Return to Work: The Perspective of Health Care Professionals, Insurers and Other Stakeholders

Recommendations for effective interventions

The following evidence-based recommendations outline interventions for target users and goals to meet to ensure a healthy and sustainable RTW for workers with MSDs and CMDs.

• Encourage interventions that include at least one component (Figure 7) in the workplace.
• Encourage the combination of several intervention components from at least two of these domains: health, service coordination, and work modifications;
• Promote multidisciplinary/interdisciplinary intervention (or program) for situations in which the worker’s absence is prolonged.

Note: The optimal combination of clinical (treatment) and non-clinical components or interventions in a program or intervention is unknown.

The recommendations aim to support you constructively in a healthy and sustainable RTW process. The recommendations highlight the knowledge (principles, essential activities, approaches) and the interventions/actions to be carried out by the actors involved that will allow for a significant improvement in your practice, i.e., the achievement of optimal practices.

Roles and responsibilities of the actors involved

The actors are specified according to the context and resources of the organization (size of the company, unionization, sector of activity, geographical location, etc.). Depending on these contextual elements, the organization may call upon internal resources or, by default, external resources (professionals, OHS consulting firms).

The roles and responsibilities of the actors specified below must be defined by the organization according to its context and resources. A role is a function of one or more individuals within the framework of a specific objective, related to the organization’s mission. The best known example is the distribution of work among team members in order to achieve productivity and quality objectives. A responsibility is one or more tasks expected and possibly measured by organizational indicators, related to a specific role assigned to an individual in the performance of his/her duties in an organization. Conducting accident investigations is an example of a responsibility.

Individual RTW approach adapted to the organizational context

Actions to be carried out in the workplace by all the actors involved, including the worker

An action is a concrete fact carried out individually or in interaction with other actors. In order to help you understand the worker’s situation in relation to your company’s needs, we suggest actions that can be carried out at each stage of the return-to-work process.

To date, in Québec, the RTW process for workers with a MSD or CMD is conceptualized in six stages (Durand et al., 2014):

• Time off and recovery period;
• Initial contact with the worker by the workplace;
• Evaluation of the worker (abilitys) and his job (demands);
• Development of the RTW plan with accommodations;
• Work resumption (day 1);
• Follow-up of the RTW (in the following weeks).

This approach emphasizes the importance of evaluating the worker in relation to his or her work situation even before the implementation of workplace accommodations.

Some stages may be iterative. For example, evaluations or selections of workplace accommodations can be repeated until the desired balance is achieved. Thus, healthy and sustainable RTW is conceived as the result of a dynamic process in which the actors communicate with each other regularly.

Actions or adjustments at work must be initiated promptly and without delay as soon as the worker is taken into care. However, they must be carried out with discernment. It is important to act at the “right time”, i.e. when the positive effects on the worker’s health outweigh the negative effects encountered. This requires taking into account all the elements of the context (biological, psychological and social), including the work environment (its problems, needs and available resources).

Although these tables are presented by category of actor, it is essential to look at the actions of other actors in order to promote collaboration and cooperation, which are fundamental to a healthy and sustainable RTW. Here are the steps in this process in which the main categories of actors are involved, although some more specific actors may sometimes be involved in other steps, as described in the tables (information adapted from Durand et al., 2014).

Evaluation of the worker

Introduction and objectives

Those involved in the rehabilitation process for workers who have suffered an occupational injury must have a good knowledge and understanding of the organizational factors (related to the work environment), personal factors and health factors (specific to the workers) that positively/negatively influence the duration of the absence or the return to work (RTW). This is an important step in the evaluation process in a rehabilitation context. After presenting and defining these factors, valid and practical measurement tools (questions, questionnaires) to measure them are proposed. However, since the evaluation of these factors is reserved for qualified professionals (clinicians, ergonomists), the other RTW stakeholders can only take note of them, with the exception of one which can and must be evaluated by the organization’s stakeholders. This is the Workplace Organizational Policies and Practices questionnaire. These tools are emerging from the scientific literature as having predictive value for RTW following a musculoskeletal disorder (MSD) or a common mental disorder (CMD). In this way, they can provide additional information when certain factors that positively/negatively influence the outcome seem to require special attention or further evaluation. At the end of this detailed evaluation, the results and items of the measurement tools can already allow targeting certain elements or more specific needs that would require a possible intervention.

