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

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

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

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.

Learning cognitive behavioural therapy: An illustrated guide

Despite this book being unrelated to pain management, I can’t go past this one for learning how to develop the basic skills in cognitive behavioural therapy.

It’s (you guessed it!) ‘Learning cognitive behavior therapy: An illustrated guide’ written by JW Wright, MR Basco & ME Thase, published by American Psychiatric Publishing, Inc, Washington, 2006.  It is one of the titles included in the ‘Core Competencies in Psychotherapy’ series, and was written to provide ‘an immersion in the fundamentals of each form of psychotherapy and explicitly addresses the seix core areas of competency needed in medical practice as outlined by ACGME and the American Board of Medical Specialties’. More importantly for me, it’s a really clear guide, based on firm evidence – and with a DVD to demonstrate how CBT is carried out.  Now that’s a bonus!  Just to top it off, purchasing the book allows you to photocopy the worksheets for clinical use (but not for organisations or people borrowing the book from libraries and so on).

What’s in the book? As expected for a book that aims to be a ‘core competencies’ resource, it covers the basics.  Basic principles, the therapeutic relationship, assessment and formulation, structuring and educating, working with automatic thoughts, behavioural methods, modifying schemas, common problems and pitfalls, treatment chronic disorders, building competence – and the worksheets and resources.

Included in each chapter are both structured learning exercises in which the reader is asked to carry out some elements of the CBT process (such as recognising automatic thoughts, questioning methods for core beliefs) and DVD illustrations of clinical encounters (with therapists acting as patients).  Throughout the book, clinical examples are used – sadly, they’re mental health cases, but you can’t have everything!  The writing style is very readable, and throughout, the reader is encouraged to consider his or her own situation.

What I liked about the book? the DVD to demonstrate one approach to approaching working with a client.  This is great when you’re not able to readily watch other therapists at work. It’s also helpful when you want to review how well you’re following CBT vs incorporating what you could call ‘eclectic’ practice!  I also liked the tables, the worked examples, the learning exercises – and the references and resources.

What I didn’t like about the book? Well, really, the only thing was that it’s not about chronic pain!

I thoroughly recommend this book as a basic text and a practical reference book for your clinical library. At US$55, it’s not too horribly expensive either.

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