Implementing the German Model of Work-Related Medical Rehabilitation: Did the Delivered Dose of Work-Related Treatment Components Increase? 

Purpose Work-related components are an essential part of rehabilitation programs to support return to work of patients with musculoskeletal disorders. In Germany, a guideline for work-related medical rehabilitation was developed to increase work-related treatment components. In addition, new departments were approved to implement work-related medical rehabilitation programs. The aim of our study was to explore the state of implementation of the guideline's recommendations by describing the change in the delivered dose of work-related treatments. Design Nonrandomized controlled trial (cohort study). Setting Fifty-nine German rehabilitation centers. Participants Patients (N=9046) with musculoskeletal disorders were treated in work-related medical rehabilitation or common medical rehabilitation. Patients were matched one-to-one by propensity scores.Interventions: Work-related medical rehabilitation in 2014 and medical rehabilitation in 2011. Main Outcome Measures Treatment dose of work-related therapies. Results The mean dose of work-related therapies increased from 2.2 hours (95% confidence interval [CI], 1.6-2.8) to 8.9 hours (95% CI, 7.7-10.1). The mean dose of social counseling increased from 51 to 84 minutes, the mean dose of psychosocial work-related groups from 39 to 216 minutes, and the mean dose of functional capacity training from 39 to 234 minutes. The intraclass correlation of 0.67 (95% CI, 0.58-0.75) for the total dose of work-related therapies indicated that the variance explained by centers was high. Conclusions The delivered dose of work-related components was increased. However, there were discrepancies between the guideline's recommendations and the actual dose delivered in at least half of the centers. It is very likely that this will affect the effectiveness of work-related medical rehabilitation in practice.

Source: Bethge M, Markus M, Streibelt M, Gerlich C, Schuler M,Archives Of Physical Medicine And Rehabilitation, Vol. 99 (12), p. 2465-2471, 2018 Dec.

Three Out of Ten Working Patients Expect No Clinical Improvement of Their Ability to Perform Work-Related Knee-Demanding Activities after Total Knee Arthroplasty: A Multicenter Study

Purpose Three out of ten patients do not return to work after total knee arthroplasty (TKA). Patient expectations are suggested to play a key role. What are patients' expectations regarding the ability to perform work-related knee-demanding activities 6 months after TKA compared to their preoperative status? Methods A multi-center cross-sectional study was performed among 292 working patients listed for TKA. The Work Osteoarthritis or joint-Replacement Questionnaire (WORQ, range 0-100, minimal important difference 13) was used to assess the preoperatively experienced and expected ability to perform work-related knee-demanding activities 6 months postoperatively. Differences between the preoperative and expected WORQ scores were tested and the most difficult knee-demanding work-related activities were described. Results Two hundred thirty-six working patients (81%) completed the questionnaire. Patients' expected WORQ score (Median = 75, IQR 60-86) was significantly (p < 0.01) higher than their preoperative WORQ score (Median = 44, IQR 35-56). A clinical improvement in ability to perform work-related knee-demanding activities was expected by 72% of the patients, while 28% of the patients expected no clinical improvement or even worse ability to perform work-related knee-demanding activities 6 months after TKA. Of the patients, 34% expected severe difficulty in kneeling, 30% in crouching and 17% in clambering 6 months after TKA. Conclusions Most patients have high expectations, especially regarding activities involving deep knee flexion. Remarkably, three out of ten patients expect no clinical improvement or even a worse ability to perform work-related knee-demanding activities 6 months postoperatively compared to their preoperative status. Therefore, addressing patients’ expectations seems useful in order to assure realistic expectations regarding work activities.

Source: van Zaanen Y, van Geenen RCI, Pahlplatz TMJ, Kievit AJ, Hoozemans MJM, Bakker EWP, Blankevoort L, Schafroth MU, Haverkamp D, Vervest TMJS, Das DHPW, van der Weegen W, Scholtes VA, Frings-Dresen MHW, Kuijer PPFM, Journal of Occupational Rehabilitation, 2018 Dec.

Better return to work and sports after knee arthroplasty rehabilitation? 

Purpose Younger knee arthroplasty patients expect to perform better in work and sports after surgery, and often at demanding levels. Although the provision of rehabilitation is almost universal, no systematic literature review reporting the effect of these exercise-based therapies on return to work and sports is available. Aim To investigate the effect of exercise-based therapies on return to work and sports after knee arthroplasty. Methods A systematic search strategy was developed by a clinical librarian (J.G.D.), and the search was performed in Ovid Medline and EMBASE up to March 2017. In line with the PRISMA statement (Preferred Reporting Items for Systematic Reviews and Meta-Analyses), three authors (P.P.F.M.K., M.M.H. and M.H.W.F.-D.) independently screened titles and abstracts, and assessed full texts for eligibility. The inclusion criteria were patients with primary knee arthroplasty, and studies that compared at least two exercise-based rehabilitation programmes and reported outcomes including return to work or sports. No restrictions were applied for language, study design or year of publication. Results After removal of duplicates, the search resulted in 3788 studies, of which 22 were selected for full text reading. After full text reading, none of these studies reported on return to work or sports. Conclusions No studies were found evaluating the effect of rehabilitation programmes for knee arthroplasty on return to work or sports. Given the importance of work and sports, especially for younger knee arthroplasty patients, these results underpin the importance of including return to work or sports in core outcome sets and future trials to eventually contribute to more satisfied knee arthroplasty patients.