General objective of this section

Know and measure the organizational, personal and health factors that can be modified by an intervention related to RTW .

Specific objectives of this section

• Provide RTW stakeholders with an overview of factors that positively/negatively influence RTW or duration of absence that have been studied to date in relation to MSDs and CMDs.
• Define the positive/negative influencing factors to be used;
• Identify and describe measurement tools to assess them.
• Indicate how to use them.

Elements of methodology and interpretation of information

Factors that positively/negatively influence the duration of absence or return to work

A review of prospective (longitudinal) studies examining the association between possible modifiable factors of duration of absence as well as RTW was necessary to first screen and then classify the factors considering the following terminology:

• The underlying health condition (MSD CMD);
• Type of factor:
  • personnal: evaluation focused on the worker;
  • organizational: organization-oriented evaluation;
  • of health: worker and organization oriented evaluation.
• The level of scientific evidence for factors that positively/negatively influence RTW or duration of absence

Measurement tools

The literature search used to identify the factors that positively/negatively influence RTW or absence duration allowed us to identify the tools that have a predictive value for absence duration and RTW. With a few exceptions, each tool has been the subject of an information sheet allowing the scientific value and applicability of the measurement tool to the user context to be judged. The members of the scientific committee of this website then made a pre-selection of the tools on the basis of scientific and usability criteria, approved by the scientific and monitoring committees (social partners), as presented in the table below.

Where possible, three tools [1-star (☆), 2-star (☆☆), or 3-star (☆☆)] are recommended for each factor, following the criteria below to associate an overall value (Table 3-1). This rating should be viewed as a trade-off between scientific and practical value to stakeholders.

This way of doing things has the advantage of not being based on a value judgment (from the most important to the least important) between scientific or practical criteria, because they are based on the needs of the users. Each tool is accompanied by an information sheet to help you choose the right tool for your needs and constraints.

Overall value assigned to measurement tools (☆☆☆, ☆☆, ☆) taking into account scientific and practical considerations.

Factors that positively/negatively influence RTW or duration of absence

Approach to be implemented

It is recommended that the following steps be taken to properly use this information:

• During the interview with the worker, conduct the interview by considering the various factors in order to make a preliminary note of the elements that seem problematic. Also emphasize to the worker the elements that positively influence the duration of the absence or the RTW.
• Factors that you feel are problematic can then be discussed in more depth with the worker. For some, you may find that you need additional information to ensure that they are present. If this is the case and you are qualified to do so, use the recommended tools to identify more specific items that could be targeted for intervention. Tools with a higher overall value (number of stars) will guide you more specifically in your interview with the worker.

Caveats and limitations

Caveats – Factors that positively/negatively influence duration of absence or RTW

The information provided here should be seen primarily as a guide to inform RTW stakeholders about the elements that can impede RTW as well as the elements that can promote RTW. It is a companion tool to facilitate communication with workers and other RTW stakeholders.

Adding up the factors to establish a severity score for the worker’s disability situation should be avoided for the following reasons: the weight or influence of the different factors is not known, nor is the interaction between these different factors. In addition, some factors that positively influence the results may counterbalance the impact of some factors that negatively influence these results.

The presence of organizational factors negatively influencing RTW should ideally be accompanied by an in-depth assessment of the work context and a workplace visit, both carried out by a qualified practitioner (e.g., ergonomist, occupational therapist, rehabilitation counsellor). As an intervener, it is important to use your judgment of the overall picture of the worker and, above all, to contextualize this picture in terms of the worker’s universe and the organization. Assessment and intervention is an art in itself.

Being aware of personal factors certainly provides a more complete picture of the worker’s situation, but must be treated with vigilance, since the spheres of work and personal life are not always watertight.

Cautions – Measuring Tools

Factors that positively/negatively influence the duration of absence or RTW can only be assessed by accredited professionals, which implies costs for the organization, if any. This information is provided in the description of the tools that allow for their measurement.

It is important to remember that self-administration or administration of a questionnaire by an unqualified person can lead to undesirable consequences such as the calculation of erroneous scores and the misinterpretation of results that may result.

