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Return to Work Rehabilitation Clare Evans Fit Mind, Fit Body, Fit Fire Service? 22 nd June 2005 RehabWorks Ltd Fitness for Work and Life Aims of the talk To explain bio-psycho-social model of rehabilitation How rehabilitation works in the workplace

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return to work rehabilitation clare evans fit mind fit body fit fire service 22 nd june 2005
Return to Work Rehabilitation

Clare Evans

Fit Mind, Fit Body, Fit Fire Service?

22nd June 2005

RehabWorks Ltd

Fitness for Work and Life

aims of the talk
Aims of the talk
  • To explain bio-psycho-social model of rehabilitation
  • How rehabilitation works in the workplace
    • National response and current evidence based guidelines
    • Hierarchy of risk control:
      • Primary prevention
      • Secondary treatment
      • Tertiary intervention (rehabilitation)
  • Benefits through a case study
main messages
Main Messages

Bio-psycho-social Rehabilitation:

  • Is a generic problem solving process
  • Evidence based
  • Not physiotherapy
  • Not psychotherapy
  • Not rest

Biological

Psychological

Social

slide4

What is Rehabilitation?

  • New WHO model of disability/illness
  • Emphasises sickness is not due to one factor
      • Pathology
      • Impairment -> (limitation in) activity
      • Disability -> (restriction on) participation
  • An educational, problem-solving process that focuses on activity limitations and aims to optimise social participation
      • A move from the impairment to functional focus
      • Improve individuals capability to function normally and RTW
the cost of work related injury
The cost of work related injury
  • 14.4 million work days lost (2001)
  • Burden to state benefits – 90% of 3,500 new benefit awards per week are work-related injuries
  • Cost to Society in UK of work-related illness is £10bn (1995)
  • Cost of musculoskeletal alone £5.5bn (2000)
slide6

A Chronic Problem

6 months 50% chance of rtw

12 months 30% chance of rtw

24 months 10% chance of rtw

Once on IB for 6 – 12 months 90% remain on for at least 5 years

Long term absence accounts for 80% of the cost

the cost of work related injury7
The cost of work related injury
  • Burden to families – 500 people leave employment every week (never to return)
  • Many result in long term incapacity to work and personal injury claims
  • Significant impact on the social functioning and quality of life
why do people become chronic
Why do people become chronic?
  • Yellow, Blue and Black Flags
  • Medical management
  • Deconditioning Cycle
  • Activity, Participation
slide9

Yellow Flags

  • Pain intensity / functional disability
  • Poor perceptions of general health
  • Psychological distress
  • Depression
  • Fear avoidance
  • Catastrophising
  • Pain behaviour
slide10

Blue Flags

  • Job (dis)satisfaction
  • Duration of sickness absence / incapacity
  • Occupational status
  • (still employed / not)
  • Expectations about
  • return to work
slide11

