NL0809A: RETURN TO WORK: BACK PAIN ISSUES AND STRESS CLAIMS The source of all articles included in this course is RTWKnowledge.org 6 Contact Hours PRINT TEST or TAKE TEST
CONSEQUENCES OF BEING OFF WORK 1. Loss of Self: A Fundamental Form of Suffering Resulting From Chronic Illness 2. The Health Effects of Being Out of Work MEDICAL FACTORS 3. Healthcare Provider Participation is Important in Achieving Early Return to Work 4. Improving Communication between Treating Practitioners Results in an Earlier Return to Work 5. Current Trends in Stress Claims 6. Predicting Stress and Strategies for Reducing It 7. Stress Management and Workplace Disability 8. Preventing Occupational Stress 9. Occupational Wellbeing and its Effect on Performance BACK PAIN 10. People Who Get Clear Advice about Their Back Problem Do Much Better 11. Will an Episode of Low Back Pain Become a Long-Term Problem? Our Psychology is Important in Deciding 12. Risk Factors for Work Related Low Back Pain and Strategies to Prevent Long Term Disability 13. Identifying the Causes of Back and Arm Pain in an Office Environment 14. Factors That Influence the Duration of Sick Leave Due to Low-Back Pain 15. A Workplace Education Program That Prevents Neck and Back Problems, and Limits Reinjury 16. A Review of Workplace Rehabilitation Approaches for Back Pain THE IMPACT OF WORKPLACE CULTURE 17. It Pays to Be Nice – Employer Worker Relationships Influence Back Pain Return to Work TOP CONSEQUENCES OF BEING OFF WORK ARTICLE #1: LOSS OF SELF: A FUNDAMENTAL FORM OF SUFFERING RESULTING FROM CHRONIC ILLNESS At a glance: Long-term health conditions often restrict people's lives, meaning they can no longer perform roles that are central to their sense of identity. For most, this is a traumatic experience and can be destructive of self-image. Along with the physical impacts of the condition, restrictions can lead the person to withdraw from their normal activities and become isolated. PERSPECTIVES: Employee It is distressing when you can't do the things that are important to you. If you become unable to do the work you used to, or play a sport you love, it can be challenging your sense of self. Work is an important part of our lives, it is one of the things that gives us a sense of who we were. When a person can't work because of a health condition it can be especially distressing – particularly if they see themselves as “the breadwinner' but are no longer able to support their family. The difficulties can be even greater for “perfectionists.' Their focus on getting things right it is more intense, and so is their distress when things don't go as planned. Employer Understanding your employee can help return to work outcomes. People have a sense of themselves, perhaps as a larrikin, a hard worker, a provider, or as a strong and healthy person. When they have a health condition that stops them from functioning normally, this ‘sense of self' can be diminished. This can make people sad and worried, without them necessarily recognising these feelings, or being able to talk about what's causing them. If you understand what is happening to your employee, you will be in a better position to help them through difficult periods, and structure their return to work program so it fits their needs. Treater Many people with long-term health problems are not able to live their lives as they expected. This can be challenging to their sense of identity. Simply recognising this fact can help. For the person, articulating their feelings can help people identify ways to improve the situation. For example, if an injured person is proud of their house-keeping, but no longer able to keep up, they're likely to be distressed. Discussing this with them can be some help. You might also be able to help them recognise that trying to keep up is admirable in itself, and acknowledge that it's ok to seek help from others. If an individual sees themselves as “the provider' but their work injury reduces the household income, it may be important to work with them to plan and understand the likely path forward. WorkCover payments will often be reduced over time, and some employers will not provide long-term modified duties. Working with the individual to get back to their normal job as quickly as possible can help. Give them a good sense of expected recovery time frames, encourage them to be active, and work with their employer to make sure they resume normal duties as soon as possible. Insurer It is important to acknowledge the impact of a work injury on an individual. Helping the person to recognise the impact themselves can enable them to find positive ways of dealing with the situation. Recognising the impact of a condition allows a person to change their situation. People who have been off work for more than a few weeks have particular trouble with motivation. Not working has become their habit. Most of us find it difficult to change our habits, even when we want to. The key aspects that motivate people to change include seeing the downside of the current situation, and the benefits that would occur with change. Original Article, Authors & Publication Details: Charmaz K. Loss of self: A fundamental form of suffering in the chronically ill. Sociology of Health & Illness Vol 5(2) Jul 1983, 168-195, 1983. Background, Study Objectives, How It Was Done: Chronic or long term health problems have significant impacts on a person's life. This paper examines what happens to people with chronic illness. It is not specifically directed at work related problems, but is included as it provides insight into some of the difficulties of having a long-term health problem such as back pain. The author of this paper performed in-depth interviews with 57 chronically ill people in North America. Their health problems included heart disease, diabetes, multiple sclerosis, cancer, back pain and other chronic conditions. The age range of those interviewed was 20 to 86 years old, with most between 40 and 60. The study proceeded from the notion that people develop a sense of themselves through social roles and relations. Based on an examination of the ways in which people come to terms with chronic health problems, the researcher hypothesized that people have a sense of identity which may be lost if health problems restrict their lives. The author suggests that medical and social systems do not do a good job of supporting people as they come to terms with chronic condition. Study Findings: The author's findings are drawn from in-depth interviews of the participants. Findings from these interviews are grouped under several headings: Living a restricted life People with long-term health problems often become restricted in their activities. Some of these restrictions may be minor, but others are more substantial or part of the person's core identity. If an individual sees themselves as strong and fit but and then becomes limited in their physical abilities, an important part of their life may be lost to them. Restriction is likely to be greater if health care professional do not give patients sufficient information or treatment that supports them in remaining active. Having an unpredictable condition sometimes means that people further restrict their activities because they are afraid of making the condition worse. Restricted function causes some people to retreat into themselves. In a small group of people this becomes a retreat into an all-consuming world of illness. For this group, life can be wholly focused on illness and fears about the future. Social isolation A restricting condition can cause people to withdraw from their normal activities. This can cause isolation at work, at home and from friends. If people feel they are devalued because of their condition, it can cause them to restrict contact with others, increasing their isolation. In some circumstances this will only occur with acquaintances or previous workmates, but in others it can extend to close friends and family. On being discredited Sometimes people respond negatively to someone with a long term health problem, or even express disbelief. The significance of these experiences depends on how often they occur, the perceived importance of those who discredit the person, and how strong the negative response seems to be. This does not affect all people equally, but for many it will weaken the foundation of an already shaky sense of self. Managing long-term health problems can be stressful for family members, who may also be struggling with the situation. Family members might not be able to provide the support a person needs, and may also discredit them. Sometimes people assume that poor outcomes are due to a lack of motivation to improve the situation. Others sometimes think that the person takes on a role of reduced function on purpose, or wishes to abandon their responsibilities. Health practitioners can contribute to the problem if the express disbelief about the person's condition. This can be a problem particularly when there is no clear diagnosis. People with long term health conditions also discredit themselves, which can be one of the most significant sources of suffering. People have expectations about their lives, and what they can do and contribute. This may include providing for a family, playing sport at a high level, or being a role model for their children. When a health condition prevents someone from performing (or believing they can perform) tasks central to their identity, the impact can be enormous. In such cases, people often discredit themselves. Profound disappointment and grief are often the result. Many people don't understand or acknowledge that losses to their sense of identity are a reason for their sadness. People may come to see themselves as permanent failures and a burden to others, causing them to further withdraw and become more isolated. Becoming a burden When people can no longer fulfil what they see as the basic obligations of their relationships, they often feel they are a burden on those around them. People often describe feelings of uselessness to themselves and others, and describe them as the worst development. A perception that one has “become a burden' may develop when people are unable to continue in their normal activities at work or at home. Sometimes other people in the household need to increase their share of responsibilities, or get a job to replace lost income. Conclusions: People with restrictive long-term health problems typically develop a higher level of self concern, meaning that they worry about who they are becoming, and suffer damage to their self image. This can cause further problems, like a tendency to scrutinize encounters with other people for signs of a negative response. Long-term health problems can make people more dependent on others. They may experience traumatic changes to their self image, and no longer feel able to claim the identity they used to feel was theirs. The author noted a striking contrast between participants. A small group had improved, and no longer suffered emotional consequences. These people had used their situation as a path to knowledge and self-discovery. They had developed an awareness of their overall situation and had developed meaningful ways to relate to their condition, themselves, and those around them. TOP CONSEQUENCES OF BEING OFF WORK ARTICLE #2. THE HEATLH EFFECTS OF BEING OUT OF WORK At a glance: People who are out of work are at greater risk of: Poor physical health and wellbeing Poor mental health Mental health problems Suicide and suicide attempts Social isolation and loss of self confidence Death PERSPECTIVES: Employee Work provides income, but it is also important to a person's mental wellbeing and self-belief. The roles people play in their family and in society are partly shaped by their work. The longer someone stays off work, the less likely they are to return. Even after a few weeks their chances of returning are reduced. Many people who have been off work for a few years acknowledge that if they had known the path ahead they would have been much more proactive about their situation. Being off work with an injury is difficult for most people. Aside from worries about health and problems coping with pain, there are the official or bureaucratic processes that need to be worked through and understood. Work is an important goal in itself. It is an essential part of your recovery process. Try to get the support you need with the return to work process. Employer Work is important for people's health and well-being. A return to work is most likely to be successful when the employee is engaged, and feels like a productive member of the team. Re-engaging people improves their well-being, and benefits the company. Treater This substantial review of a large body of literature provides solid evidence that work is generally good for people's health and well-being. Remaining off work is a hazard for medium to long-term health. It carries an increased risk of health problems and increased risk of death from a variety of conditions. A few weeks of sick leave may not seem a major problem, but we know that the longer someone stays off work the less likely they are to successfully return. This review provides good evidence that treating practitioners. In return to work this may include doctors, physiotherapists, chiropractors, osteopaths, psychologists, masseurs, etc. should give clear advice to patients. Many patients do not see the path ahead, and the authors of this paper call on treating practitioners to focus on the return to work as an important outcome. Insurer Mental health problems, depression suicide and attempted suicide, heart disease, cancers, and overall rates of illness and death increase when people remain out of work. Return to work is most successful when all parties work together towards a common goal. Clear communication and support for people with an injury is an important aspect of helping them back to work. Original Article, Authors & Publication Details: G. Waddell1, K. Burton2 and M. Aylward3 (2007). Work and Common Health Problems. Journal of Insurance Medicine; 39(2):109-120. 1Waddell –Unumprovident Centre for Psychosocial and Disability Research, Cardiff University, UK. 2Burton – Centre for Health and Social Care Research, University of Huddersfield, UK 3Aylward – Unumprovident Centre for Psychosocial and Disability Research, Cardiff University, UK Background, Study Objectives, How It Was Done: Over the last 25 years work has become safer, but sickness absence has increased. This paper was a review of a broad range of studies exploring the impact of work on health. Only the first part of this paper has been summarized here. Summaries of other parts of the paper can be found elsewhere on this site. Study Findings: The reviewers divided the analysis into the sections below. 1. Health effects of being out of work There was strong evidence that being out of work has the following consequences: Increased risk of dying Increased risk of dying from heart disease, lung cancer, and suicide Poorer physical health, including heart disease, high blood pressure and chest infections Poorer general health and poorer self reports of health and well-being Increased long-term illness Poorer mental health and well-being. Increased likelihood of suicide attempts Higher rates of medical attendance and hospital admission 2. Health effects of being long-term out of work The authors advised long-term worklessness is one of the greatest risks to health, with: 2-3 times the risk of poor health 2-3 times the risk mental illness Significantly increased risk of depression 20% excess deaths Long-term worklessness carries more risk to health than many “killer diseases," and more risk than most dangerous jobs (e.g. construction, working on an oil rig) 3. How being out of work affects health The researchers examined the evidence, and evaluated the quality of each study to ensure that their conclusions were not inaccurate. They were clear that being out of work was actually causing or contributing significantly to poorer health. 