Exploring complex issues to find return-to-work answers

Recent studies from the Institute for Work & Health highlight potentially important practices for ensuring the successful return to work of injured employees.

Disability management and return to work can be complex, often involving medical, psychological, social and workplace issues. The Institute for Work & Health (IWH) is committed to exploring this complexity in order to help policy-makers, workplaces and labour develop programs that effectively prevent and manage disability arising from work-related conditions.

In recent months, several studies have done just that. Tackling subjects ranging from work accommodations to medication overuse, these studies highlight potentially important practices for ensuring the successful return of injured employees. Here’s a brief overview of these recent research findings.

1. Work accommodations

Injured workers who are offered accommodatedwork, such as different job tasks, shorter hours and other job adaptations tailored to their physical or mental abilities, are more likely to return to work. So it’s important to know what factors affect the offer and acceptance of work accommodations.

A study led by IWH Adjunct Scientist Dr. Renée-Louise Franche, director of disability prevention at the Occupational Health and Safety Agency for Healthcare in British Columbia, looked at this very issue. Published in the August 2009 issue of the Journal of Occupational and Environmental Medicine (vol. 51, no. 8, pp. 969-983), the study is based on information collected by Franche as an IWH scientist.

Franche found that workplace factors have more effect than an injured worker’s personal factors on the likelihood that work accommodations will be offered and accepted. This is good news, says Franche. These are modifiable factors over which the workplace parties have some control.

For example, the study found that work accommodations are more likely to be offered by workplaces with strong disability management policies and practices. These practices include:

  • contacting workers shortly after injury or illness to express concern and offer help;
  • working with physicians to develop return-to-work plans;
  • following up after injured workers return to adjust the work situation as needed;
  • providing retraining when injured workers can’t return; and
  • having labour and management work together as partners in returning injured workers.

The study compiled information on about 400 workers with musculoskeletal injuries who had filed claims with Ontario’s Workplace Safety and Insurance Board (WSIB). Workers were interviewed one month post-injury about work accommodations. Their responses (as well as administrative data available from the WSIB) were linked to 18 factors that could potentially affect an offer and acceptance of accommodated work.

These factors, derived from the research literature and the researchers’ expertise, were grouped into three categories: worker-level factors (e.g. age, gender, health status, pain levels), job-level factors (e.g. job demands, tenure, supervisor support) and workplace-level factors (e.g. firm size, unionization, organizational policies and procedures). One month post-injury, nearly 60 per cent of workers had been offered accommodated work, and three quarters of these offers had been accepted by these workers.

What does this mean in practice? Focusing on optimizing workplace conditions may increase the likelihood of successful work accommodations. Don’t focus only on the worker.

2. Differences among disabled workers with low-back pain

At one time, workers with low-back pain were considered a uniform group. But recent research has been saying otherwise. This is important, because if workers disabled by low-back pain are not alike, it means different interventions may be needed to help different groups of workers with back pain disability return to work.

IWH Associate Scientist Dr. Ivan Steenstra recently led a study that confirmed back-injured workers can be grouped according to risk factors known to affect the length of absences. In a paper published online in November 2009 in the Journal of Occupational Rehabilitation (e-pub ahead of print: DOI 10.1007/s10926-009-9218-8), Steenstra identified three classes of workers with back pain.

Just because you have one worker who calls in with low-back pain, it doesn’t mean the next one who calls in is exactly the same, says Steenstra. They may need different kinds of help. Identifying different groups of workers is a promising way to determine whether interventions can be more closely tailored to individual workers’ conditions.

From information collected through Franche’s study (above), Steenstra and his team looked at these issues in 442 workers with low-back pain who had filed a lost-time injury claim with Ontario’s WSIB. The 259 who had already returned to work at the one-month mark were classified as the low-risk group. The remaining 183 workers with disability lasting longer than one month were categorized as high risk. All were scored according to these risk factors: pain, disability, fear of pain and reinjury, physical job demands, people-oriented workplace culture, workplace disability management practices and depressive symptoms.

Based on these factors, the research team identified three classes of workers who were still off work:

Class 1 — workplace issues. These workers had similar pain and disability scores as those who had returned to work. However, they had much worse scores with respect to workplace disability management practices and the worst scores on people-oriented workplace culture.

