A case of mistaken identity? The role of injury representations in chronic musculoskeletal pain.

PURPOSE: To explore how patients construe bodily injury, examine how injury representations change over the course of a rehabilitation program and how injury representations influence adaptation and recovery trajectories. METHODS: A case study method was used with qualitative interviews as the primary data source. Qualitative semi-structured interviews were conducted three times over the course of a 12-week intensive interdisciplinary occupational rehabilitation program with one interview 1 month following discharge. To capture changes in rehabilitation trajectories, data analysis employed a narrative approach informed by Bury (progression, regression, and stability) and Frank's (chaos, restitution, and quest) approaches. RESULTS: Sixteen patients (10 men and 6 women) were disabled as a result of persistent pain and impairment from a variety of work injuries participated. Progression/restitution narratives were characterized by the transformation of bone and nerve problems to include soft tissue elements. These participants expanded their scope of injury representations and appraisal to include neurobiological aspects of chronic pain and dimensions of psychosocial well-being, and linked diagnostic representations to self-management strategies in a functional manner. CONCLUSION: Body representations of injury morphology and pain mechanisms are important objects of fear and acceptance for injury recovery. Active strategies that encourage a "hands on" understanding of diagnosis may prove most effective in treating persistent pain. IMPLICATIONS FOR REHABILITATION: Patient representations of pain and body injury are windows into the personal experience of individuals with chronic musculoskeletal pain. When patients enter programs, practitioners need to assess what the patient believes is wrong with their body and what will be helpful in rectifying the problem. Based on their initial assessment, practitioners need to direct education and activity toward shifting patient beliefs to include elements of soft tissue and a broader scope of pain sensitization and psychological impact. Activity-based intervention is essential for creating coherence between injury and pain representations and coping action. During rehabilitation, practitioners need to monitor patient beliefs about their injury. Shifting beliefs are signs that the patient is adopting a more adaptive cognitive stance toward their injury. Lack of movement indicates that the message is not getting through and the approach needs to be modified. When working with patients to transform beliefs, a collaborative approach might be best to increase trust and reduce reactance.

Margin of manoeuvre indicators in the workplace during the rehabilitation process: a qualitative analysis.

INTRODUCTION: The task of evaluating workers' capacity to return to their pre-injury employment or other jobs continues to pose a daily challenge for clinicians. In this study, a concept frequently used in the field of ergonomics, the margin of manoeuvre (MM), was applied during the rehabilitation process. The study identified the indicators of the MM taken into account during the return to work of workers with musculoskeletal disorders. METHODS: This study used a multiple-case design. A case was defined as a dyad comprising a worker admitted to a work rehabilitation program and the clinician who was managing the return-to-work process. The results were then validated with investigators and expert ergonomists, through group interviews. Content analyses were performed using the conceptual framework for the work activity model adapted from Vézina and the procedures recommended by Miles and Huberman. RESULTS: A total of 11 workers, five clinicians, two experts and two investigators participated in this study. The interview analysis process resulted in a more detailed definition of the MM and the identification of 50 indicators. The indicators were classified according to six dimensions: (1) work context; (2) employer's requirements and expectations; (3) means and tools; (4) worker's personal parameters; (5) work activity; and (6) impacts of the work situation. CONCLUSIONS: The more specific indicators identified in this study will allow for more systematic observation of the MM. Subsequent studies will seek to link each indicator described in the model with a specific method of observation.

Workplace interventions for workers with musculoskeletal disabilities: a descriptive review of content.

BACKGROUND: Despite the convergence of scientific data to the effect that interventions in the workplace promote a healthy return to work, the interventions carried out in the real work environment appear to be very heterogeneous and ill-defined. OBJECTIVE: The goal of this review is to identify the different objectives pursued through the workplace interventions carried out in the context of a rehabilitation program, and to describe the activities involved. METHODS: A descriptive review of the literature, including various research designs, was carried out. RESULTS: This review reveals great heterogeneity in the content of interventions offered in the workplace to workers with musculoskeletal disabilities. The objectives of workplace interventions may range from gathering information in order to reproduce work demands in a clinical setting, to gradually exposing workers to the demands of the real work environment, or permanently reducing the demands of the work situation. A descriptive analysis of the literature also brings to light the diversity of actions carried out, human resources used, and workplace environments involved, while highlighting the few documented process outcome evaluations that have been done of workplace interventions. CONCLUSION: It is recommended that in future research in this area, efforts be made to better describe the components of the interventions, to develop process outcomes representing the multidimensional results obtained in the workplace, and to differentiate between temporary and permanent modifications made to the work situation.