4. Being out of work might affect health in the following ways: Being out of work results in reduced income for most people. Reduced income has a negative effect on health, and also causes anxiety Being out of work effects mood, which can have a negative effect on mental health Some studies suggest that being out of work increases risky behaviors, such as increased smoking and decreased exercise. Not all of the evidence supports this view, however. Being out of work for one period may increase the likelihood of being out of work again later on. The authors note that although being out of work generally had negative effects on health, it can lead to improved health and well-being for a minority of people (about 5-10%). This seems to be the case when people are financially secure, and have made a positive decision to remain out of the workforce. Health effects of re-employment: When an individual returns to employment, signs of general health and well being improve. (E.g. self-esteem, self-reported health, physical health, and self-satisfaction.) Returning to the workforce improves minor psychiatric health problems and psychiatric distress The security of the new job, as well as the person's motivation and job satisfaction are important factors in improvement after returning to work People who have returned to work are healthier than those who have not. One might assume that people with better health in the first place are simply more likely to return to work. However the researchers took this possibility into account, and concluded that most of the improvement was directly caused by re-employment. Conclusions: The authors of this paper emphasized the importance of rehabilitation and supporting employees' return to work. They indicate that work is an important goal in itself, and an essential part of any recovery process. Rehabilitation is not just a matter for doctors, but should be a focus of all parties in the work disability system. The authors comment that all players must work together to achieve common goals to care for individual patients and improve public health. TOP MEDICAL FACTORS ARTICLE #3. HEALTHCARE PROVIDER PARTICIPATION IS IMPORTANT IN ACHIEVING EARLY RETURN TO WORK At a glance: The advice of health care providers is important in encouraging early return to work. Contact between a health care professional and their patient's workplace can assist return to work. Workplaces respond positively to the advice of health care professionals regarding modifications of work space and duties. Patients respond well to positive recommendations to return to work from their health care professional. PERSPECTIVES: Employee Contact between your workplace and your treating doctor will help your recovery and return to work. When your health care provider is in contact with your workplace a realistic assessment of any modifications required to accommodate your injury is more likely. In addition, the workplace is more likely to respond to a health professional's advice and modify your workplace to help you get back to work. Encouraging your doctor and your employer to talk to each other regarding your return to work is likely to make the process easier and assist you in preventing re-injury. Employer Contact with an injured worker's health care provider makes it more likely that they will return to work soon after injury. When health care providers have an understanding of their patient's workplace and normal work activities they can make better recommendations regarding when they can return to work, what duties are suitable and any workplace modifications that are necessary. Contact with the health care provider can also give them a better understanding of the limitations the workplace may have regarding modifications and job change. Unfortunately, health care practitioners are in short supply and high demand. Communication with providers should be straightforward and make the best use of scarce time. Treater This study shows that it is important that health care providers encourage patients to return to work as early as possible. Contact with employers will better inform your recommendation regarding the patient's ability to perform their work duties, plus the employer is twice as likely to listen to your professional opinion regarding workplace modifications to accommodate the patient's injury. This study found evidence that contact between the health care provider and the patient's workplace makes it twice as likely that they will return to work early. Additionally, patients (employees) respond well to positive recommendations to return to work from their health care professional. Simply giving patients a return to work date and guidance as to how to prevent recurrence or re-injury makes an early return to work more than twice as likely to occur. Insurer Encouraging early contact between health care providers and workplaces has been shown to improve return work rates. Health care providers get a more informed understanding of the flexibility of the workplace through contact and can make clearer recommendations. Being given a clear and positive date for return to work by a health practitioner doubles the likelihood that an injured worker will return to work early. Providing the patient with advice on how to prevent re-injury also facilitates early return to work. Employers appear to be twice as likely to take notice of recommendations made by health care providers than those made by others. Health care providers are often overloaded, so communication with the patient and their workplace needs to be simple, effective and, most importantly, not time consuming. Original Article, Authors & Publication Details: A. Kosny1,2, R-L. Franche1,2, J. Pole1,2, N. Krause1,2,3, P. Côté1,2and C. Mustard1,2 (2006). Early healthcare provider communication with patients and their workplace following a lost-time claim for an occupational musculoskeletal injury. Journal of Occupational Rehabilitation; 16( 1): 27-39 1 Public Health Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada. 2 Institute for Work & Health, Toronto, Ontario, Canada. 3 Department of Medicine, University of California, San Francisco. Background, Study Objectives, How It Was Done: The Canadian Medical Association and Ontario Medical Association view the process of return to work after injury as a joint responsibility between employer, employee and health care provider. In Ontario, the province in which this study was conducted, physicians and chiropractors play an important role in the return to work process. They are responsible for directly communicating with the Workplace Safety and Insurance Board about the progress and readiness of the injured worker to return to work. This study examined the association between three actions by health care providers and early return to work after a compensated work-related musculoskeletal injury: 1. A positive return to work recommendation 2. Proactive communication with the injured worker 3. Contact with their patient's workplace From a possible study population of 6,530 Ontario workers, 417 were contacted. Of these, 205 completed the interviews, but a further 18 were excluded because of their type of injury, so 187 individuals were included in the study. Participants all had been compensated for missing time at work from back, neck, or upper limb musculoskeletal injuries. In the sample, most were full time workers, with 13% being classified as “white-collar' workers and 87% as “blue-collar' workers. The most common injury was to the back (58% of the claims). The study compared an early attempt at returning to work with the following three statements: “your health care provider told you the date you could return to work' “your health care provider advised you on how to prevent re-injury or recurrence" “your health care provider made contact with your workplace' Study Findings: For the majority of workers (74.9%) a medical doctor was their main health care provider. If a health care provider gave their patient a date after which they could return to work, they were more than three times as likely to return to work soon after injury. Forty-eight (48%) percent of patients reported their health care provider giving them a return to work date. If a patient was given guidance on how to prevent recurrence and re-injury they were more than twice as likely to return to work early.62% of patients said that their health care provider told them how to prevent re-injury. If the health care provider contacted their patient's workplace it was about twice as likely that an injured worker would return to work early. 38% of patients reported that their health care provider made contact with their workplace. Contact with the workplace involves considerable time and energy at a time when health care providers have increasing demands on their time. This study suggests future research should explore the benefits of training and institutional change to facilitate the increased involvement of health care providers in helping injured workers return to work successfully. Conclusions: The study results suggest health care providers should play an active role early on in the process of returning to work after injury, including proactive communication with the patient and direct contact with their workplace. The Interaction between the Health Care Provider and the Workplace: When recommendations for ergonomic (layout of the workplace or workstation) or job changes are made by physicians, employers tend to listen. One study found that although 48% of employers took no action in response to a worker's report of a repetitive strain injury, a recommendation from a doctor doubled the likelihood of a response. Direct communication with the workplace gives the health care provider with an understanding of the work conditions that an employee will return to after injury. This enables a better assessment of the level of recovery needed before to return to work and the kind of modifications that may be possible in the workplace. Health care provider contact with the workplace gives some weight to the worker's injury claim and need for modifications to prevent re-injury. TOP ARTICLE #4. IMPROVING COMMUNICATION BETWEEN TREATING PRACTITIONERS RESULTS IN AN EARLIER RETURN TO WORK At a glance: Improving the quality and flow of information between treating practitioners results in an earlier return to work. PERSPECTIVES: Employee Encourage your treating practitioners to talk to the other treaters involved in your care. This may mean the G.P. talking to the physiotherapist, or the physiotherapist talking to the rehabilitation provider. Getting back to work is important for your well-being, and the earlier this occurs the greater the chance of a positive outcome. Employer Improving communication between treating practitioners improves return to work outcomes. This study was about communication between practitioners, however, the same issues apply to communication between treating practitioners and the workplace. Employers can help practitioners to communicate better. Much like you, treating practitioners have many demands on their time. The barriers to better treaters' communication include: 1. Not knowing who to contact at the workplace 2. Not being able to reach the relevant person at the workplace while the patient is present 3. Confusion and lack of clarity regarding confidentiality in discussions about return to work 4. Lack of available time during the practitioner's day 5. A compensation system which relies on treating practitioners doing extra work without being paid 6. A lack of understanding about the importance of communication to return to work outcomes Employers can work to improve communication by 1. Providing clear documentation about who the treating practitioner should call at the workplace 2. Attending the practitioner's rooms with the patient, if the patient is comfortable with this approach 3. Inviting the practitioner to the workplace 4. Offering to pay practitioners for the time they devote to communication 5. Being available to take a telephone call at the time the patient is attending the practitioner Treater Communication between practitioners improves return to work outcomes. This applies to communication between general practitioners and specialists, general practitioners and allied health professionals, and communication generally regarding return to work. When return to work is a focus and recognized as a key aspect of patient management, better communication is likely to occur. It is important to understand the likely negative long-term health consequences for people who remain off work. Isolation, depression, strain on relationships and family, increased morbidity and mortality are all recognized complications of an ongoing absence from work. Good early and ongoing communication is fundamental to return to work management and the well-being of those in return to work programs. Insurer Case managers within insurers understand the challenges of communicating with treating practitioners. This simple study showed that improving communication between treaters results in better outcomes. To foster simple, clear communication about return to work issues, compensating practitioners for the time they devote to this work is useful. Being available to talk at an appropriate time (such as when the patient is present) increases the likelihood of effective communication occurring. Original Article, Authors & Publication Details: K. Mortelmans, P. Donceel and D. Lahaye (2006). Disability management through positive intervention in stakeholders' information asymmetry. A pilot study. Occupational Medicine; 56(2):129. 1Department of Insurance, Environmental and Occupational Medicine, Katholieke Universiteit Leuven, Kapucijnenvoer 35/5, Leuven 3000, Belgium. Background, Study Objectives, How It Was Done: Return to work is more successful when all of the parties involved with rehabilitation are working in a coordinated fashion. On the other hand, when people involved in the return to work process do not have the same information, return to work may be delayed. Stakeholders (the people involved in the return to work process) include the employee, the employer, the human resources manager, the claims administrator or insurer, rehabilitation providers, treating practitioners, medical specialists, occupational health specialists, and a number of others. Information exchange is an important component of disability management. The authors of this study sought to evaluate whether communication between medical practitioners could be improved, and whether earlier return to work would occur as a consequence. While this study was undertaken in Belgium, the issue of enhancing communication between treating practitioners and other stakeholders is an international problem. The researchers acknowledge that the occupational physician may be best informed about the individual's work, while the treating practitioner may know the most about the person's physical condition and their psychological and social situation. The aims of this study were: To test the feasibility of a model to improve communication To obtain preliminary data on the return to work effects of an improved exchange of information The intervention included the following 5 steps Patients attending their second work inability assessment consultation (with the social insurance physician) were enrolled in the study. The social insurance physician noted information about the patient's sickness, absence, and work resumption on the specially designed communication form. The communication form was sent to a central administrative area. Some of the patients remained as a control group and went through the usual process. Others, where there was an occupational health service, were assigned to the intervention group. On seeing the patient, the occupational physician read and completed the communication form, including information about the employee's job description. In turn the insurance physician would update the form. The information was passed back and forward between the two practitioners. Study Findings: The outcome of the assessment was measured one year after the start of the employee's sickness absence. 70 patients were included in the study, 55 in the control group and 15 in the intervention group. Improving the information exchange was associated with: Earlier return to work. The chances of resuming work increased for the patients under the intervention group, and Greater likelihood of gradual work resumption Conclusions: The author’s note that return to work is improved when parties work together to focus on return to work outcomes. Whilst this was a small study it shows that regular communication between the medical practitioners can improve return to work outcomes. The authors are currently testing this pilot in a larger study. TOP ARTICLE #5. CURRENT TRENDS IN TRESS CLAIMS At a glance: Stress-related compensation claims are a costly problem. They also represent suffering and lost productivity for workers. This review examined the research surrounding this issue. Disability and stress have many causes. Physical, psychological, emotional and social factors can contribute. Most stress-related compensation claims are genuine. A person's experience of stress-related illness can be changed by unconscious psychological processes. Compensation decreases the chance of overcoming the condition and returning to work. Remaining on compensation has serious negative consequences for health and wellbeing. Decisions about compensation need to be made with the claimant, not against them. PERSPECTIVES: Employee Dealing with stress at work can be difficult. A person experiencing stress at work may not know how to deal with the situation, and having a compensation claim can make it even more challenging. Litigation and compensation reduce the chances of a good recovery and early return to work. People involved in these processes often have higher levels of pain, disability and depression. Compensation is associated with poorer mental and physical health, and potential financial and social difficulties. These effects may be due to delays to treatment caused by the “red tape' of the compensation system, disruption of relationships at work, emotional strain and the difficulty of trying to get well while “always having to prove that you're ill." This study found that a person's beliefs, understanding and approach play a major part in how they will recover from stress. People who are depressed are more likely to remain off work, as are people who have a compensation claim. Stress situations are difficult for people to deal with. Make sure you get the best help you can. Work out how to communicate about your problem clearly. It is best to try to talk to someone in the organization who you think will listen, and people are more likely to take notice if you communicate positively and make suggestions about how to deal with the problem. Employer Employers often question stress claims. This study shows that most stress claims are made by workers with a real problem. A workers perceptions influence how they approach the problem and communicate. Some people become distressed if they do not consider they are being heard or believed, and can communicate negatively and emphasize their symptoms. In turn this can lead employers to be more doubtful about the claim. Compensation reduces the chances of good recovery, especially when there is a dispute about the claim. The workplace strongly influences whether the person will successfully return to work, or whether they will develop into a long-term problem. This study and others have found that workplaces tend to be better at dealing with stress that arises from a single traumatic incident. Chronic problems, stemming from problems with workplace organization and relationships, can be harder to deal with. However, these issues have a stronger influence on stress and stress-related compensation claims in the workplace. Early, open communication is important in dealing with stress, in order to understand the person, prevent the situation escalating, and minimize the chance of long term problems. If stress is recognized, acknowledged and managed early the problem can be dealt with before a claim needs to be lodged. Treater Determination of work disability is by its nature a difficult and unscientific process. Decisions about work need to be made in partnership with the patient, and the patient needs to know their long-term health can be affected by compensation. Communication is vital in assisting patients to deal with a stress claim. Strategies that can help workers manage stress include: • Requesting a written job description • Meeting with the supervisor to discuss work/time management issues • Changing jobs • Filing a grievance complaint • Seeking assistance with workload • Requesting training • Requesting regular staff meetings • Requesting change in physical environment • Organizing changes with co-workers Insurer An important finding of this study is that decisions