Return to work strategies to prevent disability from musculoskeletal disorders

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Esa-Pekka Takala and Kari-Pekka Martimo, Finnish Institute of Occupational Health

Introduction

Musculoskeletal disorders (MSDs) are one of the most common causes of disability, sick leave and early retirement. The natural course of MSDs varies over time and no single medical treatment has been shown to be very effective. A holistic bio-psycho-social view seems to be the best approach to achieve effective management and prevention of disability caused by chronic disorders. In order that return to work (RTW) is successful, one needs to have co-operation between the affected worker, workplace, health care providers, and the social security system.

Nature of return to work problem

Musculoskeletal disorders (MSDs) are common in workers. They can be responsible for sick leave and early retirement. Most MSDs evoke symptoms like pain only in situations when there is some physical workload. Therefore, it is often possible to work at a lower intensity and for shorter periods without worsening the basic health condition causing the MSDs. Research has shown that maintaining the daily activities after acute low back pain will result in better healing than bed rest[1][2]. The guidelines for neck pain[3] and osteoarthritis[4] also stress the maintenance of activities to achieve relief.

Course of musculoskeletal disorders in relation to work

The course of musculoskeletal disorders (MSDs) is usually periodic; acute conditions heal within some days or weeks but can appear again after several months or years. The MSDs due to chronic diseases like rheumatoid arthritis or osteoarthritis also have a course with worse and better periods.

In the acute phase of MSDs, it is important to rest and to avoid activities that aggravate symptoms. This is necessary for healing and recovery. However, if the physical loading is reduced for a longer period, the body will adapt by becoming weaker. Thus, even after a few weeks of bed rest or splinting in plaster, the musculoskeletal system will be less resistant to the usual loading. Therefore the return to ordinary work after a prolonged period of passive sick leave can lead to an increased risk for the recurrence of symptoms. Active physical training is necessary to recondition the reduced performance capacity in order to achieve full recovery.

Timing of preventive actions

The risk of most musculoskeletal disorders increases with age, which probably reflects the fact that they are often related to the degeneration of the human body with age. Physical loading with mechanical stress is one of the most clearest causes of work-related musculoskeletal disorders. If one takes into the account that we spend less than 25% of daily hours at work during our working years and similar loadings occur in many leisure activities, primary prevention of all MSDs seems to be an unrealistic goal. Therefore, in addition to attempts at primary prevention of MSDs at work, activities are needed to prevent the consequences of musculoskeletal disorders (secondary and tertiary prevention); in other words, to help workers remain active while recovering from an acute MSD, and to continue working despite having a chronic condition. Research and experiences from working life have highlighted the importance of early prevention.

The longer the absence from work, the less likelihood there is of a successful return to work[5]. This means that prevention of consequences due to MSDs should be started promptly. Most acute cases of low back pain and other MSDs recover within a few weeks. Unfortunately during these first few weeks there are no means to pinpoint those subjects who have an increased risk to suffer a prolonged or chronic disability. It is generally accepted that the rehabilitative actions should start within the first month after the disabling disorder.

Dozens of studies have shown that previous musculoskeletal disorders are the best predictor for future incidents. This means that probably there are conditions in the individual worker that makes him/her more vulnerable, or the working conditions increase the risk for MSDs. Thus if a worker has experienced several episodes or sick leaves due to MSDs, the rehabilitation needs to be started earlier after a new episode. Musculoskeletal disorders will reduce work productivity even before sick leave is necessary. If the productivity is reduced due to symptoms, early recognition and interventions, can prevent them from becoming more severe [6].

Multidisciplinary approach

Systematic research into the treatment of common low back pain has indicated that no single medical intervention is any more effective than just continuing with routine daily activities. The traditional approach focusing on the biomedical condition and treatment modalities has shown to be ineffective, and a holistic view is needed to explain chronic musculoskeletal pain, especially its consequences. The bio-psycho-social model explains that in addition to the biological or pathological conditions, personal psychological factors influence the experience of pain and the behaviour related to pain, and this is further related to the cultural and societal environment of the person[7]. The traditional way to classify occupational diseases according to the biomedical pathology seems to be insufficient. A more suitable approach is probably to use the International Classification of Functioning, Disability and Health (ICF) recommended by the World Health Organization[8].

