Evaluation of a workplace disability prevention intervention in Canada: examining differing perceptions of stakeholders.

INTRODUCTION Workplace disability prevention is important, but stakeholders can differ in their appreciation of such interventions. We present a responsive evaluation of a workplace disability prevention intervention in a Canadian healthcare organization. Three groups of stakeholders were included: designers of the intervention, deliverers, and workers. The aim was to examine the appreciation of this intervention by analyzing the discrepancies with respect to what these various stakeholders see as the causes of work disability, what the intervention should aim at to address this problem, and to what extent the intervention works in practice. METHODS A qualitative research method was used, including data-triangulation: (a) documentary materials; (b) semi-structured interviews with the deliverers and workers (n = 14); (c) participatory observations of group meetings (n = 6); (d) member-checking meetings (n = 3); (e) focus-group meetings (n = 2). A grounded theory approach, including some ethnographic methodology, was used for the data-analysis. RESULTS Stakeholders' perceptions of causes for work disability differ, as do preferred strategies for prevention. Designers proposed work-directed measures to change the workplace and work organizations, and individual-directed measures to change workers' behaviour. Deliverers targeted individual-directed measures, however, workers were mostly seeking work-directed measures. To assess how the intervention was working, designers sought a wide range of outcome measures. Deliverers focused on measurable outcomes targeted at reducing work time-loss. Workers perceived that this intervention offered short-term benefits yet fell short in ensuring sustainable return-to-work. CONCLUSION This study provides understanding of where discrepancies between stakeholders' perceptions about interventions come from. Our findings have implications for workplace disability prevention intervention development, implementation and evaluation criteria.

Implementing the work disability prevention paradigm among therapists in Hong Kong: facilitators and barriers.

INTRODUCTION: This is a discussion paper to examine the issues surrounding management of work-related injuries by physiotherapists and occupational therapists in Hong Kong. Therapists working in public hospitals are faced with managing injured workers with limited resources and this frequently results in suboptimal outcomes. METHODS: In this paper, five experienced therapists critically reviewed the current practices in the physiotherapy and occupational therapy professions in Hong Kong, with regard to managing patients with work injuries. In many hospitals, therapists still practice with a disease-based model focusing on symptom relief and restoration of general physical function. We collated information about current programs initiated by physiotherapists and occupational therapists to provide more strategic intervention strategies for early screening of high-risk patients and adaptive biopsychosocial interventions targeting return-to-work outcomes. Clinical and system-level barriers and facilitators of a major paradigm shift towards work disability prevention are discussed. CONCLUSION: Physiotherapists and occupational therapists need to develop more strategic collaborations and actively voice out the need for major systematic changes within the local healthcare system, in order to provide a more effective management approach in line with the concept of Work Disability Prevention.

Physical conditioning programs for improving work outcomes in workers with back pain.

BACKGROUND: Physical conditioning programs aim to improve work status for workers on sick leave. This is an update of a Cochrane Review (Work conditioning, work hardening and functional restoration for workers with back and neck pain) first published in 2003. OBJECTIVES: To compare the effectiveness of physical conditioning programs in reducing time lost from work for workers with back pain. SEARCH STRATEGY: We searched the following databases to June/July 2008: CENTRAL (The Cochrane Library 2008, issue 3), MEDLINE from 1966, EMBASE from 1980, CINAHL from 1982, PsycINFO from 1967, and PEDro. SELECTION CRITERIA: Randomized controlled trials (RCTs) and cluster RCTs that studied workers with work disability related to back pain and who were included in physical conditioning programs. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed risk of bias. MAIN RESULTS: Thirty-seven references, reporting on 23 RCTs (3676 workers) were included, 13 of which had a low risk of bias. In 14 studies, physical conditioning programs were compared to usual care. In workers with acute back pain, there was no effect on sickness absence. For workers with subacute back pain, we found conflicting results, but subgroup analysis showed a positive effect of interventions with workplace involvement. In workers with chronic back pain, pooled results of five studies showed a small effect on sickness absence at long-term follow-up (SMD: -0.18 (95% CI: -0.37 to 0.00)). In workers with chronic back pain, physical conditioning programs were compared to other exercise therapy in six studies, with conflicting results. The addition of cognitive behavioural therapy to physical conditioning programs was not more effective than the physical conditioning alone. AUTHORS' CONCLUSIONS: The effectiveness of physical conditioning programs in reducing sick leave when compared to usual care or than other exercises in workers with back pain remains uncertain. In workers with acute back pain, these programs probably have no effect on sick leave, but there may be a positive effect on sick leave for workers with subacute and chronic back pain. Workplace involvement might improve the outcome. Better understanding of the mechanism behind physical conditioning programs and return-to-work is needed to be able to develop more effective interventions.

