Effectiveness of Workplace Interventions in Return-to-Work for Musculoskeletal, Pain-Related and Mental Health Conditions: An Update of the Evidence and Messages for Practitioners.

Purpose The objective of this systematic review was to synthesize evidence on the effectiveness of workplace-based return-to-work (RTW) interventions and work disability management (DM) interventions that assist workers with musculoskeletal (MSK) and pain-related conditions and mental health (MH) conditions with RTW. Methods We followed a systematic review process developed by the Institute for Work & Health and an adapted best evidence synthesis that ranked evidence as strong, moderate, limited, or insufficient. Results Seven electronic databases were searched from January 1990 until April 2015, yielding 8898 non-duplicate references. Evidence from 36 medium and high quality studies were synthesized on 12 different intervention categories across three broad domains: health-focused, service coordination, and work modification interventions. There was strong evidence that duration away from work from both MSK or pain-related conditions and MH conditions were significantly reduced by multi-domain interventions encompassing at least two of the three domains. There was moderate evidence that these multi-domain interventions had a positive impact on cost outcomes. There was strong evidence that cognitive behavioural therapy interventions that do not also include workplace modifications or service coordination components are not effective in helping workers with MH conditions in RTW. Evidence for the effectiveness of other single-domain interventions was mixed, with some studies reporting positive effects and others reporting no effects on lost time and work functioning. Conclusions While there is substantial research literature focused on RTW, there are only a small number of quality workplace-based RTW intervention studies that involve workers with MSK or pain-related conditions and MH conditions. We recommend implementing multi-domain interventions (i.e. with healthcare provision, service coordination, and work accommodation components) to help reduce lost time for MSK or pain-related conditions and MH conditions. Practitioners should also consider implementing these programs to help improve work functioning and reduce costs associated with work disability.

Comparing current definitions of return to work: a measurement approach.

INTRODUCTION: Return-to-work (RTW) status is an often used outcome in work and health research. In low back pain, work is regarded as a normal activity a worker should return to in order to fully recover. Comparing outcomes across studies and even jurisdictions using different definitions of RTW can be challenging for readers in general and when performing a systematic review in particular. In this study, the measurement properties of previously defined RTW outcomes were examined with data from two studies from two countries. METHODS: Data on RTW in low back pain (LBP) from the Canadian Early Claimant Cohort (ECC); a workers' compensation based study, and the Dutch Amsterdam Sherbrooke Evaluation (ASE) study were analyzed. Correlations between outcomes, differences in predictive validity when using different outcomes and construct validity when comparing outcomes to a functional status outcome were analyzed. RESULTS: In the ECC all definitions were highly correlated and performed similarly in predictive validity. When compared to functional status, RTW definitions in the ECC study performed fair to good on all time points. In the ASE study all definitions were highly correlated and performed similarly in predictive validity. The RTW definitions, however, failed to compare or compared poorly with functional status. Only one definition compared fairly on one time point. CONCLUSIONS: Differently defined outcomes are highly correlated, give similar results in prediction, but seem to differ in construct validity when compared to functional status depending on societal context or possibly birth cohort. Comparison of studies using different RTW definitions appears valid as long as RTW status is not considered as a measure of functional status.

Disability management outcomes in the Ontario long-term care sector.

INTRODUCTION: Optimal disability management practices supporting early and safe return-to-work involve the workplace adoption of formal policies and procedures to ensure the quality of disability management outcomes. In the Canadian province of Ontario, there are approximately 60,000 health care workers in 600 licensed facilities providing long-term residential care to approximately 75,000 elderly residents. Workers in this sector are exposed to high biomechanical demands arising from care-giving tasks and have a substantial risk of work-related disability. Over the period 2000-2006, many long-term care facilities in Ontario adopted disability management practices that encourage modified work arrangements. The objective of this study was to describe differences in modified work arrangements and disability outcomes in long-term care facilities in Ontario. METHODS: Measures of disability episode outcomes are described for a representative sample of 32 Ontario long-term care facilities for two consecutive years 2005 and 2006. Data were obtained from a questionnaire survey of facilities, a survey of a representative sample of caregivers and administrative records from the provincial workers' compensation agency. RESULTS: A total of 28,747 days of disability attributed to work-related conditions were experienced by 3,271 full-time equivalent staff in 2005 (28,034 days in 2006). Average total disability days were 922 per 100 full-time equivalent staff in 2005 and 889 per 100 full-time equivalent staff in 2006. Disability compensation expenditures, measured as wage replacement benefits received by disabled workers, were estimated to be $72,332 per 100 full-time equivalent staff in 2005 and $64,619 per 100 full-time equivalent staff in 2006. On average, approximately 60% of all disability days were managed by modified duty arrangements and the proportion of total disability days managed by modified duty arrangements for each facility was correlated between the two observation years. CONCLUSIONS: Across facilities, there was no evidence that modified duty arrangements were associated with lower disability compensation expenditures and there was mixed evidence that modified duty was associated with a lower burden of disability. In this setting, disability days managed by modified duty arrangements were not accurately documented in worker's compensation claim records.

Identifying phases of investigation helps planning, appraising, and applying the results of explanatory prognosis studies.