Source: Kuijer PPFM, van Haeren MM, Daams JG, Frings-Dresen MHW, Occupational Medicine, 2018 Sep.

Early Return to Work Has Benefits for Relief of Back Pain and Functional Recovery After Controlling for Multiple Confounds

Purpose The aim of the study was to evaluate the effect on health outcomes of an early or immediate return-to-work (RTW) after acute low back pain (LBP). Methods A longitudinal cohort of workers (N = 557) consulting for uncomplicated LBP were assessed on demographic, pain, occupational, and psychosocial variables. Pain and function were assessed at 3-month postpain onset. We tested the longitudinal effects of an early RTW on 3-month outcomes. Results Pain and function improved more rapidly for workers with an immediate (30.7%) or early (1 to 7 days) RTW (36.8%). Eleven demographic, health, or workplace variables were identified as potential confounds, but controlling for these factors only partially attenuated the benefits of an early RTW. Conclusions An early RTW improves acute LBP and functional recovery, and alternate confounding explanations only partially eclipse this therapeutic effect.

Source: Shaw WS, Nelson CC, Woiszwillo MJ, Gaines B, Peters SE, Journal of Occupational & Environmental Medicine, Vol. 60 (10), p.901-910, 2018 Oct.

Managing Employees Undergoing Total Hip and Knee Replacement: Experiences of Workplace Representatives

Purpose There is little research on return to work (RTW) from a workplace perspective following hip and knee replacement (THR/TKR) despite employers and other workplace personnel having a key role. Our aim was to explore the experiences of individuals in the workplace in managing employees undergoing THR/TKR. Methods Employers and other workplace representatives from a cross-section of employment sectors and sizes, with experience of managing employees undergoing THR/TKR in the previous 12 months, were recruited. Interviewees included small business owners, line managers, colleagues, human resources managers and occupational health advisers. Semi-structured, qualitative interviews were conducted and data were analysed thematically. Results Twenty-five individuals were interviewed. The main themes identified were accommodating the employee, and barriers and facilitators to RTW. Accommodations included changes to the work environment, amended duties, altered hours, changed roles and colleague support. Perceived barriers and facilitators to RTW included the role of GPs and occupational health, surgical issues, characteristics of the work environment and of employees. Conclusions Employers are motivated to effect supported RTW for employees undergoing THR/TKR but have insufficient guidance. Strategies are required to signpost employers to existing RTW advice, and to develop recommendations specific to lower limb arthroplasty. Communication between medical practitioners and employers should be facilitated in order to enhance the RTW experience of individuals undergoing THR/TKR.

Source: Nouri F, Coole C, Narayanasamy M, Baker P, Khan S, Drummond A, Journal of Occupational Rehabilitation, 2018 Aug.

Activity levels and return to work after revision total hip and knee arthroplasty in patients under 65 years of age

Purpose The aim of this study was to identify predictors of return to work (RTW) after revision lower limb arthroplasty in patients of working age in the United Kingdom.Methods We assessed 55 patients aged ≤ 65 years after revision total hip arthroplasty (THA). There were 43 women and 12 men with a mean age of 54 years (23 to 65). We also reviewed 30 patients after revision total knee arthroplasty (TKA). There were 14 women and 16 men with a mean age of 58 years (48 to 64). Preoperatively, age, gender, body mass index, social deprivation, mode of failure, length of primary implant survival, work status and nature, activity level (University of California, Los Angeles (UCLA) score), and Oxford Hip and Knee Scores were recorded. Postoperatively, RTW status, Oxford Hip and Knee Scores, EuroQol-5D (EQ-5D), UCLA score, and Work, Osteoarthritis and Joint-Replacement Questionnaire (WORQ) scores were obtained. Univariate and multivariate analysis was performed. Results Overall, 95% (52/55) of patients were working before their revision THA. Afterwards, 33% (17/52) RTW by one year, 48% (25/52) had retired, and 19% (10/52) were receiving welfare benefit. RTW was associated with age, postoperative Oxford Hip Score, early THA failure (less than two years), mode of failure dislocation, and contralateral revision (p < 0.05). No patient returned to work after revision for dislocation. Only age remained a significant factor on multivariate analysis (p = 0.003), with 79% (11/14) of those less than 50 years of age returning to work, compared with 16% (6/38) of those aged fifty years or over. Before revision TKA, 93% (28/30) of patients were working. Postoperatively only 7% (2/28) returned to work by one year, 71% (20/28) had retired, and 21% (6/28) were receiving welfare benefits. UCLA scores improved after 43% of revision THAs and 44% of revision TKAs. Conclusions After revision THA, age is the most significant predictor of RTW: only 16% of those over 50 years old return to work. Fewer patients return to work after early revision THA and none after revision for dislocation. After revision TKA, patients rarely return to work: none return to heavy or moderate manual work. Cite this article: Bone Joint J 2018;100-B:1043-53.