Societal factors

National legislation and the social security system as well as contracts of employment can either provide opportunities or place constrains to the return to work (RTW) actions and strategies. The implementation of actions require financial resources that are available in different extends in different countries (e.g. the burden of costs due to sick leave and pensions can be divided in different ways between the enterprise and the society). This may direct the different actors to optimize their means on a manner that reduces the whole system to manage RTW on the optimal way [9].

The role of occupational health professionals may vary according to the compensation policy and the definition of occupational diseases. If the physician has to act as the gate-keeper of benefits, the focus may be on emphasising the disability in order to obtain benefits. This approach will reduce the disabled workers motivation to seek rehabilitation. The occupational health providers can better focus on rehabilitative actions if the employer has a broader responsibility for the working conditions so that the workers can continue at work – even with some disability (e.g. in the Netherlands). In some countries, it is possible to continue work (partially) instead of being totally absent[10]. This emphasises the abilities of the worker instead of the disability. The fit note -policy in UK has similar aims [11].

What is needed for successful return to work?

The complex system of working life means that good experiences about one type of return to work (RTW) cannot be directly adopted into a different social and economic environment. Therefore examples of good practice need to be tailored to the local social environment of the workplace, branch of industry, occupational health and safety system, and national legislation. The Canadian Institute for Work and Health has conducted systematic reviews of scientific research and identified the following seven basic principles for successful return to work[12].

Strong commitment to health and safety

The workplace should have a strong commitment to health and safety which is demonstrated by the behaviours of the workplace parties.

  • Top management has the main responsibility for the company policy and should provide sufficient resources to fulfil this policy
  • The policy and procedures should be visible in the practical activities going on in the workplace
  • Commitment to safety issues should be the accepted norm throughout the whole company.

Modified work

The employer shall make an offer of modified work (also known as work accommodation) to injured/ill workers so they can return early and safely to work activities suitable to their abilities.

  • Modified work shall be prepared and handled with caution to avoid any conflict between the worker's abilities and skills. A poor fit can terminate the whole return to work process. In the ideal situation, the worker returns to his/her own work area where s/he knows the environment, people and practices.

Equal support to all in the workplace

Return to work (RTW) planners shall ensure that the plan supports the returning worker without disadvantaging co-workers and supervisors.

Modification of one worker's tasks often results in changes in the manners of the whole working unit. Avoiding of high physical loading of the disabled person may increase the loading of other workers and result in conflict. If the supervisor has the responsibility to adhere to the productivity requirements of the whole unit as usual, a disabled worker with reduced productivity means that the workmates have to work harder. To be successful, the company policy should allow for a reduction of standard productivity requirements during the return to work period.

Training of supervisors

Supervisors shall be trained in work disability prevention and they need to be included in return to work (RTW) planning.

  • Supervisors are faced with the potential practical problems in RTW practice. If they are left out of disability prevention and planning of RTW, there is a major risk for failure. Educating managers and supervisors in safety training or participatory ergonomics has been found to help in successful return to work strategies.

Early contacts initiated by employer

The employer shall make an early and considerate contact with injured/ill workers.

  • The supervisor's contact to the worker on sick leave can provide the worker with a positive message that the workplace is concerned with his/her well-being. Such a message improves the motivation for recovery and RTW. The relationship between the worker and other individual in the workplace will strongly influence the way that the worker perceives the contact from the foreman: If the relations are good, the contact will probably encourage a return to work. If the relations are poor and the foreman stresses the economic losses being suffered by the company due the worker's sick leave in order to press for RTW, the effect may be the very opposite.

Good coordination of the return

Someone has to take the responsibility to coordinate the return to work.

  • Successful return to work requires co-operation of several actors: individual worker, workplace, occupational health and safety, and social security system. Planning and coordination of the process requires an awareness of the available means and possibilities. The coordinator needs to ensure that the necessary communication does not break down and that the worker and the other RTW players understand what to expect and what is expected of them. In practice, the coordinator can be an individual in the company's human resources sector, in the occupational health services, or in the insurance company.

