Developing an Intervention Toolbox for the Common Health Problems in the Workplace

Development of the Health ↔ Work Toolbox is described. The toolbox aims to reduce the workplace impact of common health problems (musculoskeletal, mental health, and stress complaints) by focusing on tackling work-relevant symptoms. Based on biopsychosocial principles this toolbox supplements current approaches by occupying the zone between primary prevention and healthcare. It provides a set of evidence-informed principles and processes (knowledge + tools) for tackling work-relevant common health problems. The toolbox comprises a proactive element aimed at empowering line managers to create good jobs, and a ‘just in time’ responsive element for supporting individuals struggling with a work-relevant health problem. The key intention is helping people with common health problems to maintain work participation. The extensive conceptual and practical development process, including a comprehensive evidence review, produced a functional prototype toolbox that is evidence based and flexible in its use. End-user feedback was mostly positive. Moving the prototype to a fully-fledged internet resource requires specialist design expertise. The Health ↔ Work Toolbox appears to have potential to contribute to the goal of augmenting existing primary prevention strategies and healthcare delivery by providing a more comprehensive workplace approach to constraining sickness absence

The costs and benefits of active case management and rehabilitation for musculoskeletal disorders

The burden of musculoskeletal disorders (MSDs) to employers and workplaces is significant; and the most important cost to employers and society is lost time from work. ‘Case management’ is a goal-oriented approach to keeping employees at work and facilitating an early return to work. There is good scientific evidence that case management methods are costeffective through reducing time off work and lost productivity, and reducing healthcare costs. There is even stronger evidence that best-practice rehabilitation approaches have the very important potential to significantly reduce the burden of long-term sickness absence due to MSDs. The combination of case management with suitable rehabilitation principles is currently being used effectively in multiple settings throughout the UK, and there is growth within the case management sector. Current providers vary widely in quality and experience. There is limited professional regulation, although localised standards of practice have recently become available. Many of the factors influencing the adoption of cost-effective case management and rehabilitation approaches rest with employers, and funders/commissioners of healthcare. It may be easier to integrate these practices into large and medium-sized workplaces, but there is no reason why the same principles cannot be applied to small businesses and the self-employed. It appears to be very timely for the distribution of information to employers and other key players about how effective case management and suitable rehabilitation approaches can be, and how applicable they are to UK settings. To this end, an integrated model specific to the UK has been developed. An evidence-based model for managing those with MSDs was developed that is widely applicable to all types of industry and business in the UK. It describes the principles to apply in order to integrate case management and rehabilitation with the workplace. It was derived from high quality scientific studies, and research conducted into views on the applicability and effectiveness within the UK. It is recommended that HSE distribute guidance based on this model

Para-infectious brain injury in COVID-19 persists at follow-up despite attenuated cytokine and autoantibody responses

To understand neurological complications of COVID-19 better both acutely and for recovery, we measured markers of brain injury, inflammatory mediators, and autoantibodies in 203 hospitalised participants; 111 with acute sera (1–11 days post-admission) and 92 convalescent sera (56 with COVID-19-associated neurological diagnoses). Here we show that compared to 60 uninfected controls, tTau, GFAP, NfL, and UCH-L1 are increased with COVID-19 infection at acute timepoints and NfL and GFAP are significantly higher in participants with neurological complications. Inflammatory mediators (IL-6, IL-12p40, HGF, M-CSF, CCL2, and IL-1RA) are associated with both altered consciousness and markers of brain injury. Autoantibodies are more common in COVID-19 than controls and some (including against MYL7, UCH-L1, and GRIN3B) are more frequent with altered consciousness. Additionally, convalescent participants with neurological complications show elevated GFAP and NfL, unrelated to attenuated systemic inflammatory mediators and to autoantibody responses. Overall, neurological complications of COVID-19 are associated with evidence of neuroglial injury in both acute and late disease and these correlate with dysregulated innate and adaptive immune responses acutely

Vocational rehabilitation – what works, for whom, and when?(Report for the Vocational Rehabilitation Task Group)

The aim of this review was to provide an evidence base for policy development on vocational rehabilitation: • To assess the evidence on the effectiveness and cost-effectiveness of vocational rehabilitation interventions. • To develop practical suggestions on what vocational rehabilitation interventions are likely to work, for whom, and when. Vocational rehabilitation was defined as whatever helps someone with a health problem to stay at, return to and remain in work: it is an idea and an approach as much as an intervention or a service. The focus was on adults of working age, the common health problems that account for two thirds of long-term sickness (mild/moderate musculoskeletal, mental health and cardiorespiratory conditions), and work outcomes (staying at, returning to and remaining in work). Data from some 450 scientific reviews and reports, mainly published between 2000 and December 2007, were included in evidence tables. Using a best evidence synthesis, evidence statements were developed in each area, with evidence linking and rating of the strength of the scientific evidence. Findings Generic findings: This review has demonstrated that there is a strong scientific evidence base for many aspects of vocational rehabilitation. There is a good business case for vocational rehabilitation, and more evidence on cost-benefits than for many health and social policy areas. Common health problems should get high priority, because they account for about two-thirds of long-term sickness absence and incapacity benefits, and much of this should be preventable. Vocational rehabilitation principles and interventions are fundamentally the same for work related and other comparable health conditions, irrespective of whether they are classified as injury or disease. Return-to-work should be one of the key outcome measures. Healthcare has a key role, but vocational rehabilitation is not a matter of healthcare alone – the evidence shows that treatment by itself has little impact on work outcomes. Employers also have a key role - there is strong evidence that proactive company approaches to sickness, together with the temporary provision of modified work and accommodations, are effective and cost-effective. (Though there is less evidence on vocational rehabilitation interventions in small and medium enterprises). Overall, the evidence in this review shows that effective vocational rehabilitation depends on work-focused healthcare. Executive summary Vocational Rehabilitation: What Works, for Whom, and When? and accommodating workplaces. Both are necessary: they are inter-dependent and must be coordinated. The concept of early intervention is central to vocational rehabilitation, because the longer anyone is off work, the greater the obstacles to return to work and the more difficult vocational rehabilitation becomes. It is simpler, more effective and cost-effective to prevent people with common health problems going on to long-term sickness absence. A ‘stepped-care approach’ starts with simple, low-intensity, low-cost interventions which will be adequate for most sick or injured workers, and provides progressively more intensive and structured interventions for those who need additional help to return to work. This approach allocates finite resources most appropriately and efficiently to meet individual needs. Effective vocational rehabilitation depends on communication and coordination between the key players – particularly the individual, healthcare, and the workplace. Condition specific findings: There is strong evidence on effective vocational rehabilitation interventions for musculoskeletal conditions. For many years the strongest evidence was on low back pain, but more recent evidence shows that the same principles apply to most people with most common musculoskeletal disorders. Various medical and psychological treatments for anxiety and depression can improve symptoms and quality of life, but there is limited evidence that