Source: Scott CEH, Turnbull GS, Powell-Bowns MFR, MacDonald DJ, Breusch SJ, The Bone & Joint Journal,  Vol. 100-B (8), p. 1043-1053, 2018 Aug.

Early Return to Work has Benefits for Relief of Back Pain and Functional Recovery after Controlling for Multiple Confounds

Purpose To evaluate the effect on health outcomes of an early or immediate return-to-work (RTW) after acute low back pain (LBP). Methods A longitudinal cohort of workers (N = 557) consulting for uncomplicated LBP were assessed on demographic, pain, occupational, and psychosocial variables. Pain and function were assessed at 3-months post pain onset. We tested the longitudinal effects of an early RTW on 3-month outcomes. Results Pain and function improved more rapidly for workers with an immediate (30.7%) or early (1-7 days) RTW (36.8%). Eleven demographic, health, or workplace variables were identified as potential confounds, but controlling for these factors only partially attenuated the benefits of an early RTW. Conclusions An early RTW improves acute LBP and functional recovery, and alternate confounding explanations only partially eclipse this therapeutic effect.

Source: Shaw WS, Nelson CC, Woiszwillo MJ, Gaines B, Peters SE, Journal of Occupational and Environmental Medicine, 2018 Jun.

Efficacy of a Work Disability Prevention Program for People with Rheumatic and Musculoskeletal Conditions: A Single-Blind Parallel-Arm Randomized Controlled Trial

Purpose Work disability rates are high among people with rheumatic and musculoskeletal conditions. Effective disability preventive programs are needed. We examined the efficacy of a modified vocational rehabilitation approach delivered by trained occupational therapists and physical therapists on work limitation and work loss over 2 years among people with rheumatic and musculoskeletal conditions. Methods Eligibility criteria for this single-blind, parallel-arm randomized trial included ages 21-65 years, 15 or more hours/week employment, a self-reported doctor-diagnosed rheumatic or musculoskeletal condition, and concern about staying employed. The intervention consisted of a 1.5-hour meeting, an action plan, written materials on employment supports, and telephone calls at 3 weeks and 3 months. Control group participants received the written materials. The primary outcome was the Work Limitations Questionnaire (WLQ) output job demand subscale. The secondary outcome was work loss. Intent-to-treat analyses were performed. Results Between October 2011 and January 2014, 652 individuals were assessed for eligibility. A total of 287 participants were randomized: 143 intervention and 144 control participants. In total, 264 participants (92%) completed 2-year data collection. There was no difference in the mean ± SD WLQ change scores from baseline to 2-year follow up (-8.6 ± 1.9 intervention versus -8.3 ± 2.2 control; P=0.93). Of the 36 participants who experienced permanent work loss at 2 years, 11 (8%) were intervention participants and 25 (18%) control participants (P=0.03). Conclusions The intervention did not have an effect on work limitations but reduced work loss. The intervention can be delivered by trained rehabilitation therapists.

Source: Keysor J, LaValley J, P.Brown M, Felson C, T.AlHeresh D, A.Vaughan R, W.Yood M, Reed R, I.Allaire J, Saralynn J, Arthritis Care & Research, Vol. 70 (7), p.1022-1029, 2018 July.

Work remains meaningful despite time out of the workplace and chronic pain

Purpose Although work has been found to be meaningful and a source of motivation to return to work in certain disabled populations, it was unclear if this was also true for people experiencing a long period of unemployment and job loss due to a musculoskeletal injury. Therefore, the aim of this phenomenological study was to explore the meaning of work for those with chronic work disability due to a musculoskeletal injury. Methods The data from 27 interviews, conducted with 9 participants, was analyzed using the Empirical Phenomenological Psychological method. Results Work remained central to the lives of the participants and aligned with previous valued work outcomes and goals regardless of the amount of time away from work. These findings point to the importance of recognizing the ongoing centrality of work for those with chronic work disability and the importance of tapping into work values and beliefs to provide workers with the motivation needed to get past physical and systemic barriers to return to work. Conclusions This study shows that a shift in focus back to meaning not only has benefits for people with chronic work disability, but for occupational therapists in their ability to make a unique and effective contribution to the field of work disability.

Source: Saunders S, Nedelec B, MacEachen E, Disability & Rehabilitation, Vol. 40 (18), p.2144-2151, 2018 Sep.

Psychologists’ application of clinical guidelines and recommended protocols and procedures within state insurance regulatory authority insurance frameworks: Outcomes for injured patients with musculoskeletal injuries