Good co-operation between employers, health care and the worker

Employers and health care providers shall communicate with each other about the workplace demands as needed, and with the worker’s consent.

  • In the workplace, the foremen and management need to be aware that the work will not cause health hazards for a person returning to work after sick leave. Furthermore, the health providers need to know the specific working conditions while estimating the necessary duration for sick leave. The working conditions can vary enormously within many sectors of industry such that the job title tells quite little about the actual working conditions. The disabled worker usually knows only his/her local conditions but not the opportunities for modification of the working environment, organization, and tasks.
  • It has been shown that the good contact between the workplace and health care providers can reduce the duration of work disability. There are different ways of contact, e.g. written or telephone communications, workplace visits and mini-conferences. The disabled worker should be aware of the communication between the workplace and health care, and s/he should be able to participate, if necessary.

Actors for effective return to work

There are several actors in the field to support the disabled workers to return to work. Their role may vary case by case but all the following partners will need to be considered while planning successful strategies for return to work (RTW).

Individual worker

The individual worker with MSDs has to have sufficient physical and mental capabilities to work as usual or in the modified tasks. In addition, motivation is needed to actively improve his/her functional capacity and to learn new skills needed to do the modified work. Personal values strongly influence the motivation. If the work is felt to be boring and stressful with poor a salary, the worker may prefer to remain absent, even with low social security compensation. Participatory return to work programmes are considered more effective [13]. Employees in Finland seeking medical advice at occupational health services due to MSDs considered themselves more often partially able than totally unable to work[14]

Workplace

The workplace has to be ready to improve the working conditions and to modify the disabled worker's job for the time needed to achieve full recovery, even for longer periods if the disability is permanent. The key persons are managers, and the human resources (HR) department should plan the general policy and return to work processes within the company. Co-workers and workmates should be motivated to support the disabled worker and informed of the modifications that will be needed. Often the needed modifications can influence the co-workers tasks. By involving co-workers in the planning of modifications, the chances for success will improve and potential conflicts can be avoided.

Occupational health services and occupational safety

Occupational health personnel need to know the medical conditions and best practice for treatment and rehabilitation of MSDs. They should also be aware sufficiently of the working conditions as well as physical and mental requirement of the disabled person's work in order to assess the potential limitations for the worker to RTW. To achieve this goal, close communication with the workplace is needed. Often the worker with a musculoskeletal disorder will require services of the general health care and rehabilitation providers. The professionals in occupational health care has to know the available services and facilities to help the disabled person in order to find the best ways to access the necessary services. Good communication between these services and occupational health is a prerequisite in order to obtain necessary information back to the occupational health and to gather a holistic view of the worker's health condition.

The occupational safety personnel of the company shall also be included into the return to work strategies. MSDs may start after minor accidents. The so called "near" accident situations may expose the musculoskeletal system to biomechanical forces that can cause microscopic injuries within the body, even though no visible accident can be recognized. A common example is low back pain that appears on the following day after a loss of balance though not accompanied by a fall while lifting or carrying heavy objects.

A disabled person is usually more vulnerable for accidents due to reduced functional capacity. Common occupational hazards for MSDs that are not a probable for healthy workers may cause fatigue in disabled workers, resulting to uncontrolled movements and accidents.

In the return-to-work phase, the safety action limits should be set at a lower level for work actions including heavy muscular efforts (e.g. manual material handling), repetitive manual work, constrained postures, or prolonged static postures without sufficient recovery.

Social security and insurance companies

Social security and insurance companies provide financial compensation and resources for medical care and rehabilitation. Many insurance companies also have developed their own systems to limit the economic burden of full compensation due to permanent work disability. They may help the workplace with investments to undertake necessary job modifications or to compensate for the vocational training for a new job. If there is a long waiting list for the required treatment or rehabilitation in the public sector, the insurance companies may purchase these facilities from the private sector in order to hasten the return to work.

Action program for return to work and prevention of disability due musculoskeletal disorders

The workplace has the main role to help the disabled worker to return to work. There is a considerable amount of systematic research and practical experience revealing that interventions conducted by the workplace can enhance successful return to work (RTW). Systematic research has also shown that some means are probably ineffective[15][16][17][18].