Management of return-to-work programs for workers with musculoskeletal disorders: a qualitative study in three Canadian provinces.

In this qualitative research project, researchers in three Canadian provinces explored the perceptions of many different actors involved in return-to-work (RTW) programs for injured workers, studying their views on successful RTW strategies and barriers to/facilitators of the RTW process, then analyzing the underlying dynamics driving their different experiences. Each research team recruited actors in a variety of different workplaces and key informants in the RTW system, and used a combination of in-depth, semi-structured interviews and focus groups to collect data, which were coded using an open coding system. Analysis took a social constructionist perspective. The roles and mandates of the different groups of actors (injured workers; other workplace actors; actors outside the workplace), while sometimes complementary, could also differ, leading to tension and conflict. Characteristics of injured workers described as influencing RTW success included personal and sociodemographic factors, beliefs and attitudes, and motivation. Human resources managers and health care professionals tended to attribute workers' motivation to their individual characteristics, whereas injured workers, worker representatives and health and safety managers described workplace culture and the degree to which workers' well-being was considered as having a strong influence on workers' motivation. Some supervisors experienced role conflict when responsible for both production quotas and RTW programs, but difficulties were alleviated by innovations such as consideration of RTW program responsibilities in the determination of production quotas and in performance evaluations. RTW program success seemed related to labor-management relations and top management commitment to Health and Safety. Non-workplace issues included confusion stemming from the compensation system itself, communication difficulties with some treating physicians, and role conflict on the part of physicians wishing to advocate for patients whose problems were non-compensable. Several common themes emerged from the experiences related by the wide range of actors including the importance of trust, respect, communication and labor relations in the failure or success of RTW programs for injured workers.

Aging and shiftwork: the effects of 20 years of rotating 12-hour shifts among petroleum refinery operators.

The survey was conducted in a Canadian refinery where operators have been working rotating 12-hour shifts for 20 years. A multidisciplinary approach was adopted, based on 12 sources of data. Descriptive statistics and chronoergonomic observations were used. The most marked consequences of the schedule were observed among former shiftworkers. Among current shift workers, sleep deficit, chronic fatigue, health problems, and disruption of social and family life were the most serious effects observed. Aging and under-staffing, however, interact with schedule by necessitating overtime and reducing the actual number of rest days, which in turn affects fatigue and reliability. In the near future, the low replacement rate of the workforce and the limitations on reassignment of aging workers to day shifts will probably prevent the selection process from playing its "protective" role. Besides, with the 5-year delay of the retirement age, the harmful effects in older operators active over the next 5-10 years may prove greater than those observed in this study.

Participation in workplace design with reference to low back pain: a case for the improvement of the police patrol car.

Thirty Canadian police officers, divided into six groups, participated in the redesign of the interior of the patrol car. Three of the groups consisted of individuals having a history of low back disease. The effect of participating in a design process on the characteristics of the final design and on the perception of the low back pain was studied in a semi-experimental setting. The participants developed a strong commitment to the participatory design process, which was reflected in their productions. The differences between participants with and without a history of a low back disease was not marked. The former tended to stress posture-related elements in their analysis and design.

["To find life": migration and subsistence strategies in the Haitian peasantry]. / "Chercher la vie": migrations et strategies de subsistance dans la paysannerie haitienne.

"The objective of this article is to present briefly some results of two research projects on migration and the subsistence strategies of Haitian households. Fieldwork for these two projects were undertaken in Haiti (1982) and French Guyana (1986-1987). The methodology is mainly qualitative and the collection of life histories constitutes the main data source." The author notes that "the increasing social and economic marginalization of the peasant population, the exodus of the young labor force, and the educational and migratory strategy of parents for their children are all but a few factors which transform the traditional peasant mode of living. Given the actual state of the economy and polity in Haiti, emigration generates emigration." (SUMMARY IN ENG)