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Alternative models of return to work. Kath McPherson Professor of Rehabilitation. Some key questions…. Alternatives to what?. Some key questions…. Alternatives to what? Clearly worth considering strengths and limits of dominant approaches eg Medical versus Social model of disability
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Alternative models of return to work Kath McPherson Professor of Rehabilitation
Some key questions…. • Alternatives to what?
Some key questions…. • Alternatives to what? • Clearly worth considering strengths and limits of dominant approaches • eg Medical versus Social model of disability • A useful argument that helped the move from sole focus on pathology but… • Has an oppositional approach to these paradigms limited advance in knowledge?
Also… • Biopsychosocial model has buy-in but… • But - a number of components (particularly the psychosocial) not well clearly understood or defined • If they are not clearly defined - how can they be measured? • A tendency to measure what we can measure – not necessarily what matters?
The ‘meaning’ of work and decision making • Its far more complicated for many people than the things we measure…. • Multiple and changing contexts & factors • A focus on ‘work is good’ has implications for those who are very expensive to RTW…. • Findings from qualitative studies highlight the complexity • An example in SCI
Fadyl & McPherson (2010). Understanding decisions about work after spinal cord injury. Journal of Occupational Rehabilitation, 20, 69-80.
A concept of value in facilitating RTW? • ‘Work ability’ or - the match between • the physical, mental, social, environmental and organisational demands of a person’s work and his or her capacity to meet these demands
A concept of value in facilitating RTW? • ‘Work ability’ or - the match between • the physical, mental, social, environmental and organisational demands of a person’s work and his or her capacity to meet these demands • Concept review (using principles of systematic review) • Identify key factors that contribute to this match • Fadyl, J. K., McPherson, K. M., Schlüter, P. J., & Turner-Stokes, L. (2010). Factors contributing to work-ability for injured workers: Literature review and comparison with available measures. Disability and Rehabilitation, 32, 1173-1183.
Some issues … • Updated the review recently (other measures of value found) but… • Still none cover all variables highlighted to influence ‘workability’ • And still - predominant focus on physical capacity and symptoms… • Still little focus on data from employer or others
Some issues … • Updated the review recently (other measures of value found) but… • Still none cover all variables highlighted to influence ‘workability’ • And still - predominant focus on physical capacity and symptoms… • Still little focus on data from employer or others • Perhaps still a tendency to ‘talk’ about rather than formally assess / measure biopsychosical aspects of importance?
Outcomes of importance addressed in pain research? Beale et al Pain 2011 Volume 152, Issue 10, 2283-86
Outcomes of importance addressed in pain research? An SF-36 ‘effect’??
A concern.. • Recent meta-analysis (David Coggan’s Group) Rheuatology 2011 early online) Parker et al • Community setting interventions for for MSK conditions (RTW and sick leave reduction) • 27 RTW trials assessed • most appeared beneficial but… • Low odds ratio (1.24 (IQR 1.06-1.71) • Low cost effectiveness • Smaller effect size in better studies
Rethinking Self Efficacy ??? • Not to discard but… to add? • Self regulation as another potentially useful psychosocial theory • (Locke & Latham, 1990; Carver et al 1992) • Increasingly underpinning rehabilitation (and self management) interventions • Appears to have particular relevance in complexity
Self regulation theory • Most human behaviour goal-directed • People strive towards multiple goals • Success in achieving desired goals determined by own skill in regulating cognition, emotions and behaviour. • Progress or failure in goal attainment has affective or emotional consequences • Goal attainment, motivation, affect and sense of self closely related and will interact
To finish… • A personal take on why we should keep considering alternate approaches • Still need better concept definition and better measurement • Potential to enhance our focus on values and meaning to get better outcomes • May be crucial for engaging people • Skills (for practitioners, clients and employers and…) • Perhaps impact on ‘how’ we work with people • Worth going beyond self efficacy • Multiple influential factors (as yet untested) amenable to change
Thankyou • Fadyl, J. K., & McPherson, K. M. (2010). Understanding decisions about work after spinal cord injury. Journal of Occupational Rehabilitation, 20, 69-80. • Fadyl, J. K., McPherson, K. M., Schlüter, P. J., & Turner-Stokes, L. (2010). Factors contributing to work-ability for injured workers: Literature review and comparison with available measures. Disability and Rehabilitation, 32, 1173-1183. • Fadyl, J. K., & McPherson, K. M. (2009). Approaches to vocational rehabilitation after traumatic brain injury – a review of the evidence. Journal of Head Trauma Rehabilitation, 24, 195-212. • Fadyl, J. K., & McPherson, K. M. (2008). Return to work after injury: A review of evidence regarding expectations and injury perceptions, and their influence on outcome. Journal of Occupational Rehabilitation, 18, 362-374. • Wasiak, R., Young, A.E., Roessler, R.T., McPherson, K.M., van Poppel, M.N. and Anema, J.R., Measuring return to work. J Occup Rehabil, 2007. 17(4): p. 766-81. • Young, A.E., Wasiak, R., Roessler, R.T., McPherson, K.M., Anema, J.R. and van Poppel, M.N., Return-to-work outcomes following work disability: stakeholder motivations, interests and concerns. J Occup Rehabil, 2005. 15(4): p. 543-56. • Young, A.E., Roessler, R.T., Wasiak, R., McPherson, K.M., van Poppel, M.N. and Anema, J.R. A developmental conceptualization of return to work. J Occup Rehabil, 2005. 15(4): p. 557-68.