When using a measurement tool with an employee or a client, we would like to specify that the philosophy of this platform’s team is, above all, to investigate certain factors in greater detail, depending on the type of absence of the worker (MSD, CMD). However, in the end, the results of these measurement tools will be used to better understand the worker and to establish a dialogue with the latter, rather than to establish thresholds that would allow the practitioner to categorize the person being evaluated. The team therefore advocates a philosophy of dialogue with the worker concerned in order to better accompany or counsel him or her.

Limitations – Factors that positively/negatively influence RTW or duration of absence

Only personal, organizational and health-related factors that predict the duration of absence or RTW are considered. Factors related to other outcome measures, such as productivity, presenteeism or work status (partial return, full return, job retention) are therefore not identified. This is also the case for factors predictive of symptoms or illnesses, which may explain why several factors that may be thought to be involved are not included here, but rather in studies or reviews on primary prevention.

The available sources also did not allow for the identification of environmental factors outside the workplace, such as factors at the societal level or at the level of the health care system, the insurance system and the community. Studies on these other factors are much less numerous, which explains this choice. The ecological model of work disability provides a good understanding of the universe in which factors can be identified.

Limitations – Measurement Tools

The same factor is often defined/operationalized differently by different authors. In addition, each tool captures only part of the “complete” definition of each factor. As a result, the use of more than one tool is sometimes necessary to get close to a complete assessment of a factor (e.g., using two questionnaires to measure perceived barriers during RTW). Finally, it should be noted that the qualities of the same tool may vary according to the language and the target population.

The assessment of each of the factors involves different types of tools that have several psychometric properties. These psychometric qualities or properties allow us to make recommendations about whether or not to use the tool. This is often a difficult exercise, as each tool has strengths and limitations. Whenever possible, we recommend one or more tools to assess a factor, based on scientific criteria and applicability in the user context. This trade-off is not always easy to determine and it is therefore strongly suggested that the arguments or criteria that have been discussed be considered before using the tool.

The measurement tools are intended for interveners, as the research was primarily concerned with their role. It was possible to determine this from the literature review.

Effective Interventions

Introduction

The interventions presented here refer to activities carried out by one or more qualified professionals (e.g., occupational therapist) in collaboration with one or more workplace actors (e.g., absence manager). Our research focuses on MSDs and CMDs. However, in the literature consulted, several authors were also interested in workers’ overall health. This is why we present the interventions for each of these problems: MSDs, CMDs and overall health. Targeting overall health opens the way to prevention (concept of integrated prevention), a major concern in many workplaces.

Several research studies agree that certain interventions aimed at healthy and sustainable RTW of workers with MSD or CMD are effective and may even have a therapeutic dimension. These studies demonstrate the effectiveness of combining clinical and work components for healthy and sustainable RTW (Cullen et al., 2018; Franche et al., 2005; Nastasia et al., 2017).

Effective interventions, sometimes referred to as programs, include a variety of components: physical activity/exercise, cognitive-behavioural principles, education and information, relaxation and breaks, and workplace accommodations (tasks, workstation or work environment).

In fact, in the context of these interventions, it is the interaction between the worker’s health and his or her work reality that is targeted. However, the effectiveness of these combinations depends on numerous factors related to the implementation of the intervention in the workplace, such as the communication/collaboration of the actors and the resources available.

Presentation of the interventions

Based on the important work of Cullen et al. (2018), it is possible to conclude that a program encompassing at least two of the three intervention domains for RTW can reduce the duration of absence. The definitions of these domains are presented in the table below. This is the most important message delivered by this work. Accordingly, effective interventions for MSDs, CMDs and overall worker health were ranked according to the number of domains identified.

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Before choosing the type of intervention you are interested in (MSD, CMD, overall health), it is important to agree on the vocabulary used in this section (Figure 7). There is a great deal of variation in the use of these terms in research and clinical settings.

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Figure 7 – Illustration of the hierarchical relationship between the concepts used in the Effective Interventions section

The intervention or program is made up of intervention components that fall into the three major intervention domains. Thus, an intervention can be made up of components that fall into one, two, or three domains of intervention.

It should be noted that work modifications can also be a component of intervention.

