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Does problem-solving therapy reduce work-related disability from nonspecific low back pain?

At a glance:
12 months after workers suffering from back pain were taught problem-solving techniques, they had fewer days on sick leave than workers provided with group education sessions. Learning problem-solving skills helps people with back pain to overcome their condition in the longer term.
Perspectives:
Employee
Back pain can interfere with a person's ability to do activities at home and work. In turn this can cause a range of other problems - disruption of home or work relationships, uncertainty and worries about the future, anxiety and in some people depression.

These issues can have just as much impact on the person's life as the pain itself. Some people find it very hard to ask others for help, or to be dependant on others to do certain tasks. People become irritable and tired with pain, it impacts many parts of a person's life.

This study shows that helping people work out ways of dealing with secondary problems such as these helps their ability to cope. It assists the person in getting through what can be a difficult time.
Employer
Return to work is improved when people can work out ways of dealing with problems. As an employer, modifying work duties, improving relations, and supporting an individual back to work are effective ways of helping.

Other studies show that when the employee is an active participant in a return to work scheme, outcomes are improved.

This study shows that helping people learn problem-solving strategies has a positive impact on them coming back to work. The people in this study learnt about problem-solving generally, and applied it in various aspects of their life. The study suggests that people worked out how to solve return to work issues as a consequence, or that their confidence was generally increased, and this had a positive impact on return to work.
Treater
People with back pain and musculoskeletal
musculoskeletal
Involving the muscles and the skeleton. This term includes the limbs, neck, shoulders and back. 'Musculoskeletal problem' refers to many different conditions that can affect the tendons, muscles and related structures.
 problems have disruption to their lives as a result of the pain and limitation of function. Some people quickly work out how to deal with the issues while others find it difficult to deal with the secondary problems. This study indicates that people can be taught positive ways of solving issues that have improved return to work outcomes.

People in this study were not specifically taught how to manage the back problem, or solve issues in relation to their back condition. They were taught problem-solving as a general strategy. This approach is also part of cognitive
cognitive
relating to the mental processes of perception, memory, judgment, and reasoning
 behaviour therapy, another strategy shown to improve outcomes for people with musculoskeletal or back pain problems.

In everyday clinical practice, professionals are constantly solving problems. Encouraging the patient to work out ways they can deal with their condition reduces suffering and improves outcomes.
Insurer
Back troubles and other musculoskeletal problems make life more difficult. The people in the study were taught how to problem - solve and returned to work more quickly. This may have come about through a general increase in confidence, or by learning how to overcome obstacles and barriers. Giving people the confidence to solve their problems can help return to work.

One of the difficulties with any workers compensation system is that people have to follow the rules. They need to obtain certificates for days off work, do what the return to work plan says, and attend various medical or other assessments. Individual responsibility becomes secondary to the rules of the system that control them.

Encouraging people to think broadly, overcome barriers, and to be an active player in their own return to work makes a difference. How can you work with claimants to achieve this?
Original Article, Authors & Publication Details:
J. H. C. van den Hout1, J. W. S. Vlaeyen1,2, P. H. T. G. Heuts3, J, H. L. Zijlema4 and J. A. G. Wijnen4 (2003).

 Secondary prevention
secondary prevention
Approaches undertaken early in a condition with the aim of preventing worsening of problems that can arise from the condition.
 of work-related disability
disability
A condition or function that leaves a person unable to do tasks that most other people can do.
 in non-specific low back pain: Does problem-solving therapy help? A randomized clinical trial.
The Clinical Journal of Pain; 19:87-96

1Department of Medical, Clinical and Experimental Psychology, Maastricht University, Maastricht; †Institute for Rehabilitation
rehabilitation
The process of helping a person back to their former abilities and quality of life (or as close as possible) after injury or a medical condition.
 Research, Hoeroek
2Pain Management and Research Center, University Hospital, Maastricht
3Department of Pain Rehabilitation, Limburg Foundation for Rehabilitation, Hoeroek
4Social Security Office USZO, Maastricht/Eindhoven, The Netherlands
Background, Study Objectives, How It Was Done:
While exercise can help prevent back pain from becoming a disability, psychological
psychological
Refers to a person's perceptions, thought processes, emotions, personality and behaviour. Psychologists can treat mental health problems.
 support, such as gradually reintroducing physical activities, is also useful in preventing back pain from continuing into the long term. Disability is more likely in people who have a negative, avoidant attitude to their back condition. The authors of this study wanted to investigate whether teaching back pain sufferers to see themselves as being able to overcome their problem and learning to control other stressful situations that may make the problem worse, can help reduce the likelihood of a person developing a disability from lower back pain and shorten their time off work. This type of approach is called problem-solving therapy.

