Jennifer Ashton

Early interventions to promote work participation in people with regional musculoskeletal pain: a systematic review and meta-analysis

Objectives: To determine the effectiveness of early multidisciplinary interventions in promoting work participation and reducing work absence in adults with regional musculoskeletal pain. Data sources: Seven databases (CENTRAL, CINAHL, EMBASE, MEDLINE, Scopus, OT Seeker, PEDro; 1990 to December 2016) were searched for eligible studies. Review methods: Trials were included if they reported on work-based outcomes for participants experiencing difficulties at work or ≤ three months’ sick leave. Interventions had to include two or more elements of the biopsychosocial model delivered as a coordinated programme. Quality was assessed using the GRADE criteria. Results were analysed by hazard ratios for return to work data; continuous outcomes were analysed as standardised mean difference with 95% confidence intervals. Results: A total of 20 randomized controlled trials, with 16,319 participants were included; the interventions were grouped according to their main components for meta-analyses. At 12-months follow-up, moderate quality evidence suggests that programmes involving a stepped care approach (four studies) were more effective than the comparisons in promoting return to work (hazard ratio (HR) 1.29 (95% confidence interval (CI) 1.03 to 1.61), p = 0.03), whereas case management (two studies) was not (HR 0.92 (95% CI 0.69 to 1.24), p = 0.59). Analyses suggested limited effectiveness in reducing sickness absences, in pain reduction or functional improvement across the intervention categories. Conclusion: There is uncertainty as to the effectiveness of early multicomponent interventions owing to the clinical heterogeneity and varying health and social insurance systems across the trials.

Advanced practice physiotherapy-led triage in Irish orthopaedic and rheumatology services: national data audit

BackgroundMany people with musculoskeletal (MSK) disorders wait several months or years for Consultant Doctor appointments, despite often not requiring medical or surgical interventions. To allow earlier patient access to orthopaedic and rheumatology services in Ireland, Advanced Practice Physiotherapists (APPs) were introduced at 16 major acute hospitals. This study performed the first national evaluation of APP triage services.MethodThroughout 2014, APPs (nu2009=u200922) entered clinical data on a national database. Analysis of these data using descriptive statistics determined patient wait times, Consultant Doctor involvement in clinical decisions, and patient clinical outcomes. Chi square tests were used to compare patient clinical outcomes across orthopaedic and rheumatology clinics. A pilot study at one site identified re-referral rates to orthopaedic/rheumatology services of patients managed by the APPs.ResultsIn one year, 13,981 new patients accessed specialist orthopaedic and rheumatology consultations via the APP. Median wait time for an appointment was 5.6xa0months. Patients most commonly presented with knee (23%), lower back (22%) and shoulder (15%) disorders. APPs made autonomous clinical decisions regarding patient management at 77% of appointments, and managed patient care pathways without onward referral to Consultant Doctors in more than 80% of cases. Other onward clinical pathways recommended by APPs were: physiotherapy referrals (42%); clinical investigations (29%); injections administered (4%); and surgical listing (2%). Of those managed by the APP, the pilot study identified that only 6.5% of patients were re-referred within one year.ConclusionThis national evaluation of APP services demonstrated that the majority of patients assessed by an APP did not require onward referral for a Consultant Doctor appointment. Therefore, patients gained earlier access to orthopaedic and rheumatology consultations in secondary care, with most patients conservatively managed.

Work Outcomes in Patients Who Stay at Work Despite Musculoskeletal Pain

Purpose To assess self-reported work impacts and associations between psychosocial risk factors and work impairment amongst workers seeking care for musculoskeletal pain while continuing to work. Methods Patients were recruited from Musculoskeletal Assessment Clinics at 5 hospitals across Ireland. Participants completed questionnaires including assessments of work impairment (Work Productivity and Activity Impairment Questionnaire), work ability (single item from the Work Ability Index) and work performance (Work Role Functioning Questionnaire; WRFQ). Logistic and hierarchical regressions were conducted to analyse the relation between psychosocial variables and work outcomes. Results 155 participants (53.5% female; mean ageu2009=u200946.50xa0years) who were working at the time of assessment completed the questionnaires. Absenteeism was low, yet 62.6% were classified as functioning poorly according to the WRFQ; 52.3% reported having poor work ability. Logistic regression analyses indicated that higher work role functioning was associated with higher pain self-efficacy (OR 1.51); better work ability was associated with older age (OR 1.063) and lower functional restriction (OR 0.93); greater absenteeism was associated with lower pain self-efficacy (OR 0.65) and poorer work expectancy (OR 1.18). Multiple regression analysis indicated that greater presenteeism was associated with higher pain intensity (βu2009=u20090.259) and lower pain self-efficacy (βu2009=u2009−u20090.385). Conclusions While individuals continue to work with musculoskeletal pain, their work performance can be adversely affected. Interventions that target mutable factors, such as pain self-efficacy, may help reduce the likelihood of work impairment.