Functional capacity evaluations for the prevention of occupational re-injuries in injured workers.

BACKGROUND: Functional capacity evaluation (FCE) has been widely used to assess workers' physical state of readiness to return to work (RTW) after an injury and to make recommendations for the time and capacity in which they might return. FCEs are also used to prevent re-injury after RTW. Despite being a commonly used tool, little is known about how effective FCE is in preventing occupational injuries. OBJECTIVES: To assess the effectiveness of FCE-based return to work recommendations in preventing occupational re-injuries of injured workers compared with no intervention or alternative interventions. SEARCH STRATEGY: We searched the following electronic databases: the Cochrane Central Register of Controlled Trials (The Cochrane Library 2009, Issue 4), MEDLINE (1966 to December 2009), EMBASE (1980 to December 2009), CINAHL (1980 to December 2009), PsycINFO (1983 to December 2009) and PEDro (1929 to December 2009). The searches were not restricted by date, language or type of publication. SELECTION CRITERIA: We included randomised controlled trials (RCTs) of FCE-based return to work recommendations for preventing occupational re-injuries in injured workers. DATA COLLECTION AND ANALYSIS: Four authors (NM, ES, JV, ML), in pairs, independently selected studies for inclusion, extracted data and assessed risk of bias. MAIN RESULTS: We found no studies that compared FCE to no intervention. We found one RCT with 372 participants in which a short-form of one FCE was compared to the standard long-form FCE (Isernhagen Work Systems). Outcomes were recurrence rates of re-injuries. There was no significant difference between the two forms of FCE.We rated the overall quality of the evidence as low. AUTHORS' CONCLUSIONS: There is no evidence for or against the effectiveness of FCE compared to no intervention. A short version of FCE showed similar effectiveness to a long version in preventing re-injury. More RCTs are needed.

Pre-employment examinations for preventing occupational injury and disease in workers.

BACKGROUND: Many employers and other stakeholders believe that health examinations of job applicants prevent occupational diseases and sickness absence. OBJECTIVES: To evaluate the effectiveness of pre-employment examinations of job applicants in preventing occupational injury, disease and sickness absence compared to no intervention or alternative interventions. SEARCH STRATEGY: We searched CENTRAL (The Cochrane Library), MEDLINE, EMBASE, CINAHL, PsycINFO and PEDro (to December 2009) not restricted by date, language or publication type. SELECTION CRITERIA: We included randomised controlled trials (RCTs), controlled before-after studies (CBA), and interrupted time-series (ITS) of health examinations to prevent occupational diseases and injuries in job applicants. DATA COLLECTION AND ANALYSIS: Four review authors (NM, ML, JV, ES) independently selected studies, extracted data, and determined study quality. The studies were too heterogeneous for statistical pooling of results. MAIN RESULTS: We included two RCTs, five CBA studies and two ITS. Seven studies with 5872 participants evaluated the screening process of pre-employment examinations and two studies with 2164 participants evaluated the measures to mitigate the risks found following the screening process.Of those studies that evaluated the screening process, one study found that a general examination did not reduce sick leave (Mean Difference -0.1 95% CI -0.5 to 0.3) but another study found that a more task focused examination did (MD -36 95% CI -68.3 to -3.8). One study found that incorporation of a bronchial challenge test decreased occupational asthma (trend change -2.6 95% CI -3.6 to -1.5). Three studies that included functional capacity evaluation found contradictory effects on injury rates and number of medical visits. The rates of rejecting job applicants varied from 2% to 35%.Neither of the two studies that evaluated risk mitigation found an increased injury rate after training or work accommodations had been implemented.We rated the evidence for all outcomes as very low quality. AUTHORS' CONCLUSIONS: There is very low quality evidence that pre-employment examinations that are specific to certain jobs or health problems could reduce occupational disease, injury, or sickness absence. This supports the current policy to restrict pre-employment examinations to job-specific examinations. More studies are needed that take into account the harms of rejecting job applicants.