Patients who had suffered back pain for more than 6 weeks and were on sick leave from work, but not long term leave (more than 20 weeks), were randomly assigned into two treatment groups. Both groups received a graded activity
graded activity
A structured program gradually increasing activity over time. The activity is increased in amount and/or intensity. This treatment can be used for conditions such as fibromyalgia
fibromyalgia
A disorder classified by the presence of chronic
chronic
continuing a long time or recurring frequently
 widespread pain. Fibromyalgia patients are also typically affected by a number of symptoms other than pain, including debilitating fatigue, abnormal sleep patterns, bowel disturbances and a variety of psychiatric problems including cognitive dysfunction, anxiety and depressive symptoms
 or chronic fatigue syndrome.
syndrome
A group of symptoms that together are characteristic of a specific disorder or disease
  The approach can also be used to help people improve fitness in preparation for return to work (work hardening).
 program that gradually reintroduced physical activity. One group also received problem-solving therapy, while the second group also received group education.

The study's treatment program was conducted over 8 weeks. The “graded activity' treatment was 15 1-hour group sessions in which each patient's initial physical capability was determined, and then a program for increasing physical activity was gradually followed, and achievements rewarded. Patients also had an individual 30-minute session once a week to plan reintroduction of a patient's normal work and home activities. Group education consisted of 10 90-minute sessions in which issues related to back pain were discussed, but no skills were taught. In contrast, in "problem-solving' therapy (also 10 90-minute sessions) patients were taught skills to help them solve problems in everyday life (not specifically related to their injury), in the following five steps:

Problem orientation.
Problem definition.
Generation of alternatives.
Decision making.
Implementation and evaluation.

Two months after the final treatment session patients returned for a “booster' session in which developments in their back conditions were discussed.

The outcome of the study was measured by the patients' work status six and twelve months after the treatment program, and their number of days on sick leave (from back pain) in the 12 months after treatment when compared to the 12 months before treatment (for patients who had returned to work on a full time or part time basis). This data was obtained from occupational health service (OHS) records.
Study Findings:
115 patients were included in the study, but OHS records were only available for 84 of the participants. Of these, 45 had been randomly assigned to receive graded activity and problem-solving therapy while 39 received graded activity and group education only.

The age of participants ranged from 23-54 years (average age 40), and 76% were men. The time since the onset of back pain for these patients ranged from 0.25-25 years (average time since onset 1.5 years). For the current episode of back pain, 67% of patients had experienced pain for more than 12 weeks, 28% for 6-12 weeks and 5% for less than 6 weeks (these patients were still included in the study because a previous episode of back pain had lasted for more than 6 weeks).

The results were corrected for differences between the study groups that existed before the treatment program began. Before treatment began, patients in the problem-solving group were more functionally disabled than the group education group, and the group education group expected their pain to improve more from group therapy than the problem-solving group. People with high functional disability are more likely to become disabled, and people with good expectations about a treatment are more likely to improve from it, so these effects were taken into account.

Six months after the treatment:

Most patients from both treatment groups (73%) had returned to full-time work.
7% of patients that received problem-solving therapy as well as graded activity and group education had not returned to work because they were still suffering from back pain.
19% of patients that received graded activity and group education treatment had not returned to work because they were still suffering from back pain.
The difference in the rate of return to work between the two treatment groups was not significant.

Twelve months after the treatment:

85% of the problem-solving group had returned to full-time work
63% of the group education group had returned to full-time work
10% of the problem-solving patients were receiving a disability pension
23% of the group education patients were receiving a disability pension

The difference in the rate of return to work and the number of disability pensions was again not significant.

The positive effect of problem-solving therapy is more apparent when comparing the days on sick leave before and after the treatment for each group. In the six months after the treatment, days on sick leave decreased for both groups. However, the type of treatment received affected days on sick leave over the next six months. No other variable (such as functional disability) affected days on sick leave due to back pain in this period. Patients that had received problem-solving therapy had even fewer days on sick leave, while group education group patients had slightly more days on sick leave than in the first six months after treatment. This result suggests that learning problem-solving skills helps people with back pain to overcome their condition in the longer term.

It is possible that exclusion of the participants for which work status and sick leave information was not available affected the study's results.
Conclusions:
The aim of this study was to see whether people with back pain were less likely to suffer long term disability if problem-solving therapy was used to supplement other treatments. One group of patients was treated with group education and problem-solving therapy, while the other was treated with graded activity and group education only. Each group's work status at six and twelve months and days on sick leave in the year after the treatment were compared.

Data analyses showed that employees in the problem-solving group had significantly fewer days of sick leave in the second half-year after the intervention. More employees had a 100% return-to-work and fewer patients ended up receiving disability pensions one year after the intervention
intervention
A treatment or management program. Interventions often combine several approaches. In this field approaches include training in problem solving, adaptation of work duties, graded activity, an exercise and stretching program and pain relief.
 with problem-solving training.  

The study therefore shows that including problem-solving therapy, along with graded activity and group education, in treatment for back pain can help prevent sick leave and promote a return to full-time work in the long term.
References:
PubMed Abstract
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