Effective workplace return-to-work interventions are multi-faceted: IWH review

New systematic review finds evidence for return-to-work programs that incorporate some combination of health services, case coordination and work modification

Workplaces that offer multi-faceted return-to-work (RTW) interventions can help reduce time away from work for workers with musculoskeletal disorders (MSDs) and pain-related conditions, a new systematic review update has found.

The review, conducted by the Institute for Work & Health (IWH) and the Institute for Safety, Compensation and Recovery Research (ISCRR) in Melbourne, Australia, found strong evidence for the effectiveness of interventions that cut across at least two of three different areas:

(1) The injured worker is provided with health services, either at work or in settings linked to work. These may include physical therapy, occupational therapy, psychological therapy, medical assessments or exercises aimed at restoring function (e.g. graded activity and work hardening).

(2) The injured worker is supported by RTW planning and coordination, which may take the form of case management, RTW plans, or improved communication between the workplace and health-care providers.

(3) The workplace addresses work modification in the form of work accommodation, ergonomics or other worksite adjustments, and supervisor training on work modification.

“This systematic review indicates that the grouping or packaging of interventions from the different domains makes them effective in a way that stand-alone interventions are not, says the review’s lead author Dr. Kim Cullen, an associate scientist and knowledge exchange associate at the Institute.

Even groups of interventions from a single domain—for example, a package of health-focused services—are found in this review to have limited or no effect, Cullen adds.

Graded activity and work accommodation are two exceptions to this pattern. The systematic review found moderate evidence that either of these two interventions, on their own, can have a positive effect on reducing lost time. If workplaces have to offer a stand-alone intervention, work accommodation and graded activity are the only interventions we would suggest, says Cullen.

Mental health studies included

This systematic review update, accepted for publication in the Journal of Occupational Rehabilitation, also covered workplace RTW interventions for mental health conditions. It found a strong level of evidence that traditional cognitive behavioural therapy (CBT) has no effect on reducing lost time.

However, it also found a strong level of evidence supporting CBT programs that are focused on work challenges. According to the systematic review, these work-focused CBT programs have a positive effect on reducing lost time and associated costs.

The key message when it comes to mental health conditions is that generic CBT doesn’t improve return-to-work outcomes, says Cullen. What does work is cognitive behavioural therapy that addresses the specific difficulties that the worker faces in returning to his or her job.

Implications for Seven Principles

The review is an update of a 2004 systematic review by IWH. The 2004 findings, which have been synthesized into what’s now commonly known as the Seven Principles of Successful Return-to-Work, found lost time and associated costs are reduced by: employer commitment to health and safety; a work accommodation offer; an RTW plan that supports the returning worker without disadvantaging co-workers and supervisors; supervisor training in work disability prevention and RTW planning; early and considerate contact with the worker by workplace; the presence of an RTW coordinator; and contact between health-care provider and workplace.

Although we may revisit the Seven Principles as a result of this work, the update would at least suggest that these practices should be offered together and not isolation, says Cullen.

How the review was conducted

The question guiding this systematic review was: What workplace-based return-to-work and work disability management/support interventions are effective in assisting workers with musculoskeletal, mental health and pain-related conditions with return to work and recovery after a period of work absence? (The paper to be published in the JOR addresses only RTW outcomes; recovery outcomes will be reported in a later paper.)

A systematic literature search covering 1990 to April 2015 resulted in 8,898 unique references. After screening abstracts and full articles for relevance, the team retained 36 unique studies of workplace-based interventions. Of these, 26 examined interventions for MSDs and pain-related conditions, and 10 were focused on mental health conditions.

The team then assessed the 36 studies for quality and found 18 were high quality and 18 were medium quality. No studies were rated as low quality. In comparison, the original review in 2005 included only 11 studies.

Return-to-work outcomes covered by the systematic review fell into three categories:

1. Lost-time measures approximated the amount of time spent away from the workplace or the rate of RTW over a given time period. These include outcomes such as days from injury until first return to work, total duration of sick leave over a given time period, work status (working or not working) at a point in time, and recurrences of sick leave/work absence. These measures were self-reported or collected from organizational or system records.

2. Work functioning measures assessed workers' function in the workplace and health-related lost productivity. These included outcomes such as self-rated work limitations and estimates of productive working hours.

3. Cost measures estimated work disability cost and lost-time costs, including income replacement, as well as the total compensation paid (where such costs included income replacement costs).

Source: At Work, Issue 87, Winter 2017: Institute for Work & Health, Toronto

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