tacking musculoskeletal problems at work · ypsychosocial interventions (problem‐solving and...
TRANSCRIPT
Kim BurtonCentre for Health and Social Care Research
University of Huddersfield, UK
Tacking musculoskeletal problems at work
www.kendallburton.com
Study Day, Leeds, 08 June 2012
Huddersfield Dispensary and Infirmary
1814
1831
‐model of charitable healthcare VR
Work is what defines us:
"Work is life, you know, and without it, there's nothing but fear and insecurity.”
But, is work healthy?
WORK HEALTH
Is work actually good for your health and wellbeing?
UK Dept for Work & Pensions commissioned a review of the evidence to find out
G Waddell, K Burton (2006)
www.tsoshop.co.uk
OverviewWork is generally good for physical and mental health and well‐being
Unemployment and unnecessarily prolonged sickness absence are generally bad for physical and mental health and well‐beingGetting work can reverse the adverse health effects of unemploymentFindings apply for healthy people of working age, for many disabled people, for most people with common health problems, and for social security recipientsWork is essentially therapeutic – helps promote recovery – leads to better health outcomes
Provisos
Beneficial health effects depend on the nature and quality of work
Good jobspay, security, support, communication, control, job satisfaction, safety
thus, workplace has an defining effect on our health
•Participation/work rarely seen as a health outcome
•25% offer advice on rehabilitation
• 10% offer advice on RTW
• NICE back pain guidelines
• occupational outcomes not included
• Signs of change!•but not in clinical guidelines yet
Work is an important health outcome
Work is an important health outcome
A health outcome depends on who you are and where you areSubjective reduction in symptomsImprovement of functional limitationRegain work participation – SAW or RTW
these are not equivalent and no linear path!
Focus: common health problems
Less severe illnesses and injuriesResponsible for ~70% of absence and long‐term incapacityMusculoskeletal conditionsMild/moderate mental health problems‘Stress’
Common health problemsHigh prevalence across populationCharacterised more by symptoms than disease or impairment Coexisting symptoms common ‐physical and mentalUntidy pattern of symptoms of varying severity at irregular intervals over life courseCare seeking for ~10% of episodes ‐most episodes settle uneventfullyMultifactorial causation – work usually only one contributory factorMost people remain at work or return to work quite quicklyEssentially whole people, with a manageable health problem
given support, opportunities and encouragement
TIME
SE
VE
RITY
CHP epidemiology – the key to understanding
Symptoms
(most people some of the time)
Healthcare or absence
No Symptoms
(all people some of the time) Work-
relevant symptoms
(fewerpeople less of the time)
Litigation
Extended absence
Workers = People
The elephant in the room
Symptoms exist irrespective of the nature of work!
Work‐relevant symptoms
Primary prevention of most common health problems is unfeasible
Symptoms may affect workabilitysymptoms may be more pronounced at workwork may be difficult because of symptoms
Health problems may be highly work‐relevant, whatever the cause
Prevailing paradox
Diminishing returns
The slide to disastersocial constructs escalating obstacles
Before symptomsPerson
At onset of symptomsPerson
At time of seeking healthcarePatient
If signed off workBeneficiary
On failure to recover/participateDispossessed
adapted from Hadler
Andy’s predicament“It all started when I woke up with severe backpain. The doc gave me tablets and told me torest and stay off work ‐ but I didn’t get anybetter. I was sent for x‐rays, which showeddegeneration. Then I had to wait around to gettreatment. The therapist said it was my job thatcaused it, so I shouldn’t go back till I was fully fit.By that stage I started to get really worried ‐ andfeeling down. The family won’t let me doanything, so I don’t get out much. The people atwork haven’t been in touch, so I don’t knowwhat’s happening about me getting back. Peoplesaid I should put in a claim: the solicitor sent meto a specialist so it must be serious. This wholeongoing saga has just taken over my life ‐ all Iwanted was a bit of help….”
The challenge: shifting the recovery curve
Vocational rehabilitation
A review for Vocational Rehabilitation Task Group (2008)
G Waddell, K Burton, N Kendall
VR can be effective + has cost‐benefits
sooner rather than later
www.tsoshop.co.uk/evidence‐based
Integrated approachVR is whatever helps someone with a health problem to stay at, return to, and remain in workSAW and RTW don’t just happen – action needed!Healthcare alone not enoughvoc rehab not something to try after healthcare has finished/failed
Workplace must be involvedfrom day #1working whilst recovering
Person Person Patient Beneficiary
Everyday symptoms: Incapacity entrenchedNo intervention? Obstacles hard to shift
Time
SAW RTWWorkplace
Healthcare
Optimal 'window' of opportunity for effective intervention
Timing is fundamental
Chasm of lost opportunity
Smarter workplaces
Smarter rehab
Smarter rehab
Prevention silo
Occupational safety:
prevention of serious injury & occupational disease possibleprevention of most CHPs unfeasible
Healthcare silo
Clinical treatments:
have small and inconsistent effect sizes on clinical outcomesdon’t impact on occupational outcomes
Smarter rehab:Early interventionidentify and address obstaclesmyth busting info
Healthcare: work‐focuseddeal with bio issues whilst supporting early RTWpsychosocial problem‐solving
Workplace: accommodatingtransitional work arrangements
Coordinationstepped care principles
...............overcoming obstacles to work participation
Why do some people become disabled?