The following list of components for actions is a summary based on research and expert opinions although the action program as a whole has not been tested in a scientific manner.

Ergonomics and training of working skills

Ergonomics means optimisation of working methods, environment, and/or tools according to the requirements of the worker. In addition, the organisation of work can be optimised with respect to the quantity and its contents as well as the work/rest schedules. In the case of return to work (RTW) this means adaptation of work to the capabilities of the disabled worker. Special adaptation e.g. with working schedules can be done for a limited period until the full recovery is achieved.

Sometimes the workers have adopted "poor" working habits which means that they are exposed to greater loads than skilled workers. Therefore training of good skills can help them to avoid this problem. However, simply training of working methods without technical and organisational ergonomic adaptations seems to be insufficient to prevent low back pain related to manual handling of heavy loads[19].

Good ergonomic solutions and training can improve the productivity of most workers, not only those returning to work after sick leave. During the early phase of return to work (within two months after the start of the sick leave) many low-cost solutions at workplace are probably the most effective[18]. Good ergonomics will probably prevent MSDs and no unexpected side effects for health have been shown[15].

Prevention of accidents

In the return to work (RTW) phase, the worker may have a reduced physical performance that makes him/her more vulnerable to suffer accidents, e.g. in the manual handling of heavy loads. RTW is a good time point to check the general safety in the workplace in addition to that related to the disabled worker. It is noteworthy that often the MSDs have their origin in accidents and therefore accident prevention can obviously be viewed as good prevention of MSDs.

Maintenance of general health and especially the functioning of the musculoskeletal system

Unhealthy lifestyles like smoking and overweight have been associated with MSDs. Restoring the function with exercises of gradually increasing activity has been shown to be effective in the rehabilitation of chronic disorders in back, neck, and joints[1][2][3](NICE, 2008).

The workplace has high potential in promotion of healthy lifestyle. The company can organise and support services like possibility for healthy meals, physical training, or help in decision to cessation of smoking or control for overweight.

Improvement of health care and rehabilitation practices; adequate medical treatment

Occupational health care providers shall adopt the "good practice guidelines" based on current medical research[1][2][3](NICE, 2008). Systems of "red and yellow flags" have been introduced into the guidelines to indicate the most important biomedical and psychosocial factors that may cause problems in recovery. The providers should also identify their processes of medical diagnosis and treatment of MSDs in order to improve the quality of their practice. For example, adequate medical treatment of acute pain that prevents sleep is necessary in the prevention of chronic pain.

Supporting workers with musculoskeletal problems

In addition to good ergonomics, the workers with MSDs can be supported by reducing their workload with modified tasks and working hours. Part-time working has been financially supported through the social security system in many EU countries[10].

Education of employers, workers, and the society about the topics related to musculoskeletal disorders

Attitudes like "you have to rest if you have back pain", "you have to stop activities if any pain appears", "working is hazardous to your health if you have pain", "you can go back to work only if you are totally fit" are common in the general public. Current research has shown these beliefs to be false. Thus correct information and awareness -campaigns are needed to remove several misconceptions about return to work. All the partners needed for successful return to work also need practical information on how to manage returning in local situations.