Proposed general approach

Suggested three-step approach to worker assessment and intervention:

1) Based on your assessment of the worker (including consideration of the factors that positively/negatively influence RT) and contextual elements (available resources), determine a priori whether the RTW plan will include the following three domains of intervention:

• Health
• Service coordination
• Work modification

2) Identify the intervention components that will be delivered for each of the domains identified in step 1. As an example, you can consult the following tables for combinations of intervention components that have already proven their effectiveness:

Table for MSD 

Table for CMD

Table for overall health

3) Finally, share your roles and responsibilities.

Examples of proven effective interventions for MSDs

To ensure a healthy and sustainable RTW for workers with MSDs, the research methodology allowed us to identify 53 interventions (programs) grouped into 11 categories (see Table 4-5). The terms intervention and program are used synonymously in this work, as in the literature.

Facts:

• The literature review conducted by the research team led to a consensus that intervention with a workplace component is beneficial to a healthy and sustainable
• An intervention encompassing at least two of the three RTW target intervention domains (Table 4.4) reduces the duration of absence.
• Among the many components identified in relation to the different effective interventions, some are more frequent than others, i.e. more often tested in the literature: physical activity/exercise in the workplace, multidisciplinary/interdisciplinary approach and back schools, ergonomic intervention and behavioral treatment.
• Physical activity/exercise can be used as a complementary intervention to ergonomic measures. When combined with another component, physical activity/exercise is seen as the primary component and workplace involvement as the secondary component.
• The essence of the back school is to encourage the worker to be active and make him/her active despite his/her inability to perform certain tasks. E.g. exercise, fitness, training on work methods and lifting techniques.
• Ergonomic intervention can refer to different approaches of the discipline: evaluation of the job demands or workstation, participatory ergonomics, adaptation of the work environment, adaptation of tasks and work hours, the active and supportive role of the immediate superior.
• The combination of components from different intervention domains (health, service coordination, work modifications) is common in the literature consulted and appears to be effective.
• Work modification can include a variety of interventions such as work environment accommodations, equipment accommodations, assessment and adjustment of physical and cognitive job demands, supernumerary replacement and temporary light duty assignments. (Learn more about workplace accommodations )
• Consideration of cognitive-behavioral principles, often considered for CMDs, also appears to be a valuable addition to other interventions for healthy and sustainable RTW for workers with MSDs

Examples of proven effective interventions for CMDs

For workers with CMD, the research methodology allowed us to identify 7 interventions (or programs) grouped into 4 categories (Table 4-6

Facts:

• Effective interventions for CMD are much fewer than for MSD and are composed primarily of the health and service coordination domains (Table 4-4).
• The components are primarily educational activities and training in problem solving and communication skills.
• We also note that, in addition to the biopsychosocial approach, there is the presence of the service coordination component in the multidisciplinary/interdisciplinary programs for a CMD .

Examples of proven effective interventions for overall health

Finally, scientific data were also found concerning overall health, i.e. interventions that apply to all health conditions of workers. In this case, the search methodology allowed us to identify 21 interventions (or programs) grouped into 7 categories (Table 4-7).

Facts:

• The components of overall health interventions may come from one or two intervention domains (Table 4-7): health, service coordination, and work modifications.
• The reduction of cognitive and physical demands generally falls under the domain of workplace accommodation (for examples of workplace accommodation, click here), as the intervention is aimed at modifying the work environment. However, an intervention aimed at increasing the worker’s capacity in the workplace would fall under the health domain, as the intervention would be aimed at educating the worker in order to control these demands.
• As with effective interventions for MSDs and CMDs, educational and training components appear to be frequently associated with overall health interventions. For example, components such as physical and mental health education, job training, leadership and workplace health training, and communication skills training can be combined with components in both the health and service coordination domains, as well as with work modifications (for examples of workplace accommodations, click here).

Summary of effective interventions

This synthesis, presented in Table 4-8, allows the information presented above (same intervention categories) to be broken down differently, by indicating the targets of the interventions. The amount of evidence available (number of systematic reviews) for MSD, CMD and overall health interventions can also be noted.

In summary:

1. Programs incorporating physical activity or a multidisciplinary/interdisciplinary approach would promote RTW for MSDs, CMDs and overall health.
2. Health promotion, social support, and workplace accommodations would support RTW for MSDs and overall health.
3. Cognitive therapies would promote RTW for CMDs, but also MSDs.