Purpose In 2010, the State Insurance Regulatory Authority (SIRA), which governs the regulatory functions of workers’ compensation insurance (WCI) and compulsory third‐party insurance (CTP) within NSW, implemented evidence‐based clinical guidelines to improve psychologists’ practice. The aims of this study were to determine (a) whether this initiative has reduced claims costs and improved injured patient outcomes and (b) whether it has resulted in psychologists using evidence‐based practice. Methods The first phase involved quantitatively determining a time‐range sample of WCI administrative records of patients with a musculoskeletal injury (n = 26,254) and musculoskeletal injury with a secondary psychological injury (n = 238). The second and third phases involved a qualitative content analysis of case‐level files belonging to individuals who had suffered a musculoskeletal injury with a secondary psychological injury under WCI (Phase 2) (n = 12) and CTP (Phase 3) (n = 9). Results The quantitative component revealed that the total claims costs and return to work timeframes for injured patients suffering from musculoskeletal injury with a secondary psychological injury remained unchanged following the implementation of the clinical guidelines. However, this contrasted with a significant increase of these measures for injured workers with only a musculoskeletal injury. The qualitative content analysis in Phases 2 and 3 of the study showed that psychologists’ application of treatment guidelines was suboptimal. Conclusions The implementation of the 2010 clinical guidelines for psychologists has led to beneficial outcomes for patients injured under the SIRA insurance frameworks; however, greater adherence by psychologists and strategies to improve the adoption of these guidelines are warranted.

Source: Haider T, Dunstan DA, Bhullar N, Australian Psychologist.

Effects of the New York State Workers Compensation Board Medical Treatment Guidelines on Return to Work

Purpose Supplemental Digital Content is available in the text Objective: Examine the association between New York State Workers’ Compensation Medical Treatment Guidelines (Guidelines) adherence and return-to-work after occupational low back injuries. Assess adherence to Guidelines by examining diagnostic and treatment utilization. Methods Retrospective chart review of cases. Outcomes of interest were lost time duration and diagnostic/treatment utilization rates. Time to event analyses performed using Kaplan–Meier plots and Cox proportional hazard model. Results Care received after implementation of Guidelines resulted in decreased lost time. Treatment rates were consistent, while diagnostic imaging use was inconsistent with Guidelines recommendations. Conclusions Guidelines use positively influenced return-to-work after acute occupational low back injuries. Inconsistencies in following Guidelines were observed for diagnostic tests, having a potential paradoxical effect on lost time. Further studies are necessary to test for additional hypotheses.

Source: Demian C, Barron B, Almudevar A, Journal of Occupational & Environmental Medicine, Vol. 60 (7), p.617-621, 2018 Jul.

Early workplace dialogue in physiotherapy practice improved work ability at 1-year follow-up--WorkUp, a randomised controlled trial in primary care

Purpose Workplace involvement in rehabilitation for patients with musculoskeletal pain may improve work ability. Convergence Dialogue Meeting (CDM) is a model aimed at helping the patient, the care giver, and the employer to support work ability and return-to-work. Our aim was to study the effect on work ability when adding a workplace dialogue according to CDM in physiotherapy practice for patients with pain in ordinary primary care. Methods We conducted a prospective pairwise cluster randomised controlled trial in primary care involving 20 primary care rehabilitation units with 1-year follow-up. Adult patients with acute/subacute neck and back pain, worked 4 weeks past year and not currently on sick leave or no more than 60 days of sick leave and considered at-risk of sick leave were included (n=5352). All patients received structured physiotherapy and the intervention was the addition of CDM, delivered by the treating physiotherapist. Results The main confirmatory outcome, work ability (defined as working at least 4 consecutive weeks at follow-up), was assessed by a weekly short text message question on number of sick leave days past week. Work ability was reached by significantly more patients in the intervention group (108/127, 85%) compared with the reference group (127/171, 74%) (P=0.02). The intervention increased the odds of having work ability at 1-year follow-up, also after adjustment for baseline health-related quality of life (odds ratio 1.85, confidence interval 1.01-3.38). Conclusions We conclude that an early workplace dialogue in addition to structured physiotherapy improved work ability significantly.

Source: Sennehed CP, Holmberg S, Axén I, Stigmar K, Forsbrand M, Petersson IF, Grahn B, Pain, Vol. 159 (8), p.1456-1464, 2018 Aug.

Return to Work in Employees on Sick Leave due to Neck or Shoulder Pain: A Randomized Clinical Trial Comparing Multidisciplinary and Brief Intervention with One-Year Register-Based Follow-Up

Purpose The aim of this study was to evaluate the effect of a multidisciplinary intervention (MDI) compared to a brief intervention (BI) with respect to return to work (RTW), pain and disability in workers on sick leave because of neck or shoulder pain. Methods 168 study participants with sickness absence for 4-16 weeks due to neck or shoulder pain were enrolled in a hospital-based clinical study and randomized to either MDI or BI. The primary outcome was RTW obtained by a national registry on public transfer payments. Secondary outcomes were self-reported pain and disability levels. One-year follow-up RTW rates were estimated by Cox proportional hazard regression adjusted for gender, age, sick leave prior to inclusion, part-time sick leave and clinical diagnosis. Secondary outcomes were analysed using logistic and linear regression analysis for pain and disability, respectively. Results In the MDI group, 50 participants (59%) experienced four or more continuous weeks of RTW while 48 (58%) returned to work in the BI group during the 1 year of follow-up. Results showed a statistically non significant tendency towards a lower rate of RTW in the MDI group than in the BI group (adjusted HR = 0.84, 95% CI 0.54, 1.31). There were no statistically significant differences in secondary outcomes between the MDI and BI groups. Conclusions The brief and the multidisciplinary interventions performed equally with respect to both primary and secondary outcomes. The added focus on RTW in the multidisciplinary group did not improve RTW rates in this group.