Black Flags

  • Specific job characteristics
    • Demand/control
    • Time pressure
    • Management style
  • Rehabiltation and Retention policies
    • Facilitation of RTW & optimal function
what is the country doing about it
What is the country doing about it?
  • Department for Work and Pensions (DWP)
  • Securing Health Together (2001) – long term occupational health strategy
  • Regulators – Health and Safety Executive (HSE)
  • Evidence based guidelines for RTW Rehabilitation
    • CSAG 1994
    • RCGP 1996
    • FOM 2000
evidence based guidelines application in oh setting
Evidence Based Guidelines: Application in OH Setting
  • Primary Intervention
  • Secondary intervention / Acute
  • Tertiary intervention / Chronic
evidence based guidelines application in oh setting14
Evidence Based Guidelines: Application in OH Setting
  • Primary Intervention
    • Risk assessment andergonomics programme 
    • Targeted training
  • Secondary intervention / Acute
  • Tertiary intervention / Chronic
evidence based guidelines application in oh setting15
Evidence Based Guidelines: Application in OH Setting
  • Primary Intervention
    • Risk assessment andergonomics programme 
    • Targeted training
  • Secondary intervention / Acute
    • Case management and advice
    • OH Physiotherapy – (+ outcome measurement)
    • Effective in first 6-weeks of absence
  • Tertiary intervention / Chronic
evidence based guidelines application in oh setting16
Evidence Based Guidelines: Application in OH Setting
  • Primary Intervention
    • Risk assessment andergonomics programme 
    • Targeted training
  • Secondary Intervention / Acute
    • Case management by OHA and advice
    • OH physiotherapy – (+ outcome measurement)
    • Effective in first 6-8 weeks of absence
  • Tertiary Intervention / Chronic
    • Bio-psycho-social functional restoration for chronic disease
bio psycho social rehabilitation a problem solving process
Bio-psycho-social Rehabilitation:a problem-solving process
  • Assessment
    • identification and analysis of problems and barriers to RTW
  • Goal setting
  • Interventions should be:
    • Active and exercise based
    • In Group's
    • Educational and use a CBT approach
    • Work related and include work conditioning and hardening
    • Able to suggest and make ergonomic interventions
    • Encouraging lifestyle changes
    • Allow graduated RTW programmes
    • Spread over-time
  • Re-assessment (monitoring)
assessment
Assessment
  • Physical (Against work/life demands)
    • Strength, flexibility, mobility, functional strength, aerobic fitness, posture
slide19

Psychological

    • Stress,
    • Depression,
    • Anxiety,
    • Catastrophising
slide20

Psycho-social

    • Beliefs
    • Fear-avoidance
    • Social support
    • Pain management
    • Litigation
    • Compensation
slide21

Work factors

    • Relationships
    • Support
    • Control
    • Beliefs
    • History
    • Restricted duties
typical problems
Typical problems
  • Poor posture
  • Loss of flexibility
  • Weak trunk musculature
  • Poor aerobic fitness
  • Poor work posture/technique
  • Loss of confidence and low in mood
  • Fear of movement, activity and work
smart goal setting
SMART Goal Setting
  • Behaviours are actions primarily directed towards function
  • Goals are directed aims based on thoughts and behaviours
    • Own hopes, family wishes, consequences of (non)-achievement etc
  • Therefore necessary to establish:
    • Patient goals (achievable chunks)
    • Rehabilitation goals

(correlate to patient goals)

negative effect of bio medical model
Negative effect of Bio-Medical model
  • Beliefs there is broken part that can be fixed
  • Ongoing expensive investigations (False Positives)
  • Patient passivity, reduced motivation
  • Patient role instead of worker role
  • Ineffective therapies
  • Low level of activity
  • Increasing levels of distress
work interventions
Work Interventions
  • Rehab not light duties
  • Vehicle assessments
  • Workplace assessments
  • Job evaluations and modifications
  • Equipment evaluations
research results utility company
Research Results: Utility Company
  • 85 employees entered programme
  • All failed Physio and absent for longer than 8-12 weeks
    • 83 completed.
    • 81 returned to work on full duties
    • 2 returned to work on restricted duties.
    • 2 dropped out and did not return to work.
  • 58 were followed up at 12 months.
pain levels
Pain levels

Pain reduced during the programme from an average of 4 on a 0 – 10+ scale to 1.5

slide34

Oswestry Disability Index

ODI Perceived disability scores decreased immediately post programme from an average of 34% to an average of 14% (t=10.244, p<.000) and the difference between pre programme scores and scores twelve months later remained significant (t=7.130, p<.000).

acute pain screening questionnaire
Acute Pain Screening Questionnaire

General Psychological status (APSQ) improved pre & post programme (t=8.113, p<.000) and at twelve months (t=5.332, p<.000).

perceived work capability epic
Perceived Work Capability ( EPIC)

Perceived work capability improved immediately post programme, (t=-6.909, p<.000) and the difference between pre programme scores and twelve months later was still significant (t=-6.476, p<.000).