about compensation should be made with the claimant and not against them. Compensation is associated with poorer outcomes. This may be due to delays to health care and the strain of trying to navigate 'the system.' Needing to prove they are sick reinforces a person's position and suffering. Some of these problems can be overcome by encouraging the employer to respond early to stress in the workplace. Addressing issues at the workplace early on can prevent the need for a claim to be lodged. Positive communication and avoiding delays will improve outcomes Original Article, Authors & Publication Details: S. M Tisza1, J. R. Mottl III2 and D. B. Matthews1. (2003). Current trends in workers compensation stress claims. Current Opinion in Psychiatry, 16:571-574 1Department of Psychiatry, John A. Burns School of Medicine, University of Hawaii at Manoa 2Private law practice, Honolulu, Hawaii Background, Study Objectives, How It Was Done: Stress-related illnesses cause pain and suffering and decrease productivity. They are also extremely expensive. This 2003 review reported stress claims cost the United States $US66 billion per year (2% of the gross national product). Work-related stress is likely to remain a problem in the future, given current issues of job insecurity, changing skill demands and longer work hours. One researcher described “work-related stress" as the problem experienced by a person when they recognize that they cannot cope with the demands of their work. Compensation claims for work-related stress are made when psychological distress at work causes mental harm. As with physical or medical illnesses, people claiming compensation or taking legal action are less likely to have a successful recovery. The authors of this paper reviewed relevant research topics on work stress claims. The review examined trends in stress claims and factors that influence recovery and return to work. Study Findings: Are stress claims genuine? People may be dubious about stress claims, as the harm isn't always obvious. This review of other studies reports that claims are rarely false. People with stress-related conditions may overstate their symptoms if they feel they are not being heard. A patient may experience physical pain as a result of their psychological distress. A patient in distress may also notice symptoms more and find them harder to cope with. Factors influencing recovery and return to work: The review found a number of factors influence the outcome: Beliefs, feelings and expectations have a powerful effect on symptoms. Disability has many causes, including physical, psychological and social factors. Mental disabilities that are not associated with physical trauma are likely to be influenced by personality and other non-work factors. Patients with symptoms of depression are significantly less likely to return to work. Symptoms of post-traumatic stress disorder contribute to negative emotions. These symptoms are common in injured workers. Workers who are satisfied in their job return to work more quickly. Married workers are more likely to return to work. People with chronic stress tend to have poorer outcomes than people whose stress resulted from a single, specific incident. Workplaces tend to respond more effectively to specific stress than chronic stress. The role of compensation in recovery Receiving compensation decreases the chance of recovery. One study suggested compensation induces feelings of ill-health. It changes the person's behavior and may cause dependency. Judging whether a person's condition is disabling or permanent is not a scientific process, and a clear conclusion can't always be reached. Awarding permanent compensation may in some cases be seriously harmful to the person. Remaining off work is harmful to many aspects of physical, mental and social health and patients need to be informed about the benefits of returning to work. One study found that litigating patients had higher rates of depression, pain and disability than working patients. The study concluded that decisions about a person's future and financial benefits need to be made with the claimant not against them. Conclusions: This review examined research concerning workers compensation stress claims. Its main findings were: Disability has many causes, including physical, psychological, emotional and social factors. Mental disabilities that are not associated with physical trauma are likely to be influenced by personality and non-work factors. Chronic stress and stress that's related to a single incident need to be dealt with in different ways. Employers don't tend to respond as well to chronic stress problems. It is likely that most stress claims are genuine. However, a worker's experience of symptoms may be exaggerated due to unconscious psychological processes. Receiving compensation decreases a workers likelihood of returning to work. Remaining off work decreases physical and mental health. Judging whether a person has a “permanent disability' is not straightforward, but the decision can have serious consequences for the persons future. Decisions about compensation need to be made with the claimant, not against them. TOP ARTICLE #6. PREDICTING STRESS AND STRATEGIES FOR REDUCING IT At a glance: Even for employees in potentially violent or distressing environments, relationships with managers and co-workers seem to have the greatest influence on stress. Conflict is a key cause of stress and the response of managers and colleagues to a person's stress affects the success of efforts to manage the problem. Stress leave is associated with significant stigma, meaning that taking stress leave can itself be a source of stress. Chronic stress seems to lead to more work absence than exposure to a single traumatic incident. PERSPECTIVES: Employee Employees who are struggling with stress are often hesitant to seek assistance, or make a claim. Employees usually try to avoid the additional stress of the associated stigma. This can mean that stress-related problems are not addressed until the person concerned has suffered for some time and developed significant symptoms. If you are struggling with stress, do what you can to address the problem as soon as possible. This might mean talking to your GP and asking about strategies for managing stress. If there's someone in management with whom you have a good relationship, speak to them about the problems you are encountering. They might be able to give you some solutions or useful advice. Some companies provide the services of a psychologist or counselor. These services can be helpful; if they're available, give them a go. Dealing with stress early can help prevent the problem getting worse. Employer Employees who take stress leave or make stress-related compensation claims often: Indicate that workplace conflict is a significant cause of their stress Take a lot of time off work in the six months prior to their compensation claim Avoid lodging a claim until their stress levels are very high. Employers can minimize stress claims by encouraging early reporting, resolution of workplace conflict, and providing support to employees who are stressed. Without good training it may be difficult for supervisors and line managers to pick up early warning signs and prevent or manage workplace stress. Remember that these employees are also subject to stress, and need to be supported. Employers can introduce mechanisms for early reporting of stress problems. This approach is most likely to be successful if managers trained to receive feedback and deal with these issues. Some companies also have a second reporting mechanism, such as a confidential phone number or hotline, which allows employees to report sensitive problems that might otherwise go unnoticed. Treater This study examined people who lodged stress claims within the welfare sector. The majority indicated that workplace conflict caused or significantly contributed to their claim. Strategies that help stressed employees to manage their stress are likely to help them return to work. Meditation, exercise and access to counseling services all have the potential to improve outcomes. Insurer Employees typically avoid lodging stress claims, and report a high level of concern about the reaction of co-workers and management. Usually a stress claim is preceded by a history of stress and workplace absence. If a stress claim is lodged, employers should be encouraged to listen carefully to the employee making the claim. The incident that precipitates the claim may actually be an issue of lesser importance to the employee – usually a stress claim is based on a long term problem that builds over time. It could be important to look behind the issue presented to see if there is a more important underlying problem that needs to be addressed. Original Article, Authors & Publication Details: M. F. Dollard1, H. R. Winefield1 and A. H. Winefield2 (1999) Predicting work stress compensation claims and return to work in welfare workers. Journal of Occupational Health Psychology 4(3): 279-87. 1School of Psychology, University of South Australia, Whyalla, SA, Australia 2Department of Psychiatry, University of Adelaide, SA, Australia Background, Study Objectives, How It Was Done: Occupational stress is common, especially in the human services sector. Employees in this area often work with clients who are distressed, dependant or experiencing difficulties. Occupational stress is costly in terms of the psychological suffering of the affected workers, and also in terms of medical and compensation costs for their employer. Claims for psychological damages are hard to measure objectively. People claiming compensation for chronic stress feel anxious that decision-makers, friends and colleagues will not believe their claim is genuine. The experiences of people who make stress-related compensation claims are less well-documented than the experiences of people with physical injuries. It is known, however, that those who make stress-related claims are: -- More likely to be female -- Have usually taken more sick leave than the average worker As with physical injuries, the longer an employee is off work due to stress, the less likely they return. This study aimed to: • Investigate the common characteristics of workers who claim stress-related leave and compensation • Explore the ways in which stress leads to psychological injuries • Describe the factors that helped or hindered the return to work in these cases The study was carried out in South Australia, in a large welfare agency of approximately 1200 employees. The agency provides services including child protection, residential care for adolescents, financial assistance and counseling. Some of the employees did shift work, and a growing proportion were employed on short-term contracts. In the 10 years prior to the study, 219 employees made stress-related compensation claims, at a cost to the organization of approximately $5 million. In the 12-month period between 1994 and 1995, 19 employees filed stress claims. The researchers recorded the gender of each employee, and the amount of sick leave they had taken in the year prior to their claim. They also recorded the number of employees that returned to work. 16 of the workers completed a 1-2 hour semi-structured interview in which they described: • How their psychological injury came about • The personal costs of their stress • Their perceptions of the claims process Study Findings: Of the 19 employees who had filed claims, 6 were male and 13 female. It should be noted that the organization employs more females than males (63% compared to 37%). Employees who filed stress claims had taken an average of about 10 sick days in the previous year, which was more than double the average number taken by other employees. 6 months or more after filing their claim, only 8 of the 16 workers had resolved their issues and returned to work. 6 had returned to work with ongoing problems, and 2 had not returned at all. Of the other 3 employees who were not interviewed, one had committed suicide, and 2 could not be contacted. The type of stress the employee experienced was important in determining how much leave they took. 3 employees had experienced a single traumatic event, 6 had experienced a traumatic event and long-term work stress, and 7 had experienced chronic stress only. Traumatic events included: • The death of a client • Being taken hostage • Being spat on • Verbal threats • Physical abuse Sources of chronic stress included: • Large workloads • Inadequate training • Conflict with co-workers or managers • The violent nature of the work environment • Job dissatisfaction • Lack of opportunities for recognition or promotion • Lack of support • High management turnover Conflicts with management or co-workers were more frequently reported as causes of stress than situations involving clients. Workers who experienced chronic stress took significantly more time off work than those who only experienced a single traumatic event. The employees reported a range of psychological symptoms, including: • Grief • Depression • Panic • Feelings of worthlessness • Suicidal thoughts • Anger These symptoms left employees unable to concentrate and thus unable to work. Employees reported significant stigma associated with stress leave. One worker was told that taking stress leave would destroy her career prospects. This stigma meant that employees generally took other kinds of leave in preference to stress leave. Some used all of their annual leave, sick leave and long service leave rather than take stress leave. All participants were very satisfied with the official procedure that was followed when a claim was lodged. Policy called for an accident assessment by a Health and Safety Advisor, which involved the worker, their manager, and co-workers. An action plan was also devised to prevent the problem recurring. Employees were less positive about rehabilitation and return to work. 7 were dissatisfied, 4 were neutral and 5 were satisfied. Some believed they had returned to work too quickly, or were unhappy with the tasks they were assigned when they returned. Interpersonal problems with managers, supervisors and co-workers created the most difficulties during the compensation and return-to-work process. 9 employees rated their managers response to their claim as “bad,' 4 employees rated it as “average' and 3 as “good.' Some positive examples were given of support from supervisors, but these were the exception. Employees appreciated being contacted by their manager or supervisor, but this rarely happened. Support from co-workers was also important. Many employees were concerned about how their colleagues would react, especially when they were transferred to a new department. Employees who returned to work were generally grateful for a transfer to a new department. Some had trouble adjusting to their new role, sometimes leading them to go on leave again. Learning a new role and joining a new group of people sometimes added to the stress the person was experiencing. Few employees consulted the staff counselor. They didn't believe the counselor would “go against management", and in some cases management was the source of the workers stress. Some were unaware that the counseling service was available. Some found counseling helpful, but felt it could not resolve the underlying issue. Conclusions: This study was conducted within the welfare sector, where client interactions are often a source of stress. Even in this environment, organizational difficulties and conflict with managers and co-workers were the most significant sources of stress. Stress-related claims were likely to be the result of chronic stress rather than a single traumatic event. Those with chronic stress took much more time off work than those who experienced a single traumatic event. Compensation claims for chronic stress are more difficult to resolve because it is harder to measure this stress objectively. When stress is caused by a traumatic event, disputes over eligibility for compensation are less likely. Cases in which management is the source of stress are particularly hard to resolve, because most solutions require positive input from management. The stigma associated with stress leave and the perceived threat it posed to peoples careers meant that a decision to take stress leave was itself a significant source of stress. Other research has suggested some strategies for reducing work stress, including: • Employee education • Supervisor training • Early intervention • Mediation • Reviewing claims to identify and reduce work stress risks • Reducing the stigma associated with stress People who make stress-related compensation claims tend to take more sick leave than average before they make their claim. This might provide an opportunity to identify those at risk of significant work stress and intervening before a claim is made. TOP ARTICLE #7. STRESS MANAGEMENT AND WORKPLACE DISABILITY At a glance: Stress causes psychological and biochemical changes in the body, including suppressing the immune system and increasing depression. Stress influences the course of an illness or recovery from an injury. In stress management programs, individuals are taught to become aware of their own response to stressful events and develop techniques for coping effectively. When implemented quickly after an injury or illness, stress management programs significantly reduce the amount of time needed off work and the risk of developing a long-term disability. Stress management programs reduce the human and financial costs of work disability. PERSPECTIVES: Employee Stress is the reaction of your body and mind to a demanding situation. Most people already know about the effect of stress on conditions like heart disease and high blood pressure, but not everyone realizes that stress influences all illness and disability. Disability can be extremely stressful, and this stress affects physical and mental health. Learning stress-management can have significant, measurable effects on your condition. It can reduce the impact of symptoms in your daily life and help you return to work sooner. Some of the conditions that have shown improvement after stress-management training include chronic pain, chronic fatigue and carpal-tunnel syndrome. Stress-management involves becoming aware of the way your body and your mind react to stress, and developing strategies to improve those reactions. It can also include relaxation training, physical exercise and improving social support. This article gives an overview of what to expect from a stress-management program. If you think stress-management might benefit your condition you can talk to your doctor or employer about where programs are available. Employer The physical and psychological effects of stress can delay recovery and return to work after an illness or injury. It's important to acknowledge stress as a legitimate concern – disability affects the whole person, not just their physical abilities. Stress-management should be a component of disability management. It has measurable benefits, including improved health outcomes and reduced sick leave. Stress management programs can be implemented in large businesses. Smaller businesses might not have the resources to have a program at the workplace, but employers could help their employees to find an appropriate program. Stress-management programs are cost-effective, with reduced medical expenses and work absence offsetting the initial costs. Treater Including stress-management as a component of disability management can improve health measures and return to work outcomes. Stress has become more widely recognized in the community as a legitimate health concern. A recommendation from a health professional could help patients embrace a treatment that might once have been considered unconventional or “airy fairy'. Insurer When included as a component of disability management, stress-management can improve health measures and return to work outcomes. Stress-management programs have also been shown to be cost-effective, with reduced medical expenses and work absence offsetting the initial costs. Original Article, Authors & Publication Details: D. L. Jones, T. Tanigawa and S. M. Weiss. (2002). Stress Management and Workplace Disability in the US, Europe and Japan. Journal of Occupational Health, 45:1-7. 