Source: Moll L, Thorndal J, KudskSchiøttz-Christensen O, BeritStapelfeldt, MalmoseChristiansen C, HøyrupNielsen D, Vinther C, Labriola M, Journal of Occupational Rehabilitation, Vol. 28(2), p.346-356, 2018 Jun.

Motivational Interviewing for Workers with Disabling Musculoskeletal Disorders: Results of a Cluster Randomized Control Trial

Purpose Although functional restoration programs appear effective in assisting injured workers to return-to-work (RTW) after a work related musculoskeletal (MSK) disorder, the addition of Motivational Interviewing (MI) to these programs may result in higher RTW. Methods We conducted a cluster randomized controlled trial with claimants attending an occupational rehabilitation facility from November 17, 2014 to June 30, 2015. Six clinicians provided MI in addition to the standard functional restoration program and formed an intervention group. Six clinicians continued to provide the standard functional restoration program based on graded activity, therapeutic exercise, and workplace accommodations. Independent t tests and chi square analysis were used to compare groups. Multivariable logistic regression was used to obtain the odds ratio of claimants’ confirmed RTW status at time of program discharge. Results 728 workers’ compensation claimants with MSK disorders were entered into 1 of 12 therapist clusters (MI group = 367, control group = 361). Claimants were predominantly employed (72.7%), males (63.2%), with moderate levels of pain and disability (mean pain VAS = 5.0/10 and mean Pain Disability Index = 48/70). Claimants were stratified based on job attachment status. The proportion of successful RTW at program discharge was 12.1% higher for unemployed workers in the intervention group (intervention group 21.6 vs. 9.5% in control, p = 0.03) and 3.0% higher for job attached workers compared to the control group (intervention group 97.1 vs. 94.1% in control, p = 0.10). Adherence to MI was mixed, but RTW was significantly higher among MI-adherent clinicians. The odds ratio for unemployed claimants was 2.64 (0.69-10.14) and 2.50 (0.68-9.14) for employed claimants after adjusting for age, sex, pain intensity, perceived disability, and therapist cluster. Conclusions MI in addition to routine functional restoration is more effective than routine functional restoration program alone in improving RTW among workers with disabling MSK disorders.

Source: Park J, Rayani ES, Norris F, M.Gross C, Douglas P, Journal of Occupational Rehabilitation, Vol. 28(2), p.252-264, 2018 Jun.

Return-to-work for multiple jobholders with a work-related musculoskeletal disorder: A population-based, matched cohort in British Columbia

Purpose Multiple jobholders (MJHs) have a higher risk of injury compared to single jobholders (SJHs), but it is unknown if return-to-work (RTW) after a work injury is affected by multiple jobholding. This study examined the association between multiple versus single jobholding and time to RTW for workers with a work-related musculoskeletal disorder (MSD). Methods We used administrative workers’ compensation data to identify injured workers with an accepted MSD lost-time claim between 2010–2014 in British Columbia, Canada (n = 125,639 SJHs and 9,029 MJHs). The outcome was days until RTW during twelve months after the first day of time-loss. The MJH and SJH cohorts were balanced using coarsened exact matching that yielded a final matched cohort of 8,389 MJHs and 8,389 SJHs. The outcome was estimated with Cox regression, using piecewise models, and the hazard ratios were stratified by type of MSD, a serious injury indicator, gender, weekly workdays preceding MSD, and wage categories. Results MJHs were less likely to RTW compared to SJHs within the first six months after the first time-loss day, with greater and longer lasting effects for males, workers with a serious injury, and a higher wage. No difference between MJHs and SJHs was found for workers who had a six- or seven-day work week preceding MSD, for workers with dislocations, and for workers who were still off work after six months. Conclusions Overall, MJHs with a workweek of maximum five days are disadvantaged compared to SJHs in terms of RTW following a work-related MSD within the first six months after the first time-loss day. This difference might be caused by more precarious job contracts for MJHs that challenges RTW because of lack of support for modified work, higher workload, and reduced likelihood that MJHs file a workers’ compensation claim. Despite adjusting for type of MSD, severity of injury and occupation, the differences persisted for the vast majority of the study sample.

Source: Maas ET, Koehoorn M, McLeod CB, PLoS ONE, Vol. 13 (4), p.1-21, 2018 Apr.

Not Physical Activity, but Patient Beliefs and Expectations are Associated with Return to Work After Total Knee Arthroplasty