References

  1. 1.0 1.1 1.2 Burton, A., Balagué, F., Cardon, G., Eriksen, H., Henrotin, Y., Lahad, A., Leclerc, A., Müller, G., van der Beek, A. European guidelines for prevention in low back pain, 2004. Available at: [1]
  2. 2.0 2.1 2.2 COST B13, 'European Guidelines for the management of low back pain', Eur Spine J 15 (suppl): 131–300, 2006.
  3. 3.0 3.1 3.2 Binder, A.I., 'Neck pain', Clin Evid (Online), 2008. Available at: [2]
  4. NHS – National Institute for Health and Clinical Excellence, Osteoarthritis – Osteoarthritis: Care and management in adults. NICE clinical guideline 177, National Institute for Health and Clinical Excellence, 2014. Available at: [3]
  5. Pengel, L.H., Herbert, R.D., Maher, C.G., Refshauge, K.M., 'Acute low back pain: systematic review of its prognosis', Bmj; 327: 323, 2003.
  6. Martimo, K.P., Shiri, R., Miranda, H., Ketola, R., Varonen, H., Viikari-Juntura, E., 'Self-reported productivity loss among workers with upper extremity disorders', Scand J Work Environ Health; 35: 301-8, 2009.
  7. Loisel, P., Buchbinder, R., Hazard, R., Keller, R., Scheel, I., van Tulder, M., Webster, B., 'Prevention of work disability due to musculoskeletal disorders: the challenge of implementing evidence', J Occup Rehabil; 15: 507-24, 2005.
  8. WHO – World Health Organization, International Classification of Functioning, Disability and Health (ICF), 2001. Available at: [4]
  9. OECD - Organisation for Economic Co-operation and development. Sickness, Disablitty and work: Breaking the barriers. 2010.
  10. 10.0 10.1 Kausto, J., Miranda, H., Martimo, K.P., Viikari-Juntura, E., 'Partial sick leave--review of its use, effects and feasibility in the Nordic countries', Scand J Work Environ Health; 34: 239-49, 2008.
  11. NHS – What are fit notes? Retrieved 4 March 2015 from [5]
  12. Institute for Work & Health – Seven ‘principles’ for successful return to work, Institute for Work & Health, 2007. Available at: [6]
  13. Vermeulen, S., Heymans, M., Anema, J., Schellart, A., van Mechelen, W., van der Beek, A., 'Economic evaluation of a participatory return-to-work intervention for temporary agency and unemployed workers sick-listed due to musculoskeletal disorders', Scand J Work Environ Health. 2013, 39(1), pp. 46–56, doi:10.5271/sjweh.3314
  14. Martimo, K.P., Varonen, H., Husman, K., Viikari-Juntura, E., 'Factors associated with self-assessed work ability', Occup Med (Lond); 57: 380-2, 2007.
  15. 15.0 15.1 EU-OSHA – European Agency for Safety and Health at Work, Report – Work-related musculoskeletal disorders: Back to work, 2007. Available at: [7]
  16. EU-OSHA – European Agency for Safety and Health at Work, Report – Work-related musculoskeletal disorders: prevention report, 2008. Available at: [8]
  17. Palmer, K.T., Harris, E.C., Linaker, C., Barker, M., Lawrence, W., Cooper, C., Coggon, D., 'Effectiveness of community- and workplace-based interventions to manage musculoskeletal-related sickness absence and job loss – a systematic review', Rheumatology (Oxford). 2012 Feb;51(2):230-42. doi: 10.1093/rheumatology/ker086
  18. 18.0 18.1 van Duijn, M., Eijkemans, M.J., Koes, B.W., Koopmanschap, M.A., Burton, K.A., Burdorf, A., 'The effects of timing on the cost-effectiveness of interventions for workers on sick leave due to low back pain', Occupational and Environmental Medicine; 67: 744-50, 2010
  19. Martimo, K.P., Verbeek, J., Karppinen, J., Furlan, A.D., Takala, E.P., Kuijer, P.P., Jauhiainen, M., Viikari-Juntura, E., 'Effect of training and lifting equipment for preventing back pain in lifting and handling: systematic review', Bmj; 336: 429-31, 2008.


Links for further reading

EU-OSHA – European Agency for Safety and Health at Work (no publishing date available). Musculoskeletal disorders. Retrieved on 29 June 2015, from: [9]

EU-OSHA - European Agency for Safety and Health and Work, OSH in figures: Work-related musculoskeletal disorders in the EU - Facts and figures, Publications Office of the European Union, Luxembourg, 2010, pp. 179. Available at: [10]

EU-OSHA - European Agency for Safety and Health and Work, Work-related musculoskeletal disorders: prevention report, Publications Office of the European Union, Luxembourg, 2008, pp. 106 Available at: [11]

EU-OSHA - European Agency for Safety and Health at Work, Work-related musculoskeletal disorders: Back to work report, Publications Office of the European Union, Luxembourg, 2007, pp. 100. Available at: [12]


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