective cohort study. BMJ doi:10.1136/bmj.38586.448704.E0.

A couple of other links for RTW info:
rtw knowledge
Institute for work and health

Where pain management meets vocational rehabilitation

I had a conversation with a case manager yesterday.  The pain management team had asked for the inclusion of several sessions with me to look at coping with pain at work, along with some anxiety management and some exercise extension for a chap who has been off work for about two years with chronic low back pain.  The case manager seemed mystified as to why I might need to work with this man, saying ‘but we’ve already got a vocational plan in place’.

I asked about the plan they had – it involved developing a good working CV/resume, obtaining a work trial, supervising that work trial, helping him develop effective interview skills, and getting him used to the routine of working again.  A good plan for returning to work.

Let me backtrack for a moment to take you through our reasoning for asking for input from me.

This man has been extremely deactivated – worried about harming himself if he moved.  He’d been depressed.  When he had a flare-up of pain he’d stopped everything he was doing.  He was very distressed about the changes in his functional abilities because he’d previously been a very fit and you could almost say ‘go-getting’ man, and for two years he’d been so scared of moving that he’d hardly left the home.  It had taken a long time for him to begin to gain confidence to move from his home environment to community settings.

He’d had some good pain management and had started to develop and use active coping skills – but in his home only.  He had some very strong beliefs about what a man ‘should’ and ‘should not’ do, and more than that, he had very strong beliefs about what an employer would tolerate.  This lead him to push himself very hard to be ‘normal’ and not accommodate his functional limitations – and you’ll know the consequences of that! Yes, he’d have a flare-up and become deactivated, despondent and distressed.

Over time he had begun to use his coping skills reasonably consistently within his home environment.  As he put it, ‘At home I know I’m the only one who is going to get worried if I leave something until later’.  But when someone came to visit who might judge him, he’d do everything he could to ‘get it all done’ – the coping strategies completely forgotten.  When we discussed going back to work with his pain – his comment was that he knew he would revert to this pattern, so his confidence to be at work – and remain there – was very low, even though working was important to him.

In fact, you could say that working was so important to him that it elicited his internal ‘shoulds’ and ‘should nots’ so he was bound to avoid using active coping skills because it was so important that he do everything to meet the expectations of his employer.  A high risk situation if ever there was one!

There was clearly a gap between his use of active coping skills at home, and his ability to manage his pain in a work situation.

Now while I value my colleagues immensely, and wouldn’t work without them, we each have an area of expertise. 

My psychology colleagues are brilliant at working with thoughts, beliefs, and introducing concepts of pain management – and yes, developing behavioural change plans. 

My physiotherapy and occupational therapy colleagues are great at helping people develop and use skills to increase activity level and engage in coping skills. 

BUT my area of expertise is the workplace – knowing about the factors that influence behaviour at work, the social and interpersonal situations, the unwritten ‘rules’ of work, the specific demands that are different about the workplace from home or social settings.

When the case manager I spoke to said ‘but why can’t the psychologist help him get confident to do pain management at work’ she had a point – that’s definitely something they can do to a certain extent.  But given the amount of time clinical psychologists get during training to learn about specific workplace and return to work factors (especially those specific to returning to work with chronic pain), that’s a little unfair (especially given the rest of the work our psychologist had to do with this man anyway!).

Knowing about pain management coping skills is one thing.  Knowing which skill to apply when, and how within the context of a workplace is a completely different thing.  It’s complex.  It’s about being cognitively flexible.  It’s about problem-solving on the fly. It’s about feeling OK about having different ways of doing things from before the pain started, and from the way other people do things. It’s about being assertive and telling people about functional limits – admitting vulnerability.  This is not easy to do when you’re a man who has prided yourself in being ‘strong’.

Simply telling someone to ‘get on with it’ and use the skills they know about in a workplace can sometimes work.  But for some people, and especially those who have very strong beliefs about how things ‘should’ be done, and those who have other vulnerabilities such as low mood, anxiety, pain-related anxiety and avoidance, or an extended period of time away from work, there is more required.

Vocational providers, by and large, are great at helping people look for work, identifying their skills, linking functional abilities to the tasks demanded in a workplace. 

But there are some things that are not always handled well – does the provider have a good grasp of chronic pain management? Do they use consistent models, do they support the strategies that the pain management provider has helped a person develop?  Do they recognise that people with pain have different vulnerabilities – some tend to over-do, as in this man’s case, while some under-do?  And how do they respond to this?  What is the scientific basis for the programme they develop for the person?

There is a dire need to develop really strong links between pain management and vocational management in New Zealand.  The workplace represents one of the contexts that people with pain identify as ‘high risk’ situations – or a situation where they are least likely to use their newly developed coping strategies.  This means additional and specialised help can be needed.  It means skills need to be robust, and professionals helping the person return to work need to be consistent in their approach.

I can’t tell you whether I’ll be able to work with this man.  What I will do is support the team to address some of the contextual issues that are common in the workplace.  And hopefully encourage providers to read more about the process people go through to return to work, so that the right support is given to the right person at the right time.

RTW Matters!

My copy of the weekly update from RTW Matters has arrived with some great new articles for people working in the field of helping others return to work.
If you haven’t been there before, head on over to take a look at the free stuff, then if you’re excited by it, think about subscribing. It’s well worth it with some of the most prominent researchers and workers in the field contributing from their experience.
Some of the articles this week:

  1. Comparing Australian and New Zealand rates and duration of durable and non-durable RTW over time
  2. Early intervention and good communication: everyone’s responsibilities. The top points from the Dr William Shaw interview.
  3. oh, and yes there’s one from me! New Zealand’s Bronnie Thompson looks at the next steps back to work – looking broadly at the path forward.

Why should we look at return to work for people with chronic pain?
Well, lots of reasons actually, but some of the most consistent findings are that people who return to work are healthier than those who don’t. In fact, being off work increases the risk of ill health (Waddell & Burton, 2006).

The link between work disability and receiving compensation means that those who continue to be off work are often still engaged in a health care system such as insurance or ACC (in NZ) that means the person has to maintain ‘disablement’ or illness behaviour to retain compensation – this means repeated assessments, programmes and justification to both health providers and the compensation provider that the person is still unfit. This isn’t conducive to people living a full and healthy life. (Hadler, 2006)

Is return to work a legitimate part of pain management? Well, apart from the need to specifically address it as an outcome for general health reasons, many people give poor pain management as their reason for not returning to work. There is no doubt that for some people, functional limitations do prevent their return to specific tasks permanently. For many, however, it’s the sense of self efficacy, or confidence to reliably manage their pain and function at work that limits their actual return.

While authors like Gordon Waddell, Kim Burton & Nick Kendall (Vocational Rehabilitation: What works, for whom, and when? 2008) suggest that ‘Vocational rehabilitation [is] defined as whatever helps someone with a health problem to stay at, return to and remain in work: it is an idea and an approach as much as an intervention or a service’, and needs to start immediately, they also state that ‘the evidence in this review shows that effective vocational rehabilitation depends on work-focused healthcare and accommodating workplaces. Both are necessary: they are inter-dependent and must be coordinated.’

I’d suggest that separating vocational management efforts from health care and especially pain management (as has happened over the past few years in New Zealand) is not effective. Both elements need to be integrated, so that the two efforts support each other.  If that means pain management needs to learn about how people experience the workplace and help them develop effective coping skills that can be used at work, then so be it! Similarly, if vocational providers need to learn about effective chronic pain management so they can provide a consistent message that hurt does not equal harm and pain should not be a guide – then so be it.