Purpose After total knee arthroplasty (TKA), 17%-60% of the patients do not or only partially return to work (RTW). Reasons for no or partial RTW remain unclear, warranting further research. Physical activity (PA) has proven beneficial effects on work participation. Therefore, we hypothesized that preoperative PA is associated with RTW after TKA. Methods Working TKA patients participating in an ongoing prospective cohort study were included. Preoperatively and 1 year postoperatively, patients were asked to define their work status and PA level according to the Dutch Recommendation for Health-Enhancing PA and the Fitnorm. Multivariate logistic regression analysis was performed to assess the effect of PA on RTW, taking into account established prognostic factors for RTW among TKA patients. Results Of 283 eligible patients, 266 (93%) completed the questionnaires sufficiently. Preoperatively, 141 patients (54%) performed moderate PA for ≥5 d/wk and 42 (16%) performed intense PA for ≥3 d/wk. Concerning RTW, 178 patients (67%) reported full RTW, 59 patients (22%) partial RTW, and 29 patients (11%) no RTW. Preoperative PA was not associated with RTW. Patients who reported that their knee symptoms were not or only partially work-related had lower odds of no RTW (odds ratio 0.37, 95% confidence interval 0.17-0.81). Also, for each additional week patients expected to be absent from work, the likelihood of no RTW increased (odds ratio 1.11, 95% confidence interval 1.03-1.18). Conclusions No association between preoperative PA and RTW after TKA was found. Patient beliefs and preoperative expectations did influence RTW and should be addressed to further improve RTW after TKA.

Source: Hoorntje A, Leichtenberg CS, Koenraadt KLM, van Geenen RCI, Kerkhoffs GMMJ, Nelissen RGHH, Vliet Vlieland TPM, Kuijer PPFM, Journal of Arthroplasty, Vol. 33 (4), p.1094-1100, 2018 Apr.

Effectiveness of Integration and Re-Integration into Work Strategies for Persons with Chronic Conditions: A Systematic Review of European Strategies

Purpose Due to low employment rates associated to chronic conditions in Europe, it is essential to foster effective integration and re-integration into work strategies. The objective of this systematic review is to summarize the evidence on the effectiveness of strategies for integration and re-integration to work for persons with chronic diseases or with musculoskeletal disorders, implemented in Europe in the past five years. Methods A systematic search was conducted in MedLine, PsycINFO, CDR-HTA, CDR-DARE and Cochrane Systematic Reviews. Overall, 32 relevant publications were identified. Of these, 21 were considered eligible after a methodological assessment and included. Results Positive changes in employment status, return to work and sick leave outcomes were achieved with graded sickness-absence certificates, part-time sick leave, early ergonomic interventions for back pain, disability evaluation followed by information and advice, and with multidisciplinary, coordinated and tailored return to work interventions. Additionally, a positive association between the co-existence of active labor market policies to promote employment and passive support measures (e.g., pensions or benefits) and the probability of finding a job was observed. Conclusions Research on the evaluation of the effectiveness of strategies targeting integration and re-integration into work for persons with chronic health conditions needs, however, to be improved and strengthened.

Source: Sabariego C, Coenen M, Ito E, Fheodoroff K, Scaratti C, Leonardi M, Vlachou A, Stavroussi P, Brecelj V, Kovačič DS, Esteban E, International Journal of Environmental Research and Public Health, Vol. 15 (3), 2018 Mar.

People with low back pain perceive needs for non-biomedical services in workplace, financial, social and household domains: a systematic review

Purpose What needs of non-biomedical services are perceived by people with low back pain? Design Systematic review of qualitative and quantitative studies examining perceived needs of non-biomedical services for low back pain, identified through searching of MEDLINE, EMBASE, CINAHL and PsycINFO (1990 to 2016). Participants Adults with low back pain of any duration. Data Extraction and Analysis Descriptive data regarding study design and methodology were extracted. The preferences, expectations and satisfaction with non-biomedical services reported by people with low back pain were identified and categorized within areas of perceived need. Results Twenty studies (19 qualitative and one quantitative) involving 522 unique participants (total pool of 590) were included in this systematic review. Four areas emerged. Workplace: people with low back pain experience pressure to return to work despite difficulties with the demands of their occupation. They want their employers to be informed about low back pain and they desire workplace accommodations. Financial: people with low back pain want financial support, but have concerns about the inefficiencies of compensation systems and the stigma associated with financial remuneration. Social: people with low back pain report feeling disconnected from social networks and want back-specific social support. Household: people with low back pain report difficulties with household duties; however, there are few data regarding their need for auxiliary devices and domestic help. Conclusions People with low back pain identified work place, financial and social pressures, and difficulties with household duties as areas of need beyond their healthcare requirements that affect their ability to comply with management of their condition. Consideration of such needs may inform physiotherapists, the wider health system, social networks and the workplace to provide more relevant and effective services.

Source: Chou L, Cicuttini FM, Urquhart DM, Anthony SN, Sullivan K, Seneviwickrama M, Briggs AM, Wluka AE, Journal of Physiotherapy, 2018 Mar.

Measuring work functioning in individuals with musculoskeletal disorders with reference to the International Classification of Functioning, Disability, and Health: a systematic literature review

Purpose The assessment of work functioning is important to define needs in the context of vocational rehabilitation. The International Classification of Functioning, Disability, and Health (ICF) serves as a framework to describe functioning and health. In reference to the ICF, work functioning can be described as consisting of work activities and work participation. A range of instruments are used in rehabilitation practice to assess work functioning. The purpose of this systematic review was to identify questionnaires measuring work functioning with reference to the ICF and to describe these instruments, their linkage to the ICF, and their psychometric properties. Instruments should be suitable for individuals with musculoskeletal disorders. Methods Web of Science and PubMed were searched for English and German studies published between 2001 and 2015. We focused on self-reported questionnaires measuring work functioning with reference to the ICF. Sixteen questionnaires fulfilled the inclusion criteria. Results The instruments varied in their linkage to the ICF and in their focus on work functioning. Questionnaires measuring concrete work activities differ from instruments measuring aspects of work participation in terms of absenteeism. The Work Rehabilitation Questionnaire is the instrument covering most ICF categories. Conclusions The results show a range of different instruments that could be useful in certain settings. The description and comparison of the questionnaires can help to choose appropriate instruments in practice.