THU0550 Early Multidisciplinary Interventions To Promote Work Participation in People with Regional Musculoskeletal Pain: A Systematic Review

Background Musculoskeletal disorders are amongst the leading causes of disability in the working age population. Whilst there is a growing body of evidence suggesting that early targeted multidisciplinary interventions can promote work retention and prevent disability, the evidence is far from conclusive as to which interventions are the most effective. Objectives To review randomised controlled trials evaluating the effectiveness of early interventions in promoting work participation in adults with regional musculoskeletal pain (RMSKP). Methods CENTRAL, MEDLINE, EMBASE, Scopus, PEDro and OT Seeker (1990 to April 2015) were searched. Reference lists of identified articles and reviews were hand searched. Only RCTs reporting on work-related outcomes were eligible for inclusion. The intervention had to include two or more elements of the biopsychosocial model delivered as an integrated programme. Participants were either experiencing difficulties at work or had less than three months sick leave as a result of their RMSKP at enrolment. Each RCT was assessed independently by two reviewers for risk of bias. Results were analysed by hazard ratios for return to work data, while continuous outcomes were analysed as mean difference (MD) with 95% confidence intervals. Results 19 RCTS were included; the considerable variation in the components employed in the interventions limited the option to pool the data statistically using meta-analysis. There was some evidence that programmes involving a stepped care approach (4 studies) increased the probability of return to work at the 12-month follow-up [HR 1.29 (95% CI, 1.03 to 1.61), p=0.03]. However, preliminary analyses indicate a lack of consistent evidence for effects on reducing sickness absences, pain reduction and functional improvement across the intervention types. Conclusions The lack of agreement as to what constitutes “early” in the context of treating RMSKP may have contributed to the rather ambiguous findings. In addition, the different health and social insurance systems across the trials have made it difficult to generalise the results. There remains a need to establish the active components that promote work retention in this population, and to identify the patients who are most likely to benefit from an integrated and cost-effective intervention. Disclosure of Interest None declared

THU0625 Healthcare Professionals' Perspectives on The Design and Implementation of An Early Integrated Care Intervention for Musculoskeletal Pain in The Irish Healthcare Setting: A Qualitative Study

Background Musculoskeletal disorders are amongst the leading causes of disability in the working age population. Growing evidence suggests early screening and targeted interventions during the acute phase can promote work retention and prevent disability. Objectives This study aims to develop and feasibility test an early, case manager-led intervention focusing on work as a clinical outcome. Here we report qualitative findings from focus groups and interviews conducted to consider issues of content, delivery and optimal timing, and to explore key priorities and potential challenges in service delivery. Methods Two focus groups and three individual interviews were conducted, involving 17 experts representing the multidisciplinary team. Thematic analysis was used to summarise the views and ideas expressed. Results Participants highlighted the importance of early access to diagnosis, relevant investigations and referral to specialists as necessary in reducing the risk of long term disability; noting the critical importance of GPs in facilitating early access. The need to provide reassurance and education about the patients condition was highlighted, as was the importance of screening for psychosocial risk factors. Patients most likely to benefit from the intervention were identified as those highly motivated to maintain their current work roles. Ready access to the MDT and the skill set of the case manager were noted as critical concerns, resource constraints pose considerable challenges. Conclusions Introduction of an early integrated care intervention that targets risk of work disability is warranted. Considerable “buy-in” is required from all stakeholders involved. The data will help to inform the planned feasibility study. Acknowledgement We would like to thank all of the individuals who participated in the interviews and focus groups. Disclosure of Interest None declared