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People Factors
Community based psychosocial intervention for musculoskeletal disorders

At a glance:
A person's perceived level of pain will influence their successful return to work. Managing psychological
psychological
Refers to a person's perceptions, thought processes, emotions, personality and behaviour. Psychologists can treat mental health problems.
 factors and maximising activity through a collaborative approach can provide greater success in returning to work.
Perspectives:
Employee
Many factors influence people returning to work. In the early stages of recovery your level of pain has a strong influence on when you return to work.

When people are off work for a long period, factors such as fear of pain, concern that harm or damage will result from being active, personal beliefs about the medical condition, fear of disability
disability
A condition or function that leaves a person unable to do tasks that most other people can do.
 and depression
depression
A symptom of mood disorder characterized by intense feelings of loss, sadness, hopelessness, failure, and rejection. Major depression is likely to interfere significantly with everyday activity, with symptoms including insomnia, irritability, weight loss, and a lack of interest in outside events. The disorder may last several months or longer and may recur, but it is generally reversible in the short run.
 have a strong bearing on a return to work.

These are modifiable factors and are not difficult to tackle. However, they require time, energy and focus. You need the right information about your condition, to be confident about returning to normality.
Employer
An approach that provides employees with information, reduces fear, solves problems, demystifies their medical condition, increases confidence about being active, and their ability to manage the situation, will improve return to work outcomes.

When a slow response is given to a return to work programme, talk to your employee to find out about any worries or fears. They may need assistance to increase their confidence in returning to work.
Treater
Management of psychosocial
psychosocial
Refers to psychological and social factors. Examples of psychosocial factors that affect return to work area include: a person's beliefs about how they will cope with their condition, the attitude of the inured worker's family to their condition and return to work, the employer's return to work policy and the influence of the WorkCover system on a person.
 factors improves return to work outcomes. Focusing on pain reduction is insufficient by itself to support a return to work. The fear of pain is often more relevant. Giving patients a good understanding of their condition and its natural history can make a difference.

This program has been specially designed to target modifiable risk factors. The outcomes when used with people who have been off work for long periods has been positive

This program can be purchased, for psychologists to be trained to administer.
Insurer
Return to work outcomes for people off work for less than two years were improved by a 10 week program targeting risk factors. The aim was not to reduce pain, but to provide the person with a good understanding of their situation, and so alter their beliefs, while reducing their fears.

When people have been off work for more than three months it becomes increasingly difficult to return to work. While the results of this study were only followed up for four weeks, they were very positive. Therefore, community based programs can have a substantial impact on return to work outcomes.

Talk to people, understand their fears, and support them to improve their confidence and ability in managing their situation.
Original Article, Authors & Publication Details:
Michael J.L. Sullivan,1 L. Charles Ward,2 Dean Tripp,3 Douglas J. French,4 Heather Adams,5 and William D. Stanish6 (2005)

Secondary prevention of work disability: Community-based psychosocial 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.
 for 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.
 disorders
. Journal of Occupational Rehabilitation; 15(3):377-392.

1Department of Psychology, University of Montreal, Montreal, Quebec, Canada.
2V.A. Medical Center, Tuscaloosa, Alabama.
3Department of Psychology, Queen's University, Kingston, Ontario, Canada.
4Department of Psychology, University of Moncton, Moncton, New Brunswick.
5Department of Psychology, University of Montreal, Montreal, Quebec, Canada.
6Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada.
Background, Study Objectives, How It Was Done:
A person's level of pain and their ability to function influences a return to work. During the last 10 to 20 years it has been increasingly recognised that many factors will influence return to work and whether somebody remains permanently disabled.

The authors note that four modifiable factors have been identified as increasing the risk of long-term work disability. These include:

Fear of movement and re-injury:

Fear of pain results in the person being focused on avoiding activities that will cause pain. Research demonstrates that fear of pain and fear of movement producing pain is associated with higher levels of disability. Pain related fears have been shown to be an important factor in whether an individual will return to work with back pain.

Catastrophising:

This term is used to describe a response to pain symptoms that includes a very high level of focus on the pain sensation, a high level of concern about the threat of the pain sensation, and a sense of helpless. There is the perception the individual will be unable to cope with the circumstances and pain.