1Department of Psychology, Barry University, USA 2Institute of Community Medicine, University of Tsukuba, Japan 3Department of Psychiatry and Behavioral Sciences, University of Miami School of Medicine, USA Background, Study Objectives, How It Was Done: Stress causes psychological and biochemical changes in the body, including suppression of the immune system and increased depression. Stress influences the course of an illness or recovery from an injury. When implemented soon after an injury or illness, stress management programs significantly reduce the amount of time needed off work and the risk of a long-term disability. Stress management programs reduce the human and financial costs of work disability. This article is an overview of stress management for disability. Study Findings: In stress management programs, individuals are taught to become aware of their own response to stressful events and develop techniques for coping more effectively. Stress management techniques include: Self-management skills Relaxation training Biofeedback Behavior modification Cognitive behavioral therapy Social support Emotional expression Physical activity Cognitive behavioral stress management helps patients to recognize the impact of their own thoughts and behaviors, to challenge irrational beliefs, reframe situations and adapt their behavior. They may also be taught relaxation, assertiveness, planning or problem-solving strategies. These techniques improve mood and self-esteem in people with chronic illness. They also increase health status and quality of life, and improve outcomes in cases of chronic pain, chronic fatigue, HIV/AIDS and carpal tunnel syndrome. Denial and avoidance, on the other hand, are associated with higher levels of depression and distress. Stress management programs can be in the form of education/support groups that focus on improving quality of life for people with disabilities (e.g. by reducing symptoms, improving function and reducing the adverse effects of medical treatments). Specific programs have been developed for a variety of conditions, including back pain and other musculoskeletal disorders, high blood pressure, chronic fatigue and psychological distress. Stress management programs are typically run over 6 – 10 weeks. They consist of three stages: Education Participants are taught to identify stress and stressors (things that cause stress). They learn that stress can have negative effects on their health, and can worsen any illness or injury. During this stage, participants also gain social support by meeting with others in the group. In cognitive-behavioral stress management programs, participants are taught techniques to reframe their beliefs and expectations and might be taught assertiveness or anger-management techniques. Social support and education improve a patient's health and reduce costs for a number of conditions, including chronic pain, musculoskeletal disorders, surgery, diabetes and stress-related conditions. Skills acquisition Patients observe their own behavior. They take note of the situations they find stressful and their physical, emotional and behavioral reactions to that stress. They may be encouraged to keep a stress diary. They also explore the role of their illness or injury in causing their stress, and any negative thoughts that might lead to feelings of hopelessness (e.g. “I can't do anything any more' or “I can't cope'). Participants also learn skills to help them cope with stress. This might include time-management, exercise or nutrition plans and relaxation techniques. Relaxation training aims to decrease the body's physical reaction to stress. Relaxation techniques include: Progressive muscle relaxation Learning to recognize feelings of tension and relaxation by tensing and relaxing different groups of muscles, often combined with breathing exercises. This technique is used for chronic pain and muscle or tissue injury. Meditative relaxation Mindfulness relaxation > Becoming peacefully aware of thoughts and sensations without judging or reacting to them. This technique is more effective than medication, physiotherapy or antidepressants for self-managing pain. Guided imagery Focusing on a peaceful image. In a cognitive behavioral stress management program, participants develop problem-solving skills and emotion-focused coping skills. The latter is used for problems that can't be solved by action and have to be tolerated emotionally. Participants might also learn assertiveness or anger management, both of which involve communication skills. Practice In the final phase of a stress-management program, participants apply their skills to stressful situations, and evaluate the usefulness of the techniques. They may revise their goals. The aim is not to decrease symptoms, but to change behaviors and reactions to stress. The health benefits of reduced stress are well-known. In previous studies various stress-management programs have produced the following results: Improved health outcomes and decreased medical visits for people with psychosomatic symptoms (symptoms that are influenced or brought about by psychological factors). Approximately 60% of visits to medical practitioners relate to psychosomatic symptoms. 36% decrease in visits to the doctor, and a decrease in anxiety, hostility and depression in chronic pain patients. A shorter hospital stay (1.5 – 2 days) for surgical patients. Decreased risk of heart attack in high stress individuals. Conclusions: Psychological factors influence all medical conditions. When combined with medical care, psychological interventions, including stress management, can improve recovery, prevent disability and increase general health and wellbeing. When implemented early after an illness or injury, interventions can improve the patient's prognosis and overall functioning. Stress-management programs are cost-effective, with reduced medical expenses and work absence offsetting the initial costs. Reducing a person's stress reduces their chance of developing diseases such as hypertension and immune suppression, or engaging in stress-related behaviors such as smoking, substance use, poor sleep or limited exercise. Stress management can provide support while people adjust to a disability, and can also improve relations between staff and management. There are a variety of publications available to help businesses set up a stress management programs. Employee assistance programs also offer on and off-site stress management programs. Many companies offer counseling services. Smaller businesses may lack the resources to manage disabilities within the workplace and therefore need to use external health services. TOP ARTICLE #8: PREVENTING OCCUPATIONAL STRESS At a glance: Occupational stress can cause: Burnout Physical illness Distress Decreased quality of life Poorer performance at work Increased work absence and turnover Increased costs for the employer and society Organizational interventions aim to reduce workplace stressors, while individual interventions aim to change the way people respond to stressful situations. There is evidence that both these strategies can reduce occupational stress, which in turn would improve physical and mental health and reduce costs. PERSPECTIVES: Employee Stress is an individual's reaction to a stressful situation or event. This means that we can reduce stress both by reducing stressful situations and by developing new skills to cope with them. Both approaches can effectively reduce stress and its associated physical symptoms. For some people experiencing stress at work, it might be difficult to embrace stress-management training or relaxation. These techniques might seem a bit woolly, or not really your cup of tea. You might feel that using the individual approach is letting the workplace “off the hook', or not dealing with the real cause of the problem. However the benefits of stress management programs are supported by scientific evidence. They give you skills and strategies that improve overall health and your ability to cope with difficult situations, which is worthwhile in itself. If you feel that workplace issues are part of the problem, discussing this with your supervisor or employer could help. Are there some positive suggestions you could make? Reducing stress in the workplace is an investment for employers as it improves the overall health of their workers and reduces sick leave. Employer Occupational stress can lead to burnout or physical illness, distress, decreased quality of life and poorer performance at work, and increase work absence and turnover. Reducing stress is a worthwhile investment for employers. Both individual and workplace interventions have been shown to be effective. Workplaces can reduce stress by promoting support and open communication in the workplace, by making changes to the organization of tasks, by offering stress-management programs and by providing training for supervisors (as supervisor behavior has been shown to have a strong influence on workers stress). Coping skills also play a role in occupational stress. However, individuals might be more likely to address personal stress management if they perceive that the organization is also making an effort to reduce stress. The following are some of the strategies that can reduce workplace stress: 1. Be aware of sources of stress - are there departments at risk? 2. Engage employees in decision making as much as possible. 3. Provide clear and meaningful job descriptions 4. Be interested and supportive toward workers 5. Encourage regular breaks, during the shift and with regular use of vacation time 6. Provide constructive feedback to staff 7. Provide appropriate physical work conditions 8. Increase worker control and autonomy where possible 9. Provide adequate training Treater Individual and organizational interventions are effective ways of managing occupational stress. Individual approaches found to be effective include cognitive behavioral therapy and relaxation training. Treating practitioners can assist patients experiencing work stress through sensible strategies: 1. Help the patient identify the sources of their stress 2. Help the patient identify whether each source of stress that can or cannot be altered 3. Help the patient identify their own signs and symptoms that indicate a stressed state 4. Help the patient develop positive coping strategies - Decreasing work hours - Controlling stress - Reducing self inflicted pressures, both at home and at work - Increasing time for self - Assertiveness – working out how to communicate issues in a clear and constructive way in the workplace - General stress management approaches - Yoga - Assertiveness training - Exercise - Diet and sleep habits Insurer Individual and organizational interventions are effective ways of managing occupational stress. Individual approaches found to be effective include cognitive behavioral therapy and relaxation training. Encourage employers to address occupational stress and regard reducing stress in the workplace as an investment. Reducing stress increases workers health and reduces sick leave. Original Article, Authors & Publication Details: A. Marine, J. Ruotsalainen, C. Serra, J. Verbeek. (2006). Preventing occupational stress in healthcare workers. Cochrane Database of Systematic Reviews (4): CD002892. Background, Study Objectives, How It Was Done: Occupational stress can lead to burnout or physical illness, distress, decreased quality of life and poorer performance at work. Increased work absence and turnover from occupational stress is costly for employers and for society. This review investigated interventions aimed at reducing stress in healthcare workers. Stress may be caused by an imbalance in demands, skills and social support at work. However, the effect of these stressors depends on an individual's coping skills. Therefore, strategies for preventing stress can be either organizational (“work-directed') or individual (“person-directed'). Individual interventions include psychological treatment and stress management programs, often including cognitive behavioral therapy or relaxation techniques. Organizational interventions include improving communication, increasing the participation of workers and changing the work environment, tasks or procedures. This review evaluates prevention strategies for occupational stress. 19 studies from Europe, North America and Asia were considered to be of high enough quality to be included in the review. Study Findings: In all 19 studies, individual or organizational interventions successfully reduced workplace stress. Individual interventions were: Cognitive behavioral therapy Relaxation training Therapeutic massage Multi-component interventions, such as combining communication skill training, stress management training, and practical skills in problem solving Music making Individual interventions resulted in: Significantly reduced stress levels Significantly reduced symptoms of burnout (emotional exhaustion and lack of accomplishment) Significantly reduced state anxiety (acute anxiety) Significantly reduced trait anxiety (general anxiety) Improvement in general health for at least 1 month after cognitive behavioral therapy Most improvements were maintained for the short and medium term. Long-term outcomes were not often recorded. In one study, however, a refresher course of cognitive behavioral therapy after 5, 11 and 17 months improved burnout in the long term. Organizational interventions were: Changes to work organization, skills training and supervisor support Psychological training to improve attitudes and communication skills A training program to improve support between colleagues, problem solving and decision making Organizational interventions resulted in: Reduced stress Reduced symptoms of burnout Improvements to general health Anxiety was not investigated in any of the studies Conclusions: Organizational interventions aim to reduce workplace stressors, while individual interventions aim to change the way people respond to stressful situations. Both have the potential to reduce occupational stress, which in turn would improve the physical and mental health of workers and reduce costs. This is an area that requires more research. Broad organizational interventions in the workplace are generally regarded as more useful and appropriate for preventing stress. Unfortunately, there are few studies evaluating these strategies. TOP ARTICLE #9: OCCUPATIONAL WELL BEING AND ITS EFFECT ON PERFORMANCE At a glance: The wellbeing of employees influences their organizations productivity and performance. Improving wellbeing increases employee performance and decreases uncertified sick leave, turnover and stress-related compensation claims. Improving wellbeing doesn't just mean reducing workplace stressors and avoiding distressing situations. It is essential to foster positive experiences and overall positive emotions towards work as well. According to this study, a lack of positive experiences and morale is actually more likely to cause stress than specific negative experiences or 'stressors.' The strongest influence on morale is the 'organizational climate': the overall conditions and culture of the workplace. Improving things like leadership, staff recognition processes and decision making procedures is likely to be the most effective way to increase morale and reduce distress. This approach can increase productivity and decrease compensation costs. PERSPECTIVES: Employee Wellbeing at work means more than just avoiding stressful experiences. We need to feel productive, supported and valued. Lacking confidence, interest or positive relationships at work can cause stress too. Not having positive feelings towards work may make it hard to deal with small problems when they arise. In this situation, addressing the small problems might not relieve the stress. The way we cope with demands depends on our overall beliefs and feelings. Our personalities also play a role in how we respond to stress. If you are feeling stressed by a situation at work, consider your workplace environment and your personal beliefs. Are there any positive suggestions to could make to your employer about how procedures or communication could be improved? Could learning new skills help you deal with the demands at work? Considering the bigger picture can help you to feel better at work. Employer Employee wellbeing is associated with lower withdrawal and greater voluntary performance. Withdrawal refers to uncertified sick leave, lateness, stress-related compensation claims and turnover. Voluntary performance includes effort and commitment, offering help and promoting the organization. The overall climate of the workplace is a stronger influence on workers wellbeing