Class 2 — positive workplace, but more back pain. These workers scored higher than any group, even those who had already returned to work, on people-oriented workplace culture and workplace disability management practices. However, they also scored relatively high with respect to pain and disability levels.

Class 3 — multiple issues. These workers fared the poorest in all areas except workplace disability management practices and workplace culture, and even here their scores were relatively worse. Their levels of depressive symptoms were much higher.

At six months post-injury, Steenstra found that 41 per cent of workers in Class 1 (workplace issues), as with 40 per cent in Class 2 (high back pain) and 43 per cent in Class 3 (multiple issues), were not working. This compared to 11 per cent of workers in the group that had returned to work at one month.

Steenstra suggests different interventions, or courses of action, that workers in each of these classes might need to ensure a timely return to work. Those with workplace issues would likely benefit most from interventions that address disability management practices and culture at work. Clinical interventions may not be the priority.

Those from a positive workplace but with ongoing pain might benefit most from interventions that target back pain, such as exercises. They might also particularly need supportive health-care providers who offer assurance and communicate with their supervisor to structure a return-to-work plan as part of recovery.

Finally, workers with multiple issues would probably benefit most from a program that intervenes on all fronts, paying special attention to the workplace and psychological issues. They might benefit from problem-solving training, development of coping skills, stress management and cognitive behavioural therapy.

The challenge now, says Steenstra, is to be able to identify as early as possible the risk category into which these workers fall. “The practical implications of this study are highly dependent on the quality of screening that can be achieved,” he says. To that end, Steenstra is currently working on a screening tool to predict time off work among people with low-back injuries.

What does this mean in practice? There might be a benefit in treating workers with low-back injuries in different ways. Tailoring interventions to improve return-to-work according to individual risk factors may be helpful.

3. Medication overuse

Some workers with work-related disabilities may frequently be prescribed pain medication in order to cope with return-to-work demands. So suggests IWH Scientist Dr. Ellen MacEachen, who observed this finding while researching the factors that account for the small (but costly) percentage of injured workers who have difficulty returning to work.

I didn’t set out to gather information on medication overuse, she said at the October 2009 Canadian Congress for Research on Mental Health and Addiction in the Workplace, where she presented her findings. However, what she found in her interviews with 48 injured workers and 21 service providers across Ontario was that the use of painkillers, such as opioids, was not uncommon among injured workers trying to manage their pain as they attempted to return to work.

They take the medication to keep moving and to be able to do work that has not been modified in the wake of their injury, explained MacEachen. And they often don’t complain, perhaps because they are too stoic or too terrified of losing their jobs and/or workers’ compensation benefits.

It’s a no-win situation, MacEachen said. Workers take the medication to cope, but the medication makes it hard for them to function. As well, the medication may also present a safety hazard. Because the medication masks pain and symptoms, workers may over-extend and experience a reinjury she said. As well, they may pose a risk to their co-workers if working in an impaired state.

The problem calls for “upstream solutions,” MacEachen said. She suggested the following:

  • more systemic oversight of workplace return to work by the Workplace Safety and Insurance Board (which the WSIB is embarking on through its new service delivery model);
  • the creation of a forum for workers to complain about poor RTW situations without fear of losing their benefits or jobs; and
  • more weight being given to the advice of physicians who say a worker is not ready to return, even if the employer indicates accommodated work is available.

As for the workplace parties, there is currently little in the way of guidance to assist workers, employers and health professionals who must deal with this issue, MacEachen said. She suggested the way forward is to improve communications.

If a worker does return to work while on strong medications, the physician should carefully monitor medication use. Also, while observing worker confidentiality, the employer should be made aware of the worker’s functional incapacity, such as concentration and coordination limitations, related not just to the original injury but to medication use as well.

What does this mean in practice? Involving workers’ health-care providers in the design of return-to-work programs that accommodate workers’ pain levels and medication use may be helpful. Be aware that returning injured workers may be taking pain medication in order to cope with job demands.

Source: At Work, Issue 59, Winter 2010: Institute for Work & Health, Toronto