Workplace interventions for preventing work disability.

BACKGROUND: Work disability has serious consequences for all stakeholders and society. Workplace interventions are considered appropriate to facilitate return to work by reducing barriers to return to work, involving the collaboration of key stakeholders. OBJECTIVES: To determine the effectiveness of workplace interventions compared to usual care or clinical interventions on work-related outcomes and health outcomes; and to evaluate whether the effects differ when applied to musculoskeletal disorders, mental health problems, or other health conditions. SEARCH STRATEGY: We searched the Cochrane Occupational Health Field Trials Register, CENTRAL, MEDLINE and EMBASE (EMBASE.com), and PsycINFO databases (to November 2007). SELECTION CRITERIA: We included randomized controlled trials of workplace interventions aimed at return to work for workers where absence from work because of sickness was reported as a continuous outcome. DATA COLLECTION AND ANALYSIS: Two authors independently extracted data and assessed risk of bias of the studies. Meta-analysis and qualitative analysis (using GRADE levels of evidence) were performed. MAIN RESULTS: We included six randomized controlled trials (749 workers): three on low back pain, one on upper-extremity disorders, one on musculoskeletal disorders, and one on adjustment disorders. Five studies were rated as having low risk of bias for the sickness absence outcome. The results of this review show that there is moderate-quality evidence to support the use of workplace interventions to reduce sickness absence among workers with musculoskeletal disorders when compared to usual care. However, workplace interventions were not effective to improve health outcomes among workers with musculoskeletal disorders. The lack of studies made it impossible to investigate the effectiveness of workplace interventions among workers with mental health problems and other health conditions. A comparison of a workplace intervention with a clinical intervention, in one study only, yielded similar results for sickness absence and symptoms for workers with mental health problems. AUTHORS' CONCLUSIONS: As a result of the few available studies, no convincing conclusions can be formulated about the effectiveness of workplace interventions on work-related outcomes and health outcomes regardless of the type of work disability. The pooled data for the musculoskeletal disorders subgroup indicated that workplace interventions are effective in the reduction of sickness absence, but they are not effective in improving health outcomes. The evidence from the subgroup analysis on musculoskeletal disorders was rated as moderate-quality evidence. Unfortunately, conclusions cannot be drawn on the effectiveness of these interventions for mental health problems and other health conditions due to a lack of studies.

Effectiveness of interventions in preventing injuries in agriculture--a systematic review and meta-analysis.

