Raymond Baril

Disability Prevention: New Paradigm for the Management of Occupational Back Pain

Occupational back pain is a widespread self-limited but recurring disease that generates major societal costs and impairs workplace productivity. However, this societal impact is mostly accounted for by a small fraction of patients with back pain who have prolonged absence from work, i.e. prolonged disability.Evidence from research from the past 2 decades has progressively shown that most efforts to prevent or cure the disease have limited results, explaining the expanding number of disability cases from back pain. However, recent evidence has also shed light on the causes of disability that are not only due to the patients’s personal characteristics (physical and psychosocial), but also stem from the patients’s environment in the disability problem — the workplace, the compensation system and even the healthcare delivery system.In addition, successful intervention studies have used an approach to disability prevention through patient reassurance and interventions linked to the workplace, instead of using a medical model of back pain treatment. It is evident that the present disease treatment paradigm should be replaced by a disability prevention paradigm for patients with subacute or chronic back pain to avoid unnecessary evolution towards prolonged disability.We propose a disability prevention management model to encourage clinicians, employers, unions and insurers, as well as researchers in the field, to work within the perspective of the disability paradigm.

Workplace Interventions for Workers with Musculoskeletal Disabilities: A Descriptive Review of Content

Background: Despite the convergence of scientific data to the effect that interventions in the workplace promote a healthy return to work, the interventions carried out in the real work environment appear to be very heterogeneous and ill-defined. Objective: The goal of this review is to identify the different objectives pursued through the workplace interventions carried out in the context of a rehabilitation program, and to describe the activities involved. Methods: A descriptive review of the literature, including various research designs, was carried out. Results: This review reveals great heterogeneity in the content of interventions offered in the workplace to workers with musculoskeletal disabilities. The objectives of workplace interventions may range from gathering information in order to reproduce work demands in a clinical setting, to gradually exposing workers to the demands of the real work environment, or permanently reducing the demands of the work situation. A descriptive analysis of the literature also brings to light the diversity of actions carried out, human resources used, and workplace environments involved, while highlighting the few documented process outcome evaluations that have been done of workplace interventions. Conclusion: It is recommended that in future research in this area, efforts be made to better describe the components of the interventions, to develop process outcomes representing the multidimensional results obtained in the workplace, and to differentiate between temporary and permanent modifications made to the work situation.

Margin of Manoeuvre Indicators in the Workplace During the Rehabilitation Process: A Qualitative Analysis

Introduction The task of evaluating workers’ capacity to return to their pre-injury employment or other jobs continues to pose a daily challenge for clinicians. In this study, a concept frequently used in the field of ergonomics, the margin of manoeuvre (MM), was applied during the rehabilitation process. The study identified the indicators of the MM taken into account during the return to work of workers with musculoskeletal disorders. Methods This study used a multiple-case design. A case was defined as a dyad comprising a worker admitted to a work rehabilitation program and the clinician who was managing the return-to-work process. The results were then validated with investigators and expert ergonomists, through group interviews. Content analyses were performed using the conceptual framework for the work activity model adapted from Vézina and the procedures recommended by Miles and Huberman. Results A total of 11 workers, five clinicians, two experts and two investigators participated in this study. The interview analysis process resulted in a more detailed definition of the MM and the identification of 50 indicators. The indicators were classified according to six dimensions: (1) work context; (2) employer’s requirements and expectations; (3) means and tools; (4) worker’s personal parameters; (5) work activity; and (6) impacts of the work situation. Conclusions The more specific indicators identified in this study will allow for more systematic observation of the MM. Subsequent studies will seek to link each indicator described in the model with a specific method of observation.

Early return to work of injured workers: multidimensional patterns of individual and organizational factors

Abstract The research reported here, part of a larger exploratory project about the factors that may play a role in the implementation of corporate return to work measures, characterized workers having suffered an occupational injury. These workers constitute the target population of a governmental policy designed to favour early return to work. The study population was composed of 13 728 cases of occupational injury. The characteristics of workers, characteristics of injuries and structural characteristics of companies in cases in which return to work measures were present were compared with these same characteristics in cases in which such measures were absent. Using correspondence and ascending hierarchical classification analyses, homogenous groups were identified. Bivariate analysis revealed that the following eight variables were associated with the presence of early return to work measures (i.e. the proportion of cases benefiting from early return to work measures was significantly higher than expected): nature of the injury (inflammation); site of injury (upper limbs and shoulder); CSST assessment category (=100%, i.e. large company); duration of absence (0–44 days and 183–365 days); gender (female); sector (rubber and plastics); relapse (present); and age (30–39 years). The presence or absence of return to work measures was a defining characteristic of five of the seven classes identified by multivariate analysis. The composition of these classes reflects the complex interaction between return to work measures on the one hand and the socio-demographic characteristics of workers, characteristics of injuries, and structural characteristics of companies on the other.