Perceived disability:

An individual who believes they have a severe health condition is more likely to remain off work through a perception of significant disability. When treatment allows the person to have greater confidence in the condition and a reduction in their perception of disability, a return to work outcome is improved.

Depression:

People who have chronic
chronic
continuing a long time or recurring frequently
 pain are more likely to have depression. Depression can cause people to leave pain management programs prematurely. Depression has also been suggested as a factor that contributes to long-term spells of sickness absence. Treatment for depression improves return to work outcomes.

The pain disability prevention program was developed in Canada as a 10 week program that could be implemented by psychologists in community practice. The program taught psychologists a specific way of dealing with people in this situation. The objective of the program was to facilitate a return to work by maximising activity involvement, and reducing psychological and social factors that can be barriers in a returning to work.

215 people who had active workers compensation claims and had been off work for two years or less agreed to be involved in the program. The average time off work was about 29 weeks. Their pain symptoms were considered to be the primary limiting factor for return to work. There was also evidence of psychological or social factors having any impact.

A range of factors were assessed at the beginning, midway point, and at the end of the program. These included a variety of questionnaires that measured the person's pain, depression, beliefs about the disability, fear of pain and fear of movement.

The program included:

1. An initial information video at the factors that contribute to successful recovery from muscle and joint problems.

2. A copy of the program client workbook. This provided information on many parts of the program, as well as playing the role of keeping a check on the person's involvement and adherence to treatment. The workbook included a log of activities, goals, and strategies to overcome barriers, and a summary of the key aspect of the program.

3. Weekly meetings for a period of up to 10 weeks. The program could be completed earlier if the participant was ready to return to work. The early stages of the program were focused on a structured activities scheduled, with activity goals for the person's family, societal, and occupational roles.

4. Treatment modules were included to target specific obstacles, such as depression, catastrophe, fear of movement, and perceived disability. The program used structured activities schedules to reduce these factors.

5. In latter stages of the program, the focus was towards activities that would facilitate return to work.

6. A structured reporting format for these psychologists to prepare in mid treatment and treatment termination reports to specific guidelines.

7. Psychologists working in community practice in Canada were taught the pain management program and were provided with appropriate written materials and training to conducting the 10 week program.

The results of the program and assessment reports were sent back to the research centre, and analysed for this study.

As well as the results of the psychologist's report, return to work status was assessed four weeks after termination of the program. This information was obtained directly through compensation schemes files. A return to work was defined as a return to full-time pre-injury employment, full-time alternate employment, or the claim was closed.
Study Findings:
Within four weeks of completion of the program, 63 participants had completed its 10 week course and had returned to work.

The percentage reduction in risk factors before and after treatment were

Catastrophising 32%
Depression 26%
Fear of movement and re-injury 11%
Perceived disability 26%
Pain severity reduced by 10%

All of these reductions were highly significant in statistical terms for the patients who completed treatment.

The authors then went on to study the factors that seem to influence a return to work. Through complex statistical analysis they found that the reduction in pain catastrophising was the major factor that influenced return to work. There was a strong correlation between a reduction in pain catastrophising, and return to work outcomes. This is consistent with other studies.

Pain reduction seemed to influence a return to work. But, when taken into account with the statistical analysis of other risk factors, the pain reduction did not correlate strongly with the return. The authors concluded that pain reduction will not necessarily achieve return to work outcomes. This is consistent with other studies that have shown 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.
 interventions that focused mainly on pain reduction will not be as effective as interventions that target other risk factors.

The authors note that this study has limitations. Specifically, a return to work was assessed at only four weeks, with longer term outcomes not assessed. The study did not have a control group for comparison, although return to work rates are generally significantly less for the periods of time people in the study had been off work.
Conclusions:
The study demonstrated that a standardised protocol can be taught to treaters and implemented in the community. This is opposed to the program being implemented in a major centre, such as a rehabilitation hospital.

The study also demonstrated that a simple approach targeting factors that contribute to people having a long-term problem or disability can be successful.
References:
PubMed Abstract
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