OBJECTIVES: This study reviewed the effectiveness of interventions in preventing occupational injuries among workers in agriculture. METHODS: Randomized controlled trials, controlled before-after studies, and interrupted time-series studies assessing interventions aimed at preventing injuries among workers in agriculture were considered. MEDLINE and five other databases were searched up to June 2006. Two authors independently assessed the eligibility of studies and the methodological quality of the ones included. Randomized controlled trials were combined in a meta-analysis. Interrupted time-series studies were reanalyzed to assess the immediate and progressive effect on injuries. RESULTS: Five randomized controlled trials and three interrupted time-series studies met the inclusion criteria. Six studies evaluated educational interventions and financial incentives, and two studies evaluated the effect of legislation. Three randomized controlled trials on educational interventions with 4670 adult participants did not indicate any injury-reducing effect, with a rate ratio of 1.02 (95% confidence interval 0.87-1.20), nor did two randomized controlled trials among children (6895 participants). Financial incentives decreased the injury level immediately after the intervention in one interrupted time-series study. Banning endosulfan pesticide in Sri Lanka led to a significant decrease in the trend of poisonings over time. Legislation requiring rollover protective structures on all tractors in Sweden did not produce a reduction in injuries, but the same requirement for new tractors was associated with a decrease in fatal injuries. CONCLUSIONS: The reviewed studies provided no evidence that educational interventions are effective in decreasing injury rates among agricultural workers. Financial incentives may be a better means of reducing injury rates. Banning highly toxic pesticides may be effective. Legislation on safety devices on tractors yielded contradictory results.

Teaching evidence-based practice: the teachers consider the content.

OBJECTIVE: To identify the views of evidence-based practice (EBP) experts about information that should be included in EBP courses. DESIGN: A two-round Delphi process. SETTING AND SUBJECT: The panel of experts in teaching EBP residing in developed and developing countries identified through purposive and snowball sampling. MAIN OUTCOME MEASURES: We developed a list of 49 topics representing key educational topics. The panel scored the importance of topics for inclusion in introductory and advanced courses. In the second round, we sent a summary of results to the panel and asked them to re-score in light of the group's responses. RESULTS: We used email to invite 105 EBP teachers to participate in the study. Fifty-one people from 15 countries agreed to participate, and 40 completed the second round. We achieved consensus that formulating clinical questions, searching pre-appraised resources, introduction to systematic reviews and critical appraisal of studies about therapy should be covered earlier in EBP courses while other critical appraisal topics and quantitative decision-making techniques should be left to more advanced levels. CONCLUSION: Experts concur that introductory EBP courses should be simple and certain topics should be avoided. Specifically, critical appraisal and statistical methods should be left to advanced courses.

Occupational health systematic reviews: An overview.

Systematic reviews have been described by leaders in the field of evidence-based practice as the most powerful and useful evidence available to guide practice. This paper gives a description and analysis of systematic reviews currently included in the Cochrane Database for Systematic Reviews which have been identified by newly formed Cochrane Occupational Health Field as having an occupational health focus.

Use of Functional Capacity Evaluations by rehabilitation providers in NSW.

Returning the disabled worker to maximum productivity is a shared responsibility between the treating health practitioners and employers, with the insurer as an overseer of the injury management plan. Allied health professionals have responded to the need for standardized tools to assess work capacity by developing Functional Capacity Evaluations (FCEs). Literature exists outlining the limitations of FCEs in injury management systems; however, little is known about their uses and perceived usefulness. Questionnaires were posted to managers and therapists of accredited rehabilitation providers. The questionnaires consisted of both open and closed format questions. The response rate for the managers' questionnaire was 53%, while the therapists' questionnaire was 27%. The majority of rehabilitation providers use an assessment of their Own Design. Eight commercial FCEs were identified as being used. The majority of therapists use only one type of FCE. Therapists rated FCEs highly on their flexibility with Own Design assessment rated as significantly more flexible than the most frequently used commercial FCEs. From the data collected, it appears that cost is the main factor influencing choice of assessment. Level of evidence supporting capabilities of particular assessments does not appear to influence use. It seems that, despite there being poor research evidence to support the use of many brands of FCEs, they are still commonly used by rehabilitation providers. To achieve optimal use of FCEs, further research is required on the types of adaptations therapists make to commercial assessments and properties of Own Design assessments, including reliability and validity studies.

WorkCover's physiotherapy forms: purpose beyond paperwork?