Source: Sternberg A, Bethge M, International Journal of Rehabilitation Research, 2018 Mar.

Effects of rehabilitation aftercare on work participation in patients with musculoskeletal disorders: a propensity score-matched analysis

Purpose Meta-analyses of rehabilitation studies in chronic back pain patients in Germany showed a lack of sustainability of rehabilitation programs. The German Pension Insurance therefore developed an intensified aftercare program to support rehabilitation outcomes. The aim of this study was to compare disability pension rates, income from regular employment, and duration of welfare benefits in patients with and without rehabilitation aftercare. Methods We used administrative data on finished rehabilitation services. Patients were included if they were aged 18-60 years, had musculoskeletal disorders, and attended an outpatient or an inpatient rehabilitation program during the first term of 2007. Patients were excluded if they received an old-age pension, started a disability pension before January 2008, or died during the follow-up period. Patients with rehabilitation aftercare were matched by propensity scores with patients without rehabilitation aftercare. Estimation of the propensity score considered 20 potential confounders. Results There were no differences in the cumulative probability of receiving a disability pension. Moreover, patients with and without aftercare did not differ in their income from regular employment and the duration of different types of welfare benefits during the follow-up period. However, stratified analyses found a positive effect of an aftercare program on income in patients who attended a postacute rehabilitation program and patients who were at least 3 months absent because of sickness during the year preceding the initial rehabilitation program. Conclusions Only patients with strong impairments benefit from attending an aftercare program. Allocation to aftercare programs and the focus on exercise only have to be reconsidered and revised.

Source: Fechtner S, Bethge M, International Journal of Rehabilitation Research, Vol. 41(1), p.74-80, 2018 Mar.

New episodes of musculoskeletal conditions among employed people in Norway, sickness certification and return to work: a multiregister-based cohort study from primary care

Purpose To identify new cases of musculoskeletal (MSK) disorders among employed people presenting in Norwegian primary care in 2012, frequency of sickness certification and length of sick leave. To identify patient-, diagnosis- and GP-related predictors of sickness certification, prolonged sick leave and return to work (RTW). Methods An observational multiregister-based cohort study covering all employed persons in Norway(1 176 681 women and 1 330 082 men) based on claims data from all regular GPs merged with individual sociodemographic data from public registers was performed. Participants were employed patients without any GP consultation during the previous 3 months who consulted a GP with a diagnosis of a MSK condition. Those not on sick leave and with a known GP affiliation were included in the analyses. Outcomes were incidence, proportion sickness certified and proportion on sick leave after 16 days, according to the diagnosis, ORs with 95% CIs for sickness certified and for sick leave exceeding 16 days and HRs with 95% CIs for RTW. Results One-year incidence of MSK episodes was 159/1000 among employed women and 156/1000 among employed men. 27.1% of the women and 28.2% of the men were sickness certified in the initial consultation. After 16 days, 10.5% of women and 9.9% of men were still on sick leave. Upper limb problems were most frequent. After adjustments, medium/high education predicted a lower risk of absence from work due to sickness and rapid RTW after 16 days. Back pain, fractures and female gender carried a higher risk of sickness certification but faster RTW. Older age was associated with less initial certification, more sick leave exceeding 16 days and slower RTW. Male patients with male GPs had a lower risk of sickness absence, which was similar to patients with GPs born in Norway and GPs with many patients. After 16 days, GP variables had no effect on RTW. Conclusions Upper limb problems and GPs as stakeholders in 'the inclusive workplace' strategy need more attention.

Source: Gjesdal S, Holmaas TH, Monstad K, Hetlevik Ø, BMJ Open, Vol. 8 (3), p.e017543, 2018 Mar.

Return to work after rehabilitation in chronic low back pain workers. Does the interprofessional collaboration work?

Purpose The objective of this study was to assess the workplace information collected and shared between professionals of the centers and occupational health professionals during functional restoration programs intended to chronic low back pain patients. Methods A descriptive study carried out by a questionnaire sent to the French rehabilitation centers offering a functional restoration program. Data collection focused on the kinds of professionals involved in programs, professionals who approach work issues, work analysis, social and occupational information collected, existence of a specific work rehabilitation program, frequency of and methods for sharing information with occupational health professionals. Occupational information was mostly collected at inclusion during an individual interview by the rehabilitation physicians, social workers, and occupational therapists. Results Workplace environment was the most poorly discussed aspect. A minority of centers adapted their programs regarding these information. Information sharing with occupational physicians was mostly through the patient and was influenced by the presence of an ergonomist or of an occupational physician in the team. The study found poor interest about work environment and that the cooperation between practitioners in disability management remains limited. Conclusions The various practitioners' cultures and interests may be a brake on cooperation and exchange of information.