safe dynamic lifting capability
Safe Dynamic Lifting Capability

Lifting capability also improves by 30%(F=34.185, p<.000)

results indicate that
Results indicate that
  • The approach is having an immediate impact on psychological status, perceived disability and perceived capability
  • The effect remains for a twelve month period.
  • Repeated measures analysis on various strength and physical capability indicates that these results improve also
  • Return of more than 80% to full time work
  • Saving of £180K and cost of £60K
main messages39
Main messages
  • Organisations must:
    • Have robust health & safety procedures
    • Provide occupational health to workforce
    • Rehabilitate employees to work through evidence-based interventions
      • Early treatment intervention
      • Tertiary Rehabilitation
  • Vocational rehabilitation must
    • Involve all parties towards an agreed goal
    • Be a team activity crossing all boundaries
  • Rehabilitation
    • is a way of thinking
case history kevin age 39
Case history – Kevin age 39
  • Married and has 2 boys ages 9 and 7
  • Job – utilities worker 30% driving 70% walking, stooping, bending to clean/ sweep/ dig channels. Climbs ladders and lifts manhole covers up to 40kg
  • Liked walking, football, swimming
the back problem
The back problem
  • 1st injury 1995 - lifting at work -1 week off
  • 2nd injury 1996 - at home – 2 weeks off work
  • 3rd injury 1998 - hurt back at work no time off
  • 4th injury 2000 - 6 weeks off work and reporting pain and niggles all the time
  • 5th injury 2002 - 9 months off
treatment to date
Treatment to date
  • Osteopathy – helped relieve symptoms at first
  • Physiotherapy – gave exercises but they hurt so patient stopped – no real benefit
  • Referred back to GP for 2nd opinion
  • Waited 6 months for MRI scan
  • Mild disc bulge and wear and tear changes – surgery not indicated
  • 2 Epidurals and 3 facet joint blocks
the effect
The effect
  • Gave up sport in 1996 on advice of GP
  • Now can’t work
    • Can’t sit for very long
    • Can’t bend or lift
  • Can’t play football with boys or walk the dog
  • Wife fed up
  • Financial problems likely to occur at 12 months
  • No help to date from the Company
the effect cont
The effect (cont)
  • Consultant says nothing can be done – has to live with it
  • Feels very angry
  • Likely to make a claim
  • Sees only way out is to get ill health early retirement
what should companies do
What should companies do?
  • Early intervention
    • Screen for red flags
    • Must not medicalise the problem
    • Use Occupational Health Professionals
  • Keep control

Only 3% of all people with back pain have a serious problem and require a consultant input or MRI scan

oh management system
OH Management system
  • Medical management
    • OHA if in acute pain or symptoms last longer than 7 days
    • Timely reviews if no RTW
  • Physio / Rehab - Competent Practitioners
    • Liaison with company – work restrictions
  • Graduated RTW
    • Goals to increase activity week by week
    • Time limited
    • Personal risk assessment
what happened to kevin
What happened to Kevin?
  • Referred to the OHA and OHP
  • Recommended functional restoration programme in line with evidence based guidelines from faculty of occupational medicine
  • 10 week programme alongside graduated return to work at RehabWorks (cost £2500)
kevin s outcome
Pain reduced ( 7 to 2)

He can walk, bend, dig, sweep channels

He can sit for an hour

He can lift 45kg (was 25kg) with excellent technique

He is back at work on normal duties

Understands how to manage his problem

Play football with kids

Exercises 3 times a week to prevent recurrence

Says he is 200% better!

Kevin’s Outcome
and if we hadn t done anything
And if we hadn’t done anything?
  • Ongoing sickness – 17 months £25,200
  • Ill health retirement?
  • Claim against the organisation for Accident at work?
  • Further medical interventions?
slide52

Take home message

  • In a work context it may be helpful to consider Pain in the context of more general symptom management.
  • Chronic cases need to be assessed and treated in a holistic way using a Bio-Psycho-Social approach.
  • Need more research and access into bio-psycho-social rehabilitation programmes
slide53

Thank you for listening

and

Any questions?

Contact: clare@rehabworks.co.uk