We retrospectively analysed 219 consecutive treatment plans submitted to a large New South Wales workers' compensation insurer for workers coded by the insurer as suffering from back pain. The purpose was to (i) describe the quality of goals of treatment provided to insurers by physiotherapists for workers with back pain using guidelines provided by the WorkCover Authority of New South Wales (WorkCover); (ii) compare the physiotherapists' prognoses against prognoses indicated in clinical practice guidelines; and (iii) make recommendations about the communication system between physiotherapists and insurers. The back pain of most treated workers was classified as acute and the majority of physiotherapists estimated that treatment would be of short duration, which is concordant with current treatment guidelines. However, most physiotherapists did not provide precise, measurable or time-specific treatment goals, despite this being emphasised by WorkCover. We propose ways of improving communication practices between physiotherapists and insurers.

Physical conditioning programs for improving work outcomes among workers with back pain.

OBJECTIVES: The aim of this review was to assess the effect of physical conditioning programs, compared to no or alternative interventions, in reducing time lost from work among patients with back pain. METHODS: We conducted a systematic review with meta-analysis and meta-regression of randomized controlled trials (RCT) of physical conditioning programs for workers with back-pain-related work disability. RESULTS: We included 23 RCT with 3676 participants, with 13 studies having a low risk of bias. In 14 studies, physical conditioning programs were compared to "usual care". Among workers with acute back pain, there was no effect on sickness absence. For workers with subacute back pain, we found conflicting results. Among workers with chronic back pain, pooled results of five studies showed a small effect on sickness absence at one year follow-up [standardized mean difference (SMD) -0.18, 95% confidence interval (95% CI) -0.37-0.00] but this effect disappeared at longer follow-up times. Six studies compared physical conditioning programs to exercise only with conflicting results. The addition of cognitive behavioral therapy to physical conditioning programs did not change the effectiveness. The meta-regression showed no significant effect of program intensity, inclusion of a workplace visit, occupation, setting of the intervention, the type of comparison, or the follow up time. CONCLUSIONS: The effectiveness of physical conditioning programs in reducing sick leave for workers with back pain remains uncertain. For acute back pain, these programs probably have no effect; for subacute back pain, the effect is unclear, and for chronic back pain there is a small effect at one year follow-up that does not last in the long run. Remaining heterogeneity could not be explained by meta-regression. A better understanding of the mechanism behind physical conditioning programs and return to work is needed to develop more effective interventions.

The value of functional and work place assessments in achieving a timely return to work for workers with back pain.

This paper reviews the current status of functional capacity evaluations in the assessment of workers with low back pain. Conceptual and practical difficulties are discussed and a new model that we call Work Capacity Evaluation (WCE) is proposed. Specific reference is made to the role of the medical practitioner in the process of injury management.

Physical conditioning programs for workers with back and neck pain: a cochrane systematic review.

OBJECTIVE: To determine the effect on time lost from work of physical conditioning programs for workers with back and neck pain. DATA SOURCES Randomized trials were located by searching MEDLINE, EMBASE, CINAHL, PsycINFO, the Cochrane Controlled Trial Register, and PEDro. REVIEW METHODS: Two reviewers independently extracted data and assessed trial quality. Where data could be pooled, meta-analysis was performed. Based on cost considerations, we nominated a mean saving of 10 sick days per year or a number needed to treat to return 1 person to work of 10 as the smallest treatment effects that would be clinically worthwhile. RESULTS: Nineteen trials in 21 publications yielded 23 contrasts relevant to this review. These trials provide evidence that physical conditioning programs that included a cognitive-behavioral approach could produce a clinically worthwhile reduction in the number of sick days taken at 12 months (average of 45 days; 95% confidence interval 3-88) when compared to general practitioner care or advice for workers with chronic back pain. There was little evidence of an effect on time lost from work of specific exercise programs that did not include a cognitive-behavioral component. CONCLUSION: Physical conditioning programs that incorporate a cognitive-behavioral approach reduce the number of sick days for workers with chronic back pain when compared to usual care.