than individual 'stressors' like traumatic events or arguments. Stressful situations can't be avoided altogether; improving overall morale and support in the workplace is more likely to reduce sick leave and compensation costs. Effective strategies include improving leadership skills, reviewing standard practices and procedures and offering counseling services. (When a person is in distress, however, specific psychological treatments are more effective than general counseling.) Treater Promoting positive attitudes and emotions towards work, rather than merely avoiding demanding situations, appears to be the most effective strategy for combating occupational stress. Obviously, by the time a patient presents with stress-related symptoms it is too late to promote positive feelings. Nonetheless, a lack of confidence, interest and positive experiences might be significant when considering the underlying cause of stress. This review found that individual psychological treatments are more effective for dealing with distress than generic counseling services or stress management training. There is still a place for these services in improving employee morale, however. Insurer Workplace health can sometimes focus on avoiding the bad rather than promoting the good. Eliminating health hazards, however, is an incomplete strategy; a lack of positive experiences or emotions towards work can also be damaging to employee wellbeing. Improving workplace morale reduces withdrawal behaviors such as stress-related compensation claims and uncertified sick leave. Apart from personality, the overall conditions and culture in the workplace are the most significant influence on wellbeing. Encourage employers to look at how they can improve leadership and training, and increase their employees' sense of confidence and support. This is likely to be the most effective strategy for reducing stress-related compensation costs. Original Article, Authors & Publication Details: P. Cotton1 and P. M. Hart1 (2003). Occupational wellbeing and performance: a review of organizational health research. Australian Psychologist, 38(2): 118 – 127 1Insight SRC Pty Ltd and the University of Melbourne Background, Study Objectives, How It Was Done: The 'organizational health framework' is a theoretical model for thinking about employee wellbeing and business performance. This study explores factors that influence employee wellbeing, productivity, sick leave and performance. It also examines the relationship between employee wellbeing and the success of the organization they work for. Study Findings: Factors that influence employee well being Employee well being involves both emotional factors and job satisfaction. An employee's job satisfaction is like a judgment the employee makes, by weighing up the positive and negative experiences they have had at work. Positive emotions towards work can be called 'morale', and include energy, enthusiasm and pride. Negative emotions include guilt, anxiety and anger and are collectively called 'distress". An individual's emotions will be influenced by the overall mood within their workgroup, and vice-versa. Other factors that can influence wellbeing are coping strategies, personality traits and conditions and culture in the workplace. Although it sounds illogical, negative emotions about work and positive emotions about work need to be considered separately. Take for example the issue of stress. Stress is often thought to be caused by negative situations or experiences at work and positive work experiences and emotions are often not considered. However when a person feels stressed, this can be due to a lack of positive experiences at work rather than a series of specific negative problems. A worker, for example, might feel that their work is pointless, they might lack social support and recognition and therefore they do not feel enthusiastic or confident at work, leading to feelings of stress and difficulty coping with small problems. In this case, targeting specific negative experiences, or trying to solve the little problems, might not be any help. Instead, a broader approach would be needed to address the underlying issue of why the person is not happy at work and how the workplace could foster a more supportive environment. Furthermore, when distressing problems do occur, the way employees cope will also depend on their previous positive experiences and their positive emotions. A person who feels that their heavy workload is causing stress might be influenced by an underlying negative sense of their work and workplace. On the other hand, a person who feels capable, valued and interested might see a heavy workload as a challenge or feel more confident that they can manage it. According to this study, the most important factors that influence employee well-being are: The 'organizational climate' in the workplace Personality factors Positive or negative experiences at work 'Organizational climate' was the most important influence. This term refers to the employees overall impression of how the organization is run, the leadership practices, standard procedures, workplace culture etc. The organizational climate has been shown to be more important than individual difficulties or stressors in determining an employee's wellbeing. The study also found that improving management styles and overall workplace practices reduces stress more effectively than teaching employees individual coping skills. Individual characteristics are also an important influence on wellbeing. This study found that an emotional personality is the strongest influence on how much distress a person will experience. In these cases, individual psychological treatments are believed to be more effective than generic stress-management or supportive counseling services. Counselors can vary in their level of training and experience, and the authors of this study suggested that clinical treatment should be available where necessary. However, employees who see workplace counselors tend to be highly satisfied with the service provided. These services may be good for improving the support and increasing morale, but may be inadequate for dealing with severe distress. The effect of wellbeing on organizational performance Increasing employee wellbeing reduces their rate of withdrawal. 'Withdrawal' refers to missed work, turnover, uncertified sick leave and stress-related compensation claims, all of which are costly for organizations. The researchers found that the strongest influences on withdrawal were personality, organizational climate, work experiences and emotions. Wellbeing also influences employees voluntary performance – that is, the work they do that supports the organization, but isn't part of their main responsibilities. Some examples are: dedication and making an effort, volunteering to do tasks, helping others in the workplace and promoting the organization to other people. Voluntary performance is increased by improving wellbeing. Conclusions: Improved wellbeing means higher morale (more positive emotions), less distress and higher job satisfaction. Job satisfaction is a judgment the employee makes about their work by weighing up their positive and negative experiences. Improved employee wellbeing improves the productivity of the organization they work for by increasing performance and reducing withdrawal behaviors such as unexplained absence, stress leave and turnover. There are several ways to improve employee wellbeing in the workplace. The authors of this paper summarized their suggestions as follows: Employees' positive and negative experiences need to be considered separately. To improve wellbeing in the workplace it is necessary to reduce distressing situations, but it is more important to increase positive experiences and foster overall positive feelings towards work. Individual cases of low wellbeing might be caused by high distress or by low morale. These two problems need to be managed in different ways. Withdrawal behaviors, including stress-related compensation claims, are often caused by low morale. The 'organizational climate' - the overall conditions and culture in the workplace - has the strongest influence on positive emotions. Organizational climate is also the strongest influence, apart from an emotional personality, on an employee's level of distress. Stress is more likely to be caused by overall organizational problems than by individual negative experiences. When it comes to preventing withdrawal from work (including absence and stress-related compensation claims), increasing morale in the workplace is more effective than decreasing distress. The most effective way to increase morale and decrease distress in the workplace is to improve leadership styles and employee recognition, and make employees responsibilities clear. This is likely to increase productivity and reduce compensation premiums. Workplace counseling services may increase support and morale in the workplace. However in cases of severe distress, clinical treatment might be necessary. TOP BACK ARTICLE #10: PEOPLE WHO GET CLEAR ADVICE ABOUT THEIR BACK PROBLEM DO MUCH BETTER At a glance: People who were given advice that empowered them to understand and manage their back problem: • had 50% less days absent from work • were twice as likely to return to work • were half as likely to have a long term disability • had 50% less disability when followed up five years later. PERSPECTIVES: Employee Understanding how to best manage your back pain will help reduce your suffering, assist you in getting back to your normal life, and speed your recovery. Back pain can settle over weeks or months, and sometimes takes a year or two to resolve. However, most people are able to return to a good level of function within a short space of time. Most people return to their normal level of home and work activity even with a sore back. This study shows that patients with a lower back problem who continued normal activities, learnt how to stretch to relieve pain, and understood that lower back pain isn't likely to be serious, recovered better. Discuss this with your doctor or treating health professional to help decide what the best treatment for your back problem is. Employer Back pain can be severe and draining. People with back pain are often worried, and their workplace can make a major contribution to improving their confidence. Those with back pain often believe that once your back goes it is serious and long term. However, research shows that back pain is not a serious long term problem for most people. Supporting employees with back pain to get the best advice and encouraging them to return to work as soon as possible is not only good for your organization but will assist them to recover and return to normal health more quickly. Treater Low-back pain is one of the most common symptoms causing adult patients to seek medical attention. A number of studies have now looked at the best practice for management of back pain. Excluding serious pathology is important. Key questions need to be asked about age, history of cancer, trauma, unexplained weight loss, immunosuppression, duration of symptoms, responsiveness to previous therapy, pain that is worse at rest, history of intravenous drug use, and urinary or other infection. After excluding these 'red flags,' the symptom of pain that radiates into the leg, particularly if it goes below the knee, and findings of a positive straight-leg raising test or its equivalent, help to separate patients with radicular back pain from those with other types of back pain. The prognosis for patients with either mechanical or radicular back pain is very good. About 50% return to normal activities within 4 weeks, and 95% return by 6 months. This favorable prognosis and the fact that history and physical examination indicate nothing serious is wrong needs to be stressed to the concerned patient. For those with back pain, the treatment should focus on an early return to usual activities. Over-medicalizing acute low-back pain through an emphasis on bed rest, continued passive treatments, or restriction of usual activities probably lengthens rather than shortens the time to improvement. A realistic approach to a patient's fears and expectations, combined with appropriate conservative care, should improve the treatment of low-back pain. Providing advice and explanations to patients often sounds simple but it takes preparation and time. The treating doctors and physiotherapists in this study provided meaningful advice, using analogies to help the person understand the condition. An interview with the clinic specialist provides an explanation. The essential elements were: • Reassurance that lower back pain does not usually indicate a serious problem • Explanation of back pain and muscle spasm • Demonstration of stretching to relieve pain • Encouragement to continue normal activities Only a small number of musculoskeletal specialists focus on providing advice and explanation. This study shows that simple information from the primary care professional can be effective in preventing disability from back pain. Insurer This study suggests we should encourage people to be as active as possible in returning to work. When patients are told to continue with normal activities, they have control over their day to day tasks at home or at work and can be active or rest and stretch when appropriate. Lower Back Pain is rarely the result of a serious disease, but an assessment by a medical practitioner is needed to exclude the presence of serious conditions before deciding on treatment. Original Article, Authors & Publication Details: A. Indahl1, L. Velund1 and O. Reikeraas2 (1995). Good prognosis for low back pain when left untampered. A randomized clinical trial. Spine; 20(4):473-477. 1Oestfold Central Hospital, Fredrikstad 2National Center for Orthopedics, Oslo, Norway Background, Study Objectives, How It Was Done: In the 1980s and 1990s rest was often recommended for back pain. However, there was little evidence rest was helping back pain sufferers, and doctors began to take a more active approach to recovering from their own back pain. The authors of this research study looked at the effects of a more active approach to treating back pain, giving patients the management program that doctors generally undertook themselves. In this study, patients with back pain who had been off work for 8-12 weeks were divided into a control group and a treatment group. The control group continued with their “normal care', which consisted of seeing their local doctor and continuing any other treatment (e.g. physiotherapy) they were having. The treatment group continued with normal care (as did the control group), but with the addition of attending the specialist clinic. The patients who attended the specialist clinic all had a CT scan of their back. The results of the CT scan did not alter the advice given. The same advice was given to people with normal scans, disc bulges (“herniated' disc) and disc prolapse (“slipped' disc), as they all had similar symptoms. Those who required surgery, however, were excluded from the study. Patients attended the clinic on two occasions, and both times were given information about their back pain. They were reassured that the back pain was unlikely to be a serious problem. It was explained to patients that severe back pain was best thought of as inadequate circulation in the muscles and that the resulting muscle spasms and pain did not indicate a serious long term problem. They were advised to continue doing normal activities. Advice to continue activities encouraged people to return to normal lives. It was strongly emphasized that the worst thing they could do for their back was to be too careful. They were advised: • There was probably a small crack in a disc in their spine • This crack caused reflex spasms and decreased circulation in the muscles of the back • The decreased circulation caused their pain and stiffness • This in turn could lead to guarding of the back muscles, increasing muscular tightness, and therefore increasing pain. • They were assured that light activity would not injure the disc or any other structure, and was more likely to enhance the repair process Further advice included: • The link between emotions and low back pain was explained as a muscular response, increasing tension in the muscles which could increase the pain • The worst thing they could do for their back was to be careful. Great emphasis was put on removing fears about low back pain • Mobilizing the spine regularly by activity such as walking would help circulation and decrease pain • They should set their own goals for recovery • They should avoid sitting or standing still, and awkward postures • Acute stabling pain as muscle spasm should be treated with stretching and light activity. Each patient was given a demonstration on how to stretch their back. Each patient was reviewed after 3 months, the advice reinforced and any questions answered. Study Findings: There was a highly significant (50%) reduction in sickness absence from work for the treatment group. That is, people who were given advice to help them understand and manage their back problem did significantly better than those who weren't. They were twice as likely to return to work, and half as likely to have a long term disability with a long period off work. The researchers were able to follow up the study participants five years later. They found that the results were long-lasting: 19% of the treatment group were off work five years after they attended the specialist clinic, while 34% of the control group, who had not been given information and advice, were off work. In addition, the treatment group had fewer recurrences of sick leave than the control group (who did not receive information and advice). Conclusions: This landmark study showed clearly that the usual treatment of rest for low back pain does not work. It also showed that that advice to be active, and return to usual activities, prevented disability and helped people to recover and get back to work. We are aware that long term disability from a back problem is associated with many other problems, such as depression, isolation, and financial difficulty. This simple intervention gave back pain sufferers advice that they understood and could use, and suggested a positive way to manage their back problem. This treatment approach took time, but was not expensive and did not have the side effects that can accompany medication or surgery. Outcomes were much better for the