The values underlying team decision-making in work rehabilitation for musculoskeletal disorders.

Purpose. This paper presents the results of a qualitative study on the values underlying the decision-making process of an interdisciplinary team working in a work rehabilitation facility of a Québec teaching hospital. Methods. In order to document the values underlying the decision-making process, a single case observational study was conducted. Interdisciplinary team weekly discussions on ongoing cases of 22 workers absent from work due to musculoskeletal disorders were videotaped. All discourses were transcribed and analyzed following an inductive and iterative approach. The values identified were validated by feedback from team members. Results. Ten common decision values emerged from the data: (1) team unity and credibility, (2) collaboration with stakeholders, (3) workers internal motivation, (4) workers adherence to the program, (5) workers reactivation, (6) single message, (7) reassurance, (8) graded intervention, (9) pain management and (10) return to work as a therapy. The analysis of these values led to the design of a model describing interrelations between them. Conclusions. This study throws light on some mechanisms underlying the decisions made by the team and determining its action. This improves understanding of the actions taken by an interdisciplinary team in work rehabilitation and may facilitate knowledge transfer in the training of other teams.

A case of mistaken identity? The role of injury representations in chronic musculoskeletal pain.

Abstract Purpose: To explore how patients construe bodily injury, examine how injury representations change over the course of a rehabilitation program and how injury representations influence adaptation and recovery trajectories. Methods: A case study method was used with qualitative interviews as the primary data source. Qualitative semi-structured interviews were conducted three times over the course of a 12-week intensive interdisciplinary occupational rehabilitation program with one interview 1 month following discharge. To capture changes in rehabilitation trajectories, data analysis employed a narrative approach informed by Bury (progression, regression, and stability) and Frank’s (chaos, restitution, and quest) approaches. Results: Sixteen patients (10 men and 6 women) were disabled as a result of persistent pain and impairment from a variety of work injuries participated. Progression/restitution narratives were characterized by the transformation of bone and nerve problems to include soft tissue elements. These participants expanded their scope of injury representations and appraisal to include neurobiological aspects of chronic pain and dimensions of psychosocial well-being, and linked diagnostic representations to self-management strategies in a functional manner. Conclusion: Body representations of injury morphology and pain mechanisms are important objects of fear and acceptance for injury recovery. Active strategies that encourage a “hands on” understanding of diagnosis may prove most effective in treating persistent pain. Implications for Rehabilitation Patient representations of pain and body injury are windows into the personal experience of individuals with chronic musculoskeletal pain. When patients enter programs, practitioners need to assess what the patient believes is wrong with their body and what will be helpful in rectifying the problem. Based on their initial assessment, practitioners need to direct education and activity toward shifting patient beliefs to include elements of soft tissue and a broader scope of pain sensitization and psychological impact. Activity-based intervention is essential for creating coherence between injury and pain representations and coping action. During rehabilitation, practitioners need to monitor patient beliefs about their injury. Shifting beliefs are signs that the patient is adopting a more adaptive cognitive stance toward their injury. Lack of movement indicates that the message is not getting through and the approach needs to be modified. When working with patients to transform beliefs, a collaborative approach might be best to increase trust and reduce reactance.

Entrevue guidée avec Yvon Quéinnec

Nous vous proposons dans ce numero une entrevue avec l’ergonome Yvon Queinnec. Il a debute sa carriere dans les annees 60 dans le domaine la physiologie de l’insecte. Il etudiait alors l’influence de l’etat interne (notamment les cycles circadiens) sur le fonctionnement des systemes sensoriels. Petit a petit, il s’est interesse a l’homme et est arrive dans le champ de l’ergonomie, plus particulierement sur les themes du travail poste et du travail de nuit en y integrant l’etude de l’activite et des relations entre les membres des equipes de travail. La revue PISTES l’a rencontre en octobre 2001 tout juste avant qu’il ne parte a la retraite pour nous faire partager certaines de ses reflexions.