Source: Michel C, Guêné V, Michon E, Roquelaure Y, Petit A, Journal of Interprofessional Care, p.1-4, 2018 Mar.

The Effect of Self-Efficacy on Return-to-Work Outcomes for Workers with Psychological or Upper-Body Musculoskeletal Injuries: A Review of the Literature

Purpose Work absence can result in substantial losses to the economy and workers. As a result, identifying modifiable factors associated with return-to-work (RTW) following an injury or illness is the focus of many empirical investigations. Self-efficacy, the belief about one’s ability to undertake behaviours to achieve desired goals, has been identified as an important factor in RTW for injured workers. This paper systematically reviewed the literature on the association between self-efficacy and RTW outcomes for workers with an upper-body musculoskeletal injury or psychological injury. Methods A systematic search was conducted across five databases using two main search concepts- ‘self-efficacy’ and ‘RTW’. After removing duplicates, our search strategy identified 836 studies, which were screened for relevance using titles and abstracts. Results A two stage screening process reduced the study pool to six studies using psychological injury cohorts and three using upper-body musculoskeletal (UB-MSK) cohorts. Eight cohorts from seven prospective cohort studies and one sample from a randomised control trial (RCT) were subjected to a risk of bias assessment. Higher levels of self-efficacy appeared to have a consistent and positive association with RTW across return-to-work status and work absence outcomes, injury type and follow-up periods. Effect ratios ranged from 1.00 to 5.26 indicating a potentially large impact of self-efficacy on RTW outcomes. The relationship between self-efficacy and RTW strengthened as the domain of self-efficacy became more specific to RTW and job behaviours. Studies assessing workers with psychological injuries were of a lower quality compared to those assessing workers with UB-MSK injuries. Conclusions Higher self-efficacy had consistent positive associations with RTW outcomes. Further empirical research should identify the determinants of self-efficacy, and explore the processes by which higher self-efficacy improves RTW outcomes.

Source: Black O, Keegel T, Sim MR, Collie A, Smith P, Journal of Occupational Rehabilitation, Vol. 28 (1), p.16-27, 2018 Mar.

Predictors of Return-To-Work in Patients with Chronic Musculoskeletal Pain: A Randomized Clinical Trial

Purpose To assess the predictive effect of a multidisciplinary intervention programme, pain, work related factors and health, including anxiety/depression and beliefs, on return-to-work for patients sick-listed due to musculoskeletal pain. Design: A randomized clinical study. Methods A total of 284 patients were randomized to either a multidisciplinary intervention programme (n = 141) or to a less resource-demanding brief intervention (n = 143). Work participation was estimated monthly from register data for 12 months. Return-to-work was defined as increased work participation in 3 consecutive months. Results In the adjusted model, return-to-work by 3 months was associated with a multidisciplinary intervention programme (odds ratio (OR) = 2.7, 95% confidence interval (95% CI) = 1.1-6.9), the factor "belief that work was cause of the pain" (OR = 2.2, 95% CI = 1.1-4.3), anxiety and depression (OR = 0.5, 95% CI = 0.2-0.98), and by an interaction between the multidisciplinary intervention and perceived support at work (OR = 0.3, 95% CI = 0.1-0.9). At 12 months, only duration of sick leave was associated with return-to-work (OR = 0.6, 95% CI = 0.5-0.8). Conclusions Multidisciplinary intervention may hasten return-to-work and benefit those who perceive low support at work, but at 12 months only duration of sick leave at baseline was associated with return-to-work.

Source: Brendbekken R, Vaktskjold A, Harris A, Tangen T, Journal of Rehabilitation Medicine, Vol. 50(2), p.193-199, 2018 Feb.

Clinical classes of injured workers with chronic low back pain: a latent class analysis with relationship to working status

Purpose To determine (a) clinical classes of injured workers with chronic low back pain (CLBP), (b) predictors of class membership and (c) associations of classes with baseline work status. Methods Patients with CLBP from a tertiary care outpatient clinic in Toronto, Canada were sampled. Latent class analysis was applied to determine class structure using physical, psychological and coping indicators. Classes were interpreted by class-specific means and analyzed for predictors of membership. Lastly, association of the classes with being off work was modeled. Results A 3-class model was chosen based on fit criteria, theoretical and clinical knowledge of this population. The resultant 3 classes represented low, moderate and high levels of clinical severity. Predictors of being in the high severity group compared to the low severity group were < high school education [odds ratio (OR) 3.06, 95% CI (1.47, 6.37)] and comorbidity total [OR 1.28, 95% CI (1.03, 1.59)]. High severity class membership was associated with four times increased risk of being off work at baseline compared to those in the low severity group [OR 3.98, 95% CI (1.61, 6.34)]. Conclusions In a cohort of injured workers with CLBP, 3 clinical classes were identified with distinct psychological and physical profiles. These profiles are useful in aiding clinicians to identify patients of high clinical severity who may be potentially at risk for problematic return to work.

Source: Carlesso L, Raja RY, Davis A, Carlesso LC, Davis AM, European Spine Journal, Vol. 27 (1), p.117-124, 2018 Jan.