patients and the community. The information from this 1993 study is not always followed. Patients with back pain are still often advised to protect their back and to avoid activities that hurt. This study shows that being active will assist recovery. TOP ARTICLE #11: WILL AN EPISODE OF LOW BACK PAIN BECOME A LONG-TERM PROBLEM? oUR PSYCHOLOGY IS IMPORTANT IN DECIDING At a glance: A person's psychology, as well as their physical symptoms, can influence whether an episode of back pain will be a “one-off' (acute condition) or become a long-term (chronic) condition. Psychological distress and/or depressed mood increase the chances that acute back conditions will become chronic. PERSPECTIVES: Employee An episode of back pain might be a one-off or the beginning of an ongoing condition. People who are more distressed or depressed are more likely to have ongoing problems. This is not an unexpected result, since doctors already know that people who are more anxious about their condition do not recover as well. There might be a few explanations for this: When people are anxious about back pain, they tend to restrict their activities. While this avoids some things that could harm them, it also limits their rehabilitation. People who are confident, on the other hand, tend to return to their normal activities more quickly. Make sure you understand your condition and that your questions are answered. When you have the information that you need, you can make a good plan, be more confident of your strategies and your ability to cope. If there are barriers that prevent you from returning to your normal activities, discuss them with your treater, family, or other people you trust. Others can help, but is your personal beliefs, attitudes and way of thinking that make the real difference. Employer When someone is distressed about their condition, it adds emotional suffering to the physical difficulties they are having. It can be hard to help people who are distressed. They may be less responsive to your approaches, challenging to communicate with, and they may take longer to return to work. This can be frustrating. It is important to support people who are distressed. Simple things like making yourself available to them can make a difference. People who are distressed may need a more focused approach on return to work and mapping out a clear rehabilitation path. Remaining off work and avoiding normal activities doesn't usually help. Employees need clear advice about the system they are operating in, and especially about your expectations of them. People need to feel confident that they will be listened to if they have issues that need discussion, or problems with return to work. People with distress need more time, more communication, and a more active planning approach to rehabilitation. Treater Treating practitioners generally know that distressed patients have worse outcomes despite spending more time in the health care system and receiving more treatment. Managing the distress requires more time, more communication and more energy. It is important to ensure that all the players are working together to focus on rehabilitation. Insurer Patients who are fearful, distressed, or worried are more likely to have a back pain episode that becomes a chronic condition. It is difficult to know whether this means they have higher levels of pain, or are more likely to have increased problems with the same level of back pain. This group needs more communication in the early stages, to make sure they understand their condition and the system in which they are working. Communications may need to be repeated on a few occasions, and the person's fears need to be addressed. When people are more confident about managing the condition they have better outcomes. Improving communication with the case manager and the workplace can be helpful. Original Article, Authors & Publication Details: T. Pincus1, A. K. Burton2, S. Vogel3 and A. P. Field4 (2002). A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain. Spine; 27(5):E109-E120 1Department of Psychology, Royal Holloway, University of London, London, UK. 2Spinal Research Unit, University of Huddersfield, Huddersfield, UK 3British School of Osteopathy, London, UK 4School of Cognitive & Computer Science, University of Sussex, Sussex, UK. Background, Study Objectives, How It Was Done: An episode of back pain may be a one-off occurrence (an acute condition) or the beginning of a long term (chronic) condition. Psychological factors are important in determining which outcome occurs. The authors of this review wished to identify the most important psychological factors in chronic disease, and investigate whether these only become important in certain environments or groups. Studies to be included in this review were identified by database searching (in October 1999). 25 papers were identified which investigated the effect of psychological factors in the transition of low back pain from acute to chronic. Some papers were based on findings from the same group of participants, so there were a total of 18 studies in the 25 papers. The reviewers considered how each study had been done, whether the psychological factors had been measured well, and whether data had been analyzed appropriately. Some studies did not take into account other factors that affect whether back pain will continue into the long term, making it impossible to estimate the contribution made by psychological factors alone. Some did not complete adequate follow up to avoid bias. Study Findings: The research papers used different measures to determine if a person's back pain persisted. Measures included how much pain the patient reported (after 1 week, 3 months and 12 months), whether the patient had returned to work by 6 months, and the total time taken off work due to back pain over 12 months. The most commonly measured psychological factor was “distress.' In some studies the psychological factor was undefined, or factors were combined to produce an overall score. Psychological distress/depressive mood: People who are distressed are more likely to develop a chronic back condition, particularly in the primary care setting. This effect was independent of physical factors such as pain and level of function. This evidence came from four studies of acceptable quality. Somatization: Somatization is when anxiety causes physical symptoms such as pain. Evidence from two studies of acceptable quality linked somatization with the development of chronic back pain. Personality: One study of acceptable quality reported that a personality test (the Minnesota Multiphasic Personality Inventory subscale of hysteria) could predict whether a person with low back pain would return to work. However, the authors of this review considered that this result was not statistically reliable. Thinking style: One study of acceptable quality reported that when patients had a poor or avoidant coping style (measured by the Coping Strategies Questionnaire) their low back pain was more likely to become chronic. Conclusions: This review investigated the role of psychological factors in the progression of a back condition from acute to chronic by reviewing research in the area. There is strong evidence that psychological distress and/or depressive mood increases the likelihood that a patient with acute back pain will develop chronic back pain. TOP ARTICLE #12: RISK FACTORS FOR WORK RELATED LOW BACK PAIN AND STRATEGIES TO PREVENT LONG TERM DISABILITY At a glance: Work-related low back pain sometimes leads to long-term disability. Some risk-factors for long-term disability can be identified soon after pain begins. Early treatment or intervention which targets these risk factors may reduce the risk of long term disability. PERSPECTIVES: Employee Back pain is very common. By the age of 40, 90% of the population has had a significant episode, and one person in six has a long term problem. There are many factors that determine whether people remain active and functional after back pain, most are not medical. Make sure you understand your back problem. Talk to your doctor, ask to see a specialist, get advice on remaining active, and find out what you can do to look after yourself. Professional athletes with medical problems can often continue to play high-level sport because they manage their condition well. They may restrict their activity at times, but usually good management means they can continue with their normal training and competition. Most people can do a lot to improve their back problem, provided they understand it, and know which behaviors are likely to be helpful. What you understand about your condition and the approach you take to managing it has a major effect on the results you achieve. Employer The workplace environment affects recovery from low back pain. If an employee perceives their work to be demanding, they are more likely to experience long term disability. Workplace relations also affect the outcome, especially if disputes are occurring at work. Anything an employer does to create a positive atmosphere at work and encourage good communication is likely to be helpful. Employees' concerns need to be taken seriously. Employees who do not feel welcome and wanted in the workplace are at a higher risk of work disability. Treater Long-term back problems can be difficult to manage. Hands-on treatment can be helpful in the short term, but generally doesn't improve outcomes for longer term back problems. Treaters sometimes instruct patients to restrict their activity, which can contribute to long term disability. Studies have shown that encouraging people to return to their usual tasks improves their long term outlook. Confidence building is usually helpful too: people who are fearful of their back problem tend to avoid activity, which impedes rehabilitation. Treating practitioners can manage long-term back problems and reduce disability by: Encouraging employers to provide regular and supportive contact Encouraging employers to provide modified work duties so the person can get back to work sooner Teaching the person how to prevent and manage future back problems through exercise Emphasizing the importance of a return to work Reassuring the person that low back pain is common, and usually improves with time Advising the person that a return to activity is not expected to cause re-injury Avoiding medicalization of the problem and avoiding over-treatment Insurer Long term disability caused by back pain is a significant burden on patients and the compensation system. Disability can be reduced by managing relationships at the workplace, and providing early treatment that focuses on advice and explanation. Claims managers can improve outcomes by avoiding delays and helping employers to understand their role as return to work managers. Delays in getting treatment demotivate everyone involved in return to work management. Above all, employees need to feel supported: those who do not are less likely to return to work. Original Article, Authors & Publication Details: W. S. Shaw, G. Pransky and T. E. Fitzgerald (2001). Early prognosis for low back disability: intervention strategies for health care providers. Disability & Rehabilitation 23(18): 815-28. 1 Liberty Mutual Center for Disability Research, 71 Frankland Road, Hopkinton, MA 01748, USA 2 Liberty Mutual Center for Disability Research and Department of Family Medicine and Community Health, University of Massachusetts Medical School, MA, USA 3 Center for Occupational Rehabilitation, Asheville, North Carolina, USA Background, Study Objectives, How It Was Done: When low back pain is work related, people tend to receive more treatment and have worse outcomes. Of those eligible for compensation for work-related low back pain, 10% suffer chronic pain and disability for more than three months. These cases account for 90% of the cost associated with work-related low back pain. This study aimed to identify the risk-factors for long-term disability following work-related low back pain. 22 studies dating from 1970 to 2000 have been reviewed. Study Findings: Risks of long-term disability The factors below were found to be associated with a risk of long-term disability following work-related low back pain. Workplace factors: The employee describes their work as heavy or demanding. The workplace is not flexible enough to accommodate employees with changed capabilities. The employee works in the construction industry The employee has been hired recently. Relationship factors: Poor relationships with co-workers Stress outside the workplace Circumstances of the injury: Having had a chronic, disabling lower back injury in the past Delays in getting treatment Delays in reporting the injury (sometimes an indicator of a poor relationship with the employer) The type of injury (Injuries such as falls seem to be associated with greater risk of long term disability) Employee reports of: Severe pain Pain that is constant rather than intermittent Pain that severely limits the person’s activities Patient's expectations and beliefs: Patient does not expect to recover or return to work Patient overly concerned with avoiding pain Patient coping poorly with pain Doctor's observations: Pain that radiates to below the knee Diagnosis of a disc-related problem Poor performance on functional tests (e.g. restricted range of motion, gait tests) Patients exaggerating their symptoms All of these risk-factors can be identified soon after an injury occurs, allowing early intervention aimed at disability prevention. Diagnostic tools such as X-rays and MRIs were found not to be good indicators of the risk of long-term disability. Many clinical tests and even the doctor's overall impression have also been found to be poor predictors. Management of risks The study also investigated the strategies that can be used to address these risk factors for long term disability. The following strategies were found to be useful. Reducing workplace risks The researchers stressed that positive communication between employee, employer and doctor helps to minimize workplace and relationship risks. This communication should be established as early as possible. Providing alternative, more manageable work duties reduces the risk of long-term disability. A program of modified duties is likely to be more successful if the worker and their supervisor are both involved in modifying duties. Reducing risks related to pain Because severe pain is associated with a higher risk of disability, pain relief should be a high priority. Useful pain relief strategies include: Medication Relaxation techniques Training in cognitive distraction (a technique for shifting ones attention away from pain) Training in self-efficacy (ones belief in ones ability to cope with pain) Some complementary medicine techniques such as massage and acupuncture Reducing risks related to patient beliefs and expectations Patients' thoughts and beliefs influence their recovery, so it's important to provide reassurance that back pain is common and that most people recover without treatment. People with low back pain often fear that returning to their normal activities will make their condition worse. In the vast majority of cases, this is not so. An early return to normal activities is rarely harmful and is associated with a better recovery. Psychological treatments can also be useful. These include: Referral to specialists for positive reinforcement Cognitive-behavioral skills training or cognitive restructuring. These techniques involve recognizing and changing the thoughts and beliefs that cause negative emotions and behaviors. Conclusions: Work-related low back pain usually passes quickly and needs little treatment, but sometimes it can lead to long term disability. Some of the factors that seem to put people at risk of long term disability can be identified soon after pain begins, allowing early treatment. This might reduce the chances of long term disability. The risk factors for long term disability can be related to: • The person's relationships at work and outside of work • The nature of the patient's work and their work environment • How the injury occurred • Whether the injury was reported and treated quickly • How the patient perceives their pain and responds to their situation If a person is at risk of long term disability, it is important to identify the risk early, and provide treatments and interventions as soon as possible. A successful response requires cooperation between worker, employer, doctor, insurer and the person's family. TOP ARTICLE #13: IDENTIFYING THE CAUSES OF BACK AND ARM PAIN IN AN OFFICE ENVIRONMENT At a glance: A number of factors influence muscular pain. This study shows that ergonomic factors in an office environment influence the likelihood of arm and back symptoms. Other factors include, time pressure and the ability to constantly process and think through information. PERSPECTIVES: Employee A range of factors can increase pain in the arm or back. If you have concerns about the set-up of your workstation, or that the flow of your work is contributing to health issues, speak to your employer. Employer During the 1980s there was an epidemic of RSI or repetitive strain injury. Over time it became apparent that ergonomic factors were playing a role. Other factors, such as a person's feeling of well-being, their sense of confidence in the job and workplace support were also important. The study indicates that time pressures and constantly processing information can contribute to arm or back soreness. Treater Medical treatments can help some people with back pain symptoms, although they are particularly unsuccessful in treating arm pain. This study indicates that workplace factors play a role, and that thinking about the way the job is done, modifying some of these factors, and offering an opportunity to improve management of the condition, is important. Insurer Changing a person's workstation setup is critical, but encouraging the employer to think broadly about the job, there capability for the role, time pressures, workplace relations etc, is worthwhile in musculoskeletal cases. Original Article, Authors & Publication Details: Grant DH, Michael F. Identifying Work Organization Targets for a Work-Related Musculoskeletal Symptom Prevention Program. Journal of Occupational Rehabilitation 2004;14(1):13 Background, Study Objectives, How It Was Done: Musculoskeletal problems impact employee's health, ability to function, and productivity. The authors of this study noted that musculoskeletal outcomes have been shown to relate to medical, ergonomic, psychosocial and workplace organizational factors. Workplace organizational factors include: 1. Job design 2. Work scheduling 3. Interpersonal components 4. Career concerns 5. Management style 6. Organizational characteristics The authors suggest that there has been a focus on the biomechanical conditions, such as the postures adopted to work, the physical strain on the body or the level of repetition in tasks. There has been significantly less research conducted on psychosocial factors in the workplace, and the influence on work outcomes. The authors of this study sought to develop practical information about workplace organizational factors that can help a return to work. The study obtained information from 250 United States Marines. The Marines were asked about soreness in their arms and back, the physical demands of the job and psychosocial factors at home and work. The results were analyzed, put through appropriate statistical techniques, and associations between symptoms and workplace organizational factors analyzed. People were asked about ergonomic factors, or how their workstation was set up. They were also asked about job stress, including time pressure, mental and interpersonal demands, management style, job responsibility and career concerns. Questionnaires identified an individual's personality, psychosocial status, and health including musculoskeletal symptoms and daily ability to function. Study Findings: The participants were mainly office-based workers. Only people who had no clear identifying cause for their problem, such as a car accident or sport injury were included in the study. 30% of people reported they did not have any symptoms. 20% advised that they were sore in the low back, and 21% indicated they had soreness in the arms. Approximately 29% indicated they had both low back and arms soreness. The average age of the participant was 28, and the majority male. The study found that: Ergonomic stresses, such as having to adopt awkward postures, were a risk factor for symptoms Time pressure was a significant risk factor for all groups Having to think and process information made it more likely that staff would have both lower back and arm pain Interpersonal demands did not increase the risk of symptoms Conclusions: The authors of this study found an association between ergonomic factors in an office environment and back and arm symptoms. They also found that people who believed they were under time pressure were more likely to experience soreness in the back or arms, as were workers who were required to constantly process and think through high-level information. TOP ARTICLE #14: FACTORS THAT INFLUENCE THE DURATION OF SICK LEAVE DUE TO LOW BACK PAIN At a glance: Certain risk factors have been identified which predict whether sick leave from low back pain is likely to be long term. Some of these factors identified in this study include: How much sick leave the person expected to need Whether they were treated by a doctor Whether their mobility was reduced Whether they reported job stress This study showed that a questionnaire on the first day of sick leave can give an idea of how long the person is likely to be absent from work. PERSPECTIVES: Employee Most patients recover from back pain within a few weeks, but pain can last much longer. Unfortunately, the longer a person is on sick leave, the less likely they are to return to work. Most people recover from back pain within four weeks without any special treatment, and studies have identified differences between those who recover and those who remain on sick leave. People are at higher risk of long term sickness absence if their mobility is reduced. You can't change your level of pain, however, you can decide to remain active, and this will lower your risk of becoming disabled. Light exercise and stretching can be helpful. People are also at risk of long term sickness absence if they expect to be on sick leave for more than 10 days. Expectation about sick leave can come for your level of discomfort, or from your job conditions. Talk to your employer about accommodating your injury in the workplace, or temporarily reducing your hours, so that you feel comfortable returning to work as early as possible. People are at risk of sickness absence if they have heavy lifting duties or job stress. People responsible for heavy lifting may find it difficult to return to work because of the physical demands of their job. If you have a back condition and do heavy lifting, discuss return to work options with your treating practitioner. It's important to recognize that job stress is a problem in itself and can reduce your chances of returning to work. If you are stressed at work, speak to your doctor, employer, or someone you trust about how you might be able to make it easier to cope. If any of these risk factors sound like you, it's worth speaking to your treating health professional to get some advice. Employer This study showed that most people recover from back pain within four weeks without any special treatment. It identified differences between those who recovered and those who remained on sick leave. 1. People are at risk of disability if they expect to be on sick leave for more than 10 days. 2. People are at risk of disability if they do heavy lifting. 3. People are at risk of disability they are stressed at work. If you can help your injured workers get back to work earlier, it's likely to help them recover more quickly. Offer modified work duties or hours, or a temporary job as an alternative to heavy lifting. It's important to recognize that job stress is a real issue and can affect physical health. Anything that can be done to reduce stress is valuable. Treater Some disability risk factors are well-understood, and identifying whether these are present (perhaps by questionnaire) at the beginning of absence can show if there is a risk of long term sick leave. It is important to assure patients that people normally recover from back pain quickly, and that remaining active will help them recover, not make their problem worse. If possible, take the time to communicate with the patient about the causes of their back pain, and give them whatever advice you can on how to get back to work. Insurer The longer a person remains on sick leave from work-related low back pain, the more compensation and treatment costs they generate. Interventions for low back pain can reduce costs and personal suffering. Most people recover from back pain without treatment. This study identified some risk factors for disability, and showed that a short questionnaire given in the first few days of sick leave can identify those at risk. Once identified, those at risk of disability can be treated early, reducing sick leave and hence costs. It may be worthwhile to incorporate a short questionnaire into routine compensation claims, to identify cases where more communication and more assistance will be necessary. Original Article, Authors & Publication Details: Ivan A. Steenstra,1,2 Fieke S. Koopman,1,2 Dirk L. Knol,3 Eric Kat,4 Paulien M. Bongers,1,2 Henrica C.W. de Vet,5and Willem van Mechelen1,2 (2005). Prognostic factors for duration of sick leave due to low-back pain in Dutch health care professionals. Journal of Occupational Rehabilitation; 15(4):591. 1Department of Public and Occupational Health, VU University Medical Center, Amsterdam. 2Body@Work, Research Center Physical Activity, Work and Health TNO, VU University Medical Center, Amsterdam. 3Department of Clinical Epidemiology and Biostatistics, VU University Medical Center, Amsterdam. 4Occupational Health Services, Academic Medical Center, Amsterdam. 5EMGO Institute, VU University Medical Center, Amsterdam. Background, Study Objectives, How It Was Done: The longer a person remains on sick leave from work-related low back pain, the more compensation and treatment cost they generate. To control costs and personal suffering, we need to identify risk factors for disability, so that intervention can be targeted where it is most needed. Previous research has suggested that age, gender, level of disability, heaviness of work, social isolation and compensation status can all affect duration of sick leave in cases of low back pain. Workers' self-reports of their psychosocial environment can be used to predict long-term sick leave. Psychosocial risks for disability include job circumstances, strategies for coping with pain and recovery expectations. This study aimed to determine factors that influence sick leave duration in cases of low back pain. 615 workers who reported sick leave from low back pain within a 2 year period were included in the study. All participants were employees of an Amsterdam university hospital. 64% of the study participants were female and the average age was 42. After calling in sick, workers were asked to complete a standard sick leave questionnaire and return it to the hospital within 2 days. The questionnaire asked 10 questions about the patients' reason for sick leave, expectations about recovery and use of health care services. Outcomes were measured from the patients' employment records over the six months following the beginning of sick leave. They were: Return to work – duration of sick leave during the 6 month follow-up period Lasting return to work – days on sick leave until returning to work for four continuous weeks Study Findings: Course of low back pain: 11% of all sick leaves were due to musculoskeletal disorders. The average time taken to return to work was 5 days. 90% of workers recovered after 4 weeks, and 95% after 3 months. 3% of workers still hadn't returned six months after sick leave began. The average time taken to return to work was 6 days. 87% had a lasting return to work by 4 weeks, and 94% by 3 months. 4% of workers hadn't had a lasting return to work six months after sick leave had begun. 87% had less than 28 days of sick leave. Factors predicting delayed return to work Employees took to longer to return to work if: They predicted they would take more than 10 days to return to work Their sick leave was caused by: * Work * Heavy lifting * Job stress Their mobility was limited by their condition They were admitted to hospital They were a maintenance worker Some of these factors had more or less effect when they occurred together. A worker was at highest risk of delayed return to work (10 times greater risk than workers without risk factors)if they: 1. Expected to stay on sick leave for more than 10 days 2. Were treated by a GP or medical specialist A worker was at highest risk of delayed lasting return to work (10 times greater risk than workers without risk factors) if they: 1. Expected to stay on sick leave for more than 10 days 2. Reported job stress as a reason for taking sick leave Factors predicting more days on sick leave: Workers had more days on sick leave if: They were older They predicted they would take more than 10 days to return to work They saw a GP or specialist for their condition Their condition was due to work Their condition was due to heavy lifting They were admitted to hospital Their mobility was limited by their condition They were a maintenance worker Conclusions: Interventions for low back pain can be targeted to people at risk of remaining on long-term sick leave. A short questionnaire completed by injured workers at the beginning of sick leave could identify people at risk of longer absence. Most people recover from back pain and get back to work within 4 weeks. It is uncommon for workers to remain on sick leave for more than 6 months. The strongest risk factor for delayed return to work identified in this study was the workers own prediction of a need for more than 10 days leave. Workers who reported that their condition was due to job stress returned to work as quickly as others, but took longer to have a lasting return to work. TOP ARTICLE #15: A WORKPLACE EDUCATION PROGRAM THAT PREVENTS NECK AND BACK PROBLEMS, AND LIMITS RE-INJURY At a glance: This study evaluated the effectiveness of Vocational Oriented Medical Rehabilitation (VOMR). Aircraft maintenance workers are a high-risk group for back and neck problems, their job involves constant bending and twisting. VOMR showed good results in reducing severity of pain, days on sick leave, and in decreasing limitation of function over five years. PERSPECTIVES: Employee If you work in awkward or fixed posture positions for long periods you are more likely to experience soreness in the neck or back. This study shows that learning how to alter posture and using stretching exercises improve outcomes and prevents reinjury. A lot of research has shown that the best way to prevent back problems or reinjury is to improve general and back fitness. This study supports these conclusions and indicates that changing posture regularly while keeping the muscles active and strong improves outcomes. Talk to your employer about what can be done to enable changes in posture and mobility if your job requires long periods in a fixed or awkward posture. Employer Some employees work in awkward positions for long periods of the day. This study shows that people can be taught how to improve the situation, i.e. by learning about the difficulties of awkward postures, improving fitness, and being given the opportunity to change posture regularly. Productivity is improved when such an education program is implemented. Does your workplace have people doing difficult jobs for long periods? If so, involving a professional in setting up an appropriate education program and reviewing tasks can pay long-term dividends. Treater The best way to prevent recurrent spinal problems is to have a fit and active spine. This study demonstrates that people can be taught to self manage, and reduce musculoskeletal problems. The employees in this study undertook long periods of tasks requiring an awkward posture. When they were encouraged to improve their general level of fitness and flexibility and to change posture regularly, outcomes improved and pain was reduced. Encouraging fitness and activity is an important part of managing musculoskeletal and spinal problems. Insurer People who have had a problem with their back often experience a recurrence. Teaching people how to self manage carries the best chance of preventing further injuries. This study shows that even people who undertake tasks requiring an awkward posture can be shown how to manage the situation and reduce longer term problems, by changing postures and position regularly and improving fitness. Original Article, Authors & Publication Details: K. Holopainen1, N. Nevala2, P. Kuronen3, J. P. A. Arokoski4 (2004) Effects of vocationally oriented medical rehabilitation for aircraft maintenance personnel – A preliminary study of long-term effects with 5-Year follow-up. Journal of Occupational Rehabilitation; 14(4):233-242 1Finnish Institute of Occupational Health, Helsinki, Finland. 2Finnish Institute of Occupational Health, Kuopio, Finland. 3Headquarters of the Finnish Air Force, Tikkakoski, Finland. 4Department of Physical and Rehabilitation Medicine, Kuopio University Hospital Kuopio, Finland. Background, Study Objectives, How It Was Done: Developed in Finland for workers in various industries, Vocational Oriented Medical Rehabilitation (VOMR) is a program to help people actively recover from workplace injury. The aim of this study was to characterize poor work techniques in Finnish Air Force machinists and determine the effect of the VOMR program on their physical capacity, symptoms and perceived work ability at six months and five years after the course. Participants: The Finnish Air Force was chosen for this study as machinists work in uncomfortable postures for long periods and are typically not taught correct techniques for minimizing strain. Twenty male air force workers were included in the study. They had worked for an average of 15 years in their profession, and had been at least 3 years in their current position. All participants had been on sick leave (less than 60 days) due to musculoskeletal symptoms (back or neck pain) in the last two years, but had no other medical condition and wanted to continue working. All of the subjects participated over the entire five year study period. VOMR course: The rehabilitation course consisted of physical exercises and training in how to minimize discomfort and strain at work (ergonomic techniques). It aimed at teaching participants about their physical functioning, to encourage them to exercise regularly and increase their strength and flexibility whilst improving their mental and physical health. Participants were trained in groups of 10, in two rehabilitation periods. The first for 12 days, and then for 5 days six months later. The course was taught by a team of health professionals, including a physiotherapist; psychologist; physician; physical trainer; an ergonomics instructor; a social worker and a nurse. Postures: Each machinist's work postures analyzed by a computer program after being videoed working the three daily tasks of working under the plane, checking the flight deck and working with the engine. By dividing the work postures into different classes and estimating the weight of the load or the amount of force used, the degree of harmfulness to the musculoskeletal system (back, neck, arms and legs) can be estimated. The degree of potential problems from the job was ranked in four categories: 1. Normal posture – no need for corrective measures 2. May cause problems dash; corrective measures needed in the near future 3. Likely to cause problems dash; corrective measures needed as soon as possible 4. Very likely to cause problems – corrective measures needed immediately Questionnaires: The patients completed a questionnaire one month before each rehabilitation period and five years after the completion of the rehabilitation course. They rated how severe they felt their pain was, and the level of physical and mental strain they felt at work. They were asked how many times they had visited a doctor or physiotherapist, and how many sick days they had taken due to their injury in the last six months. They were also asked how often they did vigorous exercise (e.g. jogging, cycling) in their own time and how often they took exercise breaks at work. Measurement of physical capacity: During each rehabilitation period the subjects' physical fitness (oxygen uptake/heart rate vs workload), strength (lifting weight/bodyweight) and flexibility (range of motion) were measured. The tests were carried out by the same health professional in both periods. Study Findings: Postures: • The machinists worked most of the time in a bent posture. • They worked with a twisted back:    - 66% of the time when working under the plane.    - 56% of the time when working on the engine. • Their arms were over shoulder level when working with the engine 85% of the time. • They were kneeling when checking the flight deck or working with the engine 45% of the time. Most of these common work postures were problematic and needed correction (i.e. fell into categories 2-4, above), especially those used when working under the plane or with the engine. Questionnaires: Over the five year study period: Low back pain decreased in severity Neck pain decreased after six months but increased back to similar levels as before rehabilitation after five years. The number of sick days the participants took decreased. The number of times the participants visited a doctor/physiotherapist didn't change. The amount of physical exercise the participants did in their own time didn't change. The number of exercise breaks the participants took at work increased. The physical and mental strain of the work decreased after six months but increased back to similar levels as before rehabilitation after five years. Measurement of physical capacity: Six months after the rehabilitation period: • The range of motion of the participants' spines increased. • The strength of the participants' abdominal, back, and upper arm muscles increased. • The participants' physical fitness did not change. Conclusions: This particular rehabilitation program tried to prevent disability by acknowledging that the worker's physical environment and postures can contribute to the condition. This study shows that workers can be taught the correct techniques to minimize the strain of physical work. Work techniques that have been learnt over years may be difficult to change. The postures that are possible may be limited by the workplace, as is the case for aircraft maintenance machinists. Workers in this situation were able to be taught self care and techniques specific to their workplace. The participants reported that their pain decreased six months after rehabilitation. After five years, the severity of back pain was still less than it was prior to rehabilitation, but neck pain had increased back to a similar a level of severity. The program encouraged the participants to exercise regularly in order to strengthen their ability to perform work tasks. While the amount of physical exercise the participants did in their own time didn't change, they were taking more exercise breaks at work five years after the program. The number of sick days the participants took had decreased five years after the rehabilitation program, which may have been due to the participants leading a generally healthier lifestyle after the training. TOP ARTICLE #16: A REVIEW OF WORKPLACE REHABILITATION APPROACHES FOR BACK PAIN At a glance: A review of 198 research articles on management and rehabilitation of lower back pain in the workplace found: 15 articles (10 studies) of high quality and relevant to the topic The studies suggest the best intervention for back pain is to advise an injured worker to be active, and to return to modified work duties early. If this advice was followed workers returned to work earlier, with less pain and disability. PERSPECTIVES: Employee This review looked at many pieces of research to find the most effective approach to the rehabilitation of low back pain in the workplace. The review found that the most effective way to manage low back pain is for health care professionals to advise light activity and an early return to work with some changes in work tasks initially. Try to encourage discussion between your doctor, your employer and yourself on this subject. Work with your employer in a partnership to facilitate your return to work. Employer This review shows that clinical treatment involving light activity and early return to work, with some initial adaptation of work tasks and hours, reduces pain and disability and results in an earlier return to normal work duties. Some initial adaptation of workplace tasks and working hours is important to reduce pain and suffering and lost work days. Initiatives in the workplace have a major impact on outcomes for people with back pain. Treater This systematic review light activity and early return to work, with some initial adaptation of work tasks and hours, reduces pain and disability and results in an earlier return to normal work duties and hours. Insurer Clinical intervention involving early return to work with some work task adaptation and flexible hours, along with light exercise and activity, increased return to work rates. It is worth encouraging the employer to understand the major role they can play in assisting the employee get back to work. Original Article, Authors & Publication Details: R. M. Williams1, M. G. Westmorland1, C. A. Lin2, G. Schmuck3 and M. Creen4 (2007). Effectiveness of workplace rehabilitation interventions in the treatment of work-related low back pain: A systematic review. Disability and Rehabilitation; 29(8): 607-24. 1 School of Rehabilitation Science, McMaster University, Hamilton, Ontario 2 CanChild Centre for Childhood Disability Research, School of Rehabilitation Science, McMaster University, Hamilton, Ontario 3 Link With Work, Grand River Hospital, Kitchener, Ontario, and 4Manulife Financial, Toronto, Ontario, Canada Background, Study Objectives, How It Was Done: This was an extensive Review of studies in this area, evaluating the effectiveness of workplace rehabilitation interventions for lower back pain. Five reviewers examined 1244 articles and selected 198 that were relevant to the topic. Of these, 15 articles on 10 studies were of a high enough quality to be included. The Review focused on strategies for the management of work related musculoskeletal problems that were implemented in the workplace and involved secondary prevention. Secondary preventions are approaches undertaken early in a condition with the aim of preventing the worsening of symptoms and disability. In the workplace these may include actions such as modifying work duties to make them manageable for an injured worker, or structuring a gradual return to work program. Study Findings: Clinical treatment involving light activity and early return to work with initial adaptation of work tasks and hours reduces pain and disability. The effectiveness of this clinical treatment was not increased by adding workplace interventions. Low back pain affects workers and their families and employers. Although most (80%) people with low back pain recover in the first 3 months a small number remain affected for 6 months and some become permanently disabled. Disability from back pain causes high costs to health systems. This review of relevant studies found the following: Early Return to Work / Modified Work: An intervention of immediate assessment, treatment and return to modified work duties was provided to a group of nurses with back problems, and the results compared to those who received usual care. The results showed that the group with the workplace intervention had less had time off from injury, lower pain, less disability, and increasing physical ability to perform normal duties. Occupational Interventions with Clinical Interventions: A study examined return to work outcomes for people with back pain who were treated with one of four approaches. One group had traditional physical fitness rehabilitation (work hardening, fitness program and alternate days at work with increased tasks), the second group had an occupational intervention (evaluation and modification of work environment and duties), the third group received both of these interventions, and the fourth group did not receive either of the interventions. The study found that the group that received both interventions returned to work 2.4 times faster than the group that did not receive either intervention. Ergonomic Interventions: A major study examined the results of ergonomic interventions (adapting the workplace environment, work duties and hours) for over 1600 workers in five countries who were off work. This study showed that adaptation of job tasks and working hours was effective in helping workers to return to work after 200 days off sick. Adaptation of the work site was also found to improve the likelihood of return to work. Exercises and Workplace Visit: Two articles indicated that light exercise at first, with gradually increasing activity, were more effective in reducing days on sick leave, pain and difficulty with daily activities than “usual' care. The interventions were carried out in a clinic. The addition of a worksite visit and suggestion of modified work environment and duties was not shown to increase the effectiveness of the treatment. Supervisor Involvement: An educational program to train supervisors in return to work management resulted in increased contact between supervisors and employees with an injury, a more active approach to adapting the workplace for return to work by supervisors, and increased confidence of employees in their supervisors. Conclusions: Back pain interfering with return to work is a common problem. This review was conducted to evaluate the effectiveness of workplace rehabilitation interventions for injured workers with low back pain. The study found advising the injured worker to be active and supporting return to work in the workplace, including modifying work duties, produces the best treatment outcomes. TOP ARTICLE #17: THE IMPACT OF WORKPLACE CULTURE It Pays to Be Nice – Employer Worker Relationships Influence Back Pain Return to Work At a glance: Workers satisfaction with their employer's treatment is important in explaining if they will have multiple periods off work. Workers satisfaction with their employer is more important than their own expectations about recovery and it is more important than their satisfaction with their health care provider in determining their stability of employment after injury. Being nice pays off for the firm, by lowering both the likelihood of lost time claims from injured workers and the likelihood that they will have multiple spells of time off work (after at least one period of time off work). Workers who are more satisfied with their employer's response to a worker's compensation claim have higher expectations of a good recovery (26.5% versus 17.2%) and less severe pain than those who are dissatisfied. PERSPECTIVES: Employee This study shows that a positive relationship with your employer is the most important influence in your return to work following a low back pain injury. It also influences how your injury will affect your ongoing employment pattern in the future. Being off work is difficult in many ways. It helps if you can talk to your employer so that they understand your situation. Let them know how you are going and keep in touch regularly. It will help them to help you and keep communication channels open. Employer Responding positively with strong support, being in regular communication and assisting your employee to get the treatment they need for low back pain injuries is the most important factor determining how quickly the person will return to work. Your positive attitude also contributes to how well the worker is able to manage any low back problems in the future. Being nice, respecting and caring for your employees in a personal and professional manner, pays off. Treater In addition to reassuring the patient, demonstrating suitable stretching exercises and recommending normal activities to people with low back pain who do not display a serious pathology, encouraging positive communication between worker and employer is an important element in treatment of low back pain injuries. Insurer Advising and guiding employers to take a positive, supportive and professional approach to their workers low back injuries results in the earliest return to work and the most stable future employment pattern, with a consequent reduction in the cost of claims. Original Article, Authors & Publication Details: R. J. Butler1, W. G. Johnson2 and P. Côté3 (2007). It pays to be nice: employer-worker relationships and the management of back pain claims. Journal of Occupational & Environmental Medicine; 49(2):214-25. 1Department of Economics, Martha Jane Knowlton Coray University Professor, Brigham Young University, Provo, UT 2School of Computing and Informatics, Ira A. Fulton College of Engineering, Arizona State University Tempe, AZ 3Institute for Work and Health and Department of Public Health Sciences, University of Toronto, Toronto, Ontario Canada. Background, Study Objectives, How It Was Done: Over the last twenty years there has been increasing interest in what the workplace can do to help people to recover from injury and return to work. Workplace relations affect an employee's return to work after injury. The researchers in this study sought to better understand the relationship between employers approaches to managing workplace injury and workers employment stability in the 12 months after an injury claim. The Arizona State University Healthy Back Study investigated back pain claims from five employers with company branches in one or more of 37 states in the US. The subjects were workers aged 18 and older who filed workers compensation claims for work-related back pain between January 1, 1999 and June 30, 2002.The study observed this group of employees over the next year, to see whether their injury continued to affect their employment. The researchers wanted to know how much influence workers satisfaction with the firms treatment of their disability claim has on their return to work, compared to satisfaction with health care and expectation of recovery. The data was collected from workers compensation claim files and health care billing records, supplemented by interviews with workers conducted at the beginning of the claim, and 6 and 12 months later. Of 3,621 claims, 1831 (51%) of the workers agreed to participate in the survey and completed the initial interview. Of these, 87% of were still participating in the study after one month, 62% after six months, and 42% after one year. The survey obtained detailed information about the workers periods of time at and off work after the back pain claim had been lodged. Four patterns of post injury employment were defined, and workers divided into these groups at 6 and 12 months after their injury claim. Workers report no time off work following the onset of back pain. Workers are initially off work for a period but then return to work and have no subsequent absences over the next year. Workers return to work after an initial absence but experience one or more subsequent work absences related back pain. Workers absent from work from the date of onset to the date of interview. Workers were said to be satisfied with their employer's response if they reported, at the follow-up one month after the claim, that they were “satisfied" or “very satisfied" with how their employer had treated them following their injury. Study Findings: At the six month interview, poor employment patterns (patterns 3 and 4) were observed in about 22% of workers who are satisfied with their employer's responses to their claims and 45% or workers who are dissatisfied with their employer's responses. This difference is statistically significant, and therefore suggests that satisfaction with their employer's treatment of them after injury influences workers employment patterns in the future. The authors of the study used statistical techniques to also take into account the effects of other factors: the severity of the pain, whether the employee was male or female, the employee's expectations of recovery, the employer variables and whether the employee was able to choose their doctor. The researchers found, after taking these factors into account, that those who were dissatisfied with their employer were 1.5 times more likely to have negative return to work outcomes (i.e. patterns 3 or 4). Satisfaction with health care also influenced workers future employment patterns: 26% of the workers who were satisfied with their health care one month after their claim and 41% or workers who were dissatisfied with their health care had poor employment patterns when interviewed at six months. This difference is also statistically significant. Workers who are satisfied with the employer's response to their injury are more likely to only claim medical expenses, and not claim lost time (64% versus 56% for those dissatisfied with their treatment). Conclusions: The principal finding of this study is that workers' satisfaction with their employers' responses to their claims is the most important single influence on employment stability after the onset of back pain. It is roughly comparable to the severity of back pain itself in explaining differences in patterns of absence from work following injury. Worker's satisfaction with their employer's treatment is more important than satisfaction with health care or worker's own expectations about recovery in determining whether a worker will return to stable employment. Dissatisfied workers have worse return to work outcomes: they are more likely to make "time lost' claims and are more likely to have multiple spells off work. Occupational back pain is a common problem, and a target for disability management programs that attempt to reduce workers compensation costs by shortening work absences. The programs, widely practiced among large firms, are most successful when they include good communication and create trust between employers and workers. Workers who are unhappy with their employers reaction to their workers compensation claim will be reluctant to cooperate with disability management initiatives and may be absent from work for a longer period as a result. The effect of employer-worker relationships on the course of work-related back pain is one example of the influence of employer-worker interactions on industrial relations in general. The results show that the stability of post injury work attendance is greater among workers who are satisfied with their employer's responses to their compensation claims. Workers who are satisfied with their health care are also less likely to have multiple spells off work. However, all else being equal, worker's satisfaction with their employer's behavior has a much larger impact on employment after injury than does their satisfaction with health care. TOP