The components that affect the occurrence and chronicity of musculoskeletal disease are multifactorial. The return to work process and prevention of future chronic disability commences at the time of the initial assessment. The clinician can identify, at an early stage, patients with negative expectations of return to work and adopt a care plan oriented to functional adaptation. Medical and psychosocial treatment plans taking account of coping preferences, beliefs and practices are more likely to help prevent chronic disability. Other factors that can influence the long-term disability rate include medically discretionary or unnecessary time off work and litigation itself. Workplace factors can result in unnecessary absenteeism and poorly managed presenteeism.
Long-term work absence, work disability and unemployment are harmful to physical and mental health and well-being . The negative impacts of remaining away from work not only affect the absent worker, but also families, including the children of parents out of work, who suffer consequences including poorer physical health, decreased educational opportunities and reduced long-term employment prospects . Work in general is good for health and well-being; work absence is not. Prolonged work absence and chronic disability, however, are never simply a matter of physical pathology. Clinicians play a vital role in the interactions amongst individuals, the employer, society and the legal system in preventing long-term chronic disability.
Definition of disability
The international classification of functioning (WHO, 2000) is based on the biopsychosocial model. Disability encompasses interrelated and interacting dimensions. Disability depends upon interactions between the individual and his or her social context. Capacity for work depends upon interactions between the worker’s health condition, his or her physical and mental capabilities, the demands of the job and other psychosocial factors .
Clinicians are aware of the discordance in presentation of patients with persisting pain and the level of work disability:
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patients with significant structural abnormalities presenting with no pain;
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patients with minimal pathology presenting with severe pain;
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patients with severe pain, functioning well; and
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patients with much less pain, presenting with high levels of disability .
Our role as medical practitioners is to identify, at an early stage, patients at greatest risk of long-term disability, and to orient clinical care towards functional adaptation rather than necessarily finding a ‘cure’. Our role is to recognise and address individual barriers and concerns about return to work, facilitate ‘stay at work’ options and to instigate an early and timely return to work to prevent long-term disability.
Identification of the at-risk patient
Early identification of patients at greatest risk of long-term disability is critical. Once identified, the clinician is then able to address the presenting condition in the context of known barriers to return to work and focus on the patient’s functional adaptation with a multidisciplinary approach.
We know that strong predictors of chronic pain and disability include:
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older age, that is, greater than 55 years;
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duration of time off work;
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being non-job attached;
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high local unemployment rate; and
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negative expectations regarding return to work .
Predictors of chronic pain and disability of moderate strength include:
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type of occupation;
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education level;
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previous work record;
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psychological distress;
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job dissatisfaction and worker dissatisfaction;
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duration of sickness absence;
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pain intensity/functional disability;
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poor perception of general health;
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depression;
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fear-avoidance behaviour;
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maladaptation of coping; and
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catastrophising/pain behaviour .
Predictors of chronic pain and disability of weak strength include:
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co-morbidities;
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anxiety;
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personality traits;
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psychological history;
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stressful life events;
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alcohol and substance abuse; and
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gender; immigrant status .
A study which focussed on patients’ expectation of return to work assessed injured workers soon after pain onset and ‘before’ obtaining medical care, lessening the risk that the study was confounded by treatment, clinical course and provider advice . Patient expectations for return to work were unrelated to age, gender, education, income and ethnicity, consistent with other studies of disability duration. Demographic variables were poor predictors of return to work. However, patients who had negative expectations of returning to work were less likely to have resumed normal work at 1 month and at 3 months.
They found at 1 month:
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57% of workers had returned to full-time duties after an injury;
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19% had returned to modified alternative duties; and
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24% had not returned to work.
And at 3 months:
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74% had returned to full-time duties;
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8% had returned to modified alternative duties; and
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18% had not returned to work.
Therefore three-quarters of those workers off work at 1 month were still off work at 3 months. (Other authors have found that 10–15% of workers remain off work into the longer term.) .
The study confirmed that patients with (early) poor expectations of return to work were predictive of long-term work absence and chronic disability.
Another study also examined the association between work-related recovery expectations and return to work. The workers’ ‘Recovery Expectation Scores’ were strongly associated with length of time lost, controlling for injury duration, clinician recommendations to return to work and the Pain Disability Index. The authors concluded that, in addition to history taking aimed at diagnostic decision making, primary care providers should explore their patients’ beliefs regarding return to work to identify potential barriers .
Patients at long-term risk of chronic disability can be identified at the first consultation with a simple questionnaire. The primary question that clinicians should ask at the first consultation has been identified as: “When do you think you might return to work?”
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this week?
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one month?
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three months?
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six months?
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one year?
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greater than a year? and
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probably never?
Recommended further associated questions included:
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“What do you think are the problems/obstacles for you returning to work?”
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“How do you think these problems/obstacles may be overcome?” and
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“How do you think that I or your employer can help to overcome these problems/obstacles?”
In the first few days post-injury, identification of patients with negative expectations of return to work provides the clinician with the opportunity to explore barriers and to set up a clinical care plan that is orientated towards functional adaptation and improving the patient’s ability to cope with pain and other psychosocial factors.
The probability of return to work as a function of time off work is shown below :
| Time off work | The odds of still being off work 1 year later |
|---|---|
| Day 1 | 1–10% |
| 1 Month | 20% |
| 6 Months | Greater than 50% |
Related posts:
Hand pain other than carpal tunnel syndrome (CTS): The role of occupational factors
Shoulder pain at the workplace
Neck and back pain and intervertebral disc degeneration: Role of occupational factors
Hip and knee pain: Role of occupational factors
Epidemiological aspects of studying work-related musculoskeletal disorders
Management of occupation-related musculoskeletal disorders
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