OBJECTIVE: To present an explanatory framework for understanding prognosis and illustrate it using data from a systematic review. STUDY DESIGN AND SETTING: A framework including three phases of explanatory prognosis investigation was adapted from earlier work and a discussion of causal understanding was integrated. For illustration, prognosis studies were identified from electronic and supplemental searches of literature between 1966 and December 2006. We extracted characteristics of the populations, exposures, and outcomes and identified three phases of explanatory prognosis investigation: Phase 1, identifying associations; Phase 2, testing independent associations; and Phase 3, understanding prognostic pathways. The purpose of each phase is exploration, confirmation, and development of understanding, respectively. RESULTS: It is important to consider a framework of explanatory prognosis studies for: (1) defining the study objectives, (2) presenting the study methods and data, and (3) interpreting and applying the results of the study. CONCLUSION: When conducting and reporting prognosis studies, researchers should consider the approach to prognosis (explanatory or outcome prediction) and phase of investigation, use best methods to limit biases, report completely, and cautiously interpret results. Readers of health care research will then be better able to evaluate the goals and interpret and appropriately use the results of prognosis studies.

The effectiveness of graded activity for low back pain in occupational healthcare.

BACKGROUND: Low back pain is a common medical and social problem associated with disability and absence from work. Knowledge on effective return to work (RTW) interventions is scarce. OBJECTIVE: To determine the effectiveness of graded activity as part of a multistage RTW programme. DESIGN: Randomised controlled trial. SETTING: Occupational healthcare. SUBJECTS: 112 workers absent from work for more than eight weeks due to low back pain were randomised to either graded activity (n = 55) or usual care (n = 57). INTERVENTION: Graded activity, a physical exercise programme aimed at RTW based on operant-conditioning behavioural principles. MAIN OUTCOME MEASURES: The number of days off work until first RTW for more then 28 days, total number of days on sick leave during follow up, functional status, and severity of pain. Follow up was 26 weeks. RESULTS: Graded activity prolonged RTW. Median time until RTW was equal to the total number of days on sick leave and was 139 (IQR = 69) days in the graded activity group and 111 (IQR = 76) days in the usual care group (hazard ratio = 0.52, 95% CI 0.32 to 0.86). An interaction between a prior workplace intervention and graded activity, together with a delay in the start of the graded activity intervention, explained most of the delay in RTW (hazard ratio = 0.86, 95% CI 0.40 to 1.84 without prior intervention and 0.39, 95% CI 0.19 to 0.81 with prior intervention). Graded activity did not improve pain or functional status clinically significantly. CONCLUSIONS: Graded activity was not effective for any of the outcome measures. Different interventions combined can lead to a delay in RTW. Delay in referral to graded activity delays RTW. In implementing graded activity special attention should be paid to the structure and process of care.

Prognostic factors for duration of sick leave in patients sick listed with acute low back pain: a systematic review of the literature.

BACKGROUND: The percentages of patients with acute low back pain (LBP) that go on to a chronic state varies between studies from 2% to 34%. In some of these cases low back pain leads to great costs. AIMS: To evaluate the evidence for prognostic factors for return to work among workers sick listed with acute LBP. METHODS: Systematic literature search with a quality assessment of studies, assessment of levels of evidence for all factors, and pooling of effect sizes. RESULTS: Inclusion of studies in the review was restricted to inception cohort studies of workers with LBP on sick leave for less than six weeks, with the outcome measured in absolute terms, relative terms, survival curve, or duration of sick leave. Of the studies, 18 publications (14 cohorts) fulfilled all inclusion criteria. One low quality study, four moderate quality studies, and nine high quality studies were identified; 79 prognostic factors were studied and grouped in eight categories for which the evidence was assessed. CONCLUSIONS: Specific LBP, higher disability levels, older age, female gender, more social dysfunction and more social isolation, heavier work, and receiving higher compensation were identified as predictors for a longer duration of sick leave. A history of LBP, job satisfaction, educational level, marital status, number of dependants, smoking, working more than 8 hour shifts, occupation, and size of industry or company do not influence duration of sick leave due to LBP. Many different constructs were measured to identify psychosocial predictors of long term sick leave, which made it impossible to determine the role of these factors.

Participatory ergonomics as a return-to-work intervention: a future challenge?

BACKGROUND: Participatory ergonomics (PE) are often applied for prevention of low back pain (LBP). In this pilot-study, a PE-program is applied to the disability management of workers sick listed due to LBP. METHODS: The process, implementation, satisfaction, and barriers for implementation concerning the PE-program were analyzed quantitatively and qualitatively for 35 workers sick listed 2-6 weeks due to LBP and their ergonomists. RESULTS: Two-hundred-and-seventy ergonomic solutions were proposed to the employer. They were targeted more at work design and organization of work (58.9%) than at workplace and equipment design (38.9%). They were planned mostly on a short-term basis (74.8%). Almost half (48.9%) of the solutions for work adjustment were completely or partially implemented within 3 months after the first day of absenteeism. Most workers were satisfied about the PE-program (median score 7.8 on a 10-point scale) and reported a stimulating effect on return-to-work (66.7%). Main obstacles to implementation were technical or organizational difficulties (50.0%) and physical disabilities of the worker (44.8%). CONCLUSIONS: This study suggests that compliance, acceptance, and satisfaction related to the PE-program were good for all participants. Almost half of the proposed solutions were implemented.