They do not have a more serious health condition or more severe injurySo, it’s not about what has happened to them; rather its about why they don’t recover
They face obstacles to recovery and participation
biopsychosocial approach
applying the
biopsychosocial model
Tackling Musculoskeletal ProblemsA GUIDE FOR CLINIC AND WORKPLACEidentifying obstacles using the psychosocial flags framework
Kendall, Burton, Main, & Watson: TSO Books, 2009 ww.tsoshop.co.uk/flags
Flags are about identifying obstacles to being active and working
The important thing is to figure out how these can be overcome or bypassed
Combining work-focused healthcare with an accommodating workplace is best: all players onside - consistency, coordination and collaboration
PERSON
WORKPLACE
CONTEXT
Remember six words…
Person
Workplace
Context
Identify Plan Action
Important flags to identify ‐ Person
• Thoughts• Catastrophising (focus on worst possible outcome, or interpretation that
uncomfortable experiences are unbearable) • Unhelpful beliefs and expectations about pain, work and healthcare • Negative expectation of recovery • Preoccupation with health
• Feelings• Worry, distress, low mood (may or may not be diagnosable anxiety or depression)• Fear of movement• Uncertainty (about what’s happened, what’s to be done, and what future holds)
• Behaviours• Extreme symptom report• Passive coping strategies• Serial ineffective therapy
• Employee• Fear of re‐injury• Low expectation of resuming work• High physical job demand (perceived or actual)• Perception of high mental job demand (‘stress’)• Low job satisfaction
• Workplace• Lack of job accommodations/modified work• Lack of employer communication with employees• Low social support or social dysfunction in workplace
Important flags to identify ‐Workplace
Important flags to identify ‐ Context
Significant others with negative expectations or beliefs
Unhelpful policies/procedures used by company
Process delays (e.g. waiting lists, claim acceptance)
Role ambiguity or disagreements between key players (employee <> employer <> healthcare)
Financial, compensation or legal issues
Identification of flags - simple stepped hierarchy:
ObservationOpen questions
Structured questionnaires
Develop a plan with the person
Key Players Communicate:
agree the specific obstacles and actionsagree timeframe and communication channelsuse (conditional) confidentiality waiversemphasise ability rather than disabilityall players sign up to the plankey players work together to ensure accommodating workplace
Useful questions to ask
What do you think has caused your problem?
What do you expect is going to happen?
When do you think you’ll get back to work?
How are you coping with things?
Is it getting you down?
What can be done at work to help?
Action: principles
Early intervention: it must address the identified obstacles, using both healthcare and workplace interventions Communication is key: ensure all players know what’s to be done, by whom, and when. Psychosocial interventions (problem‐solving and coping) are a supplement to effective healthcare ‐focus is on increasing participationAn accommodating workplace is the key to work retention and early return to work.
ActionStepped care approachjust what’s needed when its needed
Identify and tackle obstaclesMyth‐busting info/adviceWork‐focused healthcare: deal with biomedical issues whilst supporting early return to workpsychosocial problem‐solving
Workplace accommodationease the worker back to usual duties
Communication between the players to interweave the actions
Who is involved in RTW
Person Line Manager
ClinicianErgonomist
can facilitate or sabotage
Clinician as ‘advocate’
Person Line Manager
ClinicianErgonomist
GOOD ‐major injury
GOOD ‐ serious disease
UNHELPFUL ‐minor injuries
UNHELPFUL ‐ common health problems
confounders & complications
Person Line Manager
Cliniciane.g. consultant
e.g. lawyer e.g. union
Over servicing:‐ what ‘messages’ does the worker get?
•The problem should have been prevented
• There is a problem needing treatment
• The treatment will cure the problem
• Pain reduction is necessary before rehab
• The clinician is responsible for getting you better (patient has passive role)
• The ergonomist/employer should have prevented you getting hurt
‘the right treatment at the right time’
it’s possible to deliver useless treatments efficientlyeffective treatments inefficiently
both can have negative impact individual with the problemwaste of resources
Stepped approach “just what’s needed when it’s needed”
www.tsoshop.co.uk/flags
Case coordination
Person Line Manager
Clinician
Intermediarye.g. case
coordinator
Why case coordination?
For many people with musculoskeletal problems, their journey is fraught with uncertainty. It’s a maze
Unclear paths
Dead ends
ContradictionsUnhelpful policies
Unhelpful people
Unclear destination
Uncertain future
Maze versus Labyrinth
Sorts out the maze, makes the journey a labyrinth
Path leads inexorably from start to finish
No dead ends
No monsters
Smooth and serene
Visible destination
Coordinator may be in workplace
“We’re a small company with a simple protocol formanaging pain and injury. It’s my job to put it intoaction. Basically, I act as a case manager withsupport from professionals, to coordinate things.I get informed at day one of absence, and stay incontact. I liaise with the doc, but also send ourpeople to a local clinic. They tell me what mycolleague can do (we use a confidentialitywaiver), which helps me figure out how best tohelp my colleague back to work. They point outthe obstacles and what needs to be done toovercome them, as well as giving treatment. Idevise the Plan with my colleague and we sortout any work modifications as a team. I also useinformation leaflets to help bust the myths. Itworks well!”
Myths
Beliefs are central to what we do about injury and diseaseHealth myths aboundheld by clinicians as well as by the public
Myths are major obstacles to work participation
Myths:Rest always needed
until pain goes
It's a health problem, so there must be a cure....
It hurts at work, so I was damaged by my
workWorking whilst ill or
‘injured’ will just make matters worse
Contacting absent worker is intrusive
No return to work until 100% fit
We need to shift the culture
Working while recovering
Key players must be onside and acting
Poor communication is a major obstacle
Hand of dogYou say dog, I hear god
Information, for all the players, needs to be:
• consistent
• accurate
• unambiguous
• pertinent
• understandable
Words that do harm
What is said can be a major obstacle to early RTW (or SAW)The words the clinician uses are very powerful
“it’s probably happened because of your work” “ if it doesn’t improve, I’ll have to send you for tests”“these things don’t really get better you know”
Dispelling myths and shifting the culture
• Set of guidance material developed
• 3 leaflets• common set of messages• focus on how players interact• evidence-based• believable and doable• wide stakeholder support• target the key players
WorkplacePlayers in and around the workplace
senior management • line managers •human resources • small employers •unions • health & safety advisers •occupational health professionals •rehabilitation providers •employment advisers • claims handlers • lawyers
6 pages of information + practical advice on RTW proceduresPDF downloads
www.tsoshop.co.uk/evidence-based
Workers‐patients
Booklet for patients/workersIn style of Back Bookstraightforward languagedistribution by healthcare or employers20 pages: information, practical advice + patient stories6‐page PDF leaflet also
www.tsoshop.co.uk/evidence-based
Healthcare
Leaflet for health professionalsdiscusses evidence on work and healthpractical advice on how to tackle this difficult topic6 pages + 1‐page e‐summaryPDF downloads
www.tsoshop.co.uk/evidence-based
www.tsoshop/co/uk/flags
Downloadable resources
Health care and work
GPs and other health professionals:have a key role in advising and supporting patients about (return to) workneed to understand their patients’ work situationshould appreciate that (return to) work is an important outcome for clinical managementshould help patients develop a return to work plancan facilitate return to work by communication and coordination with the workplace
But, need confidence and knowledge to do itMyth busting info and advice
Fit note
It’s a great idea, but the doc generally has little notion of the work or workplace.
Recommendations will need to be interpreted.......
Altered hoursReduced work hours/daysAdditional rest breaksAllow work at home
Amended dutiesAchievable goals, scheduled at start of dayReduce pace of workReduce task frequencyIncrease task varietyCo‐worker as buddy
Phased return to workFlexible start‐finish timesGraded return to workStart work on a WednesdaySelected duties
Workplace adaptationsReduce reachingProvide seatingReduce weightsDifferent department
Implementation at the workplace
Interpretation of medical advice can be trickyLine managers are keyUncertain
about healthabout what is safeabout the lawabout what the doc meansabout what they can do
Need confidence and knowledgeMyth busting info and advice
The nature of accommodation
Transitional work arrangementsTemporary facilitation of SAW or RTW
DON’T SIT DOWN CAUSE I'VE MOVED YOUR CHAIR• Arctic Monkeys 2011
Accommodating WorkplacesWhat is reasonable?
‘Light duties’
Alternative duties
Modified work
Selected duties
Worker knows best
Participatory ergonomicsInvolve person:identifying the obstaclesselecting the solutions
Communicationperson
line manager
clinician
Whither healthcare?Treatment may be needed, butbeware iatrogenesis:
what is said can undo what is done
More and better health care alone is not the answer!Health care needs to work to a new integrated paradigm:recovering while workingwork with employer and worker
Whither prevention?
Preventive intervention alone will have little impact on common health problems among workers.
Undue emphasis on ergonomic solutions may engender counterproductive beliefs
More and better ergonomics alone is not the answer!Yet, ergonomics does have a major role in return‐to‐work and work‐retention programs.Workplace accommodationImplementing fit note recommendations
‘work should be comfortable when we are well, and accommodating when we are ill or injured’Nortin Hadler (1997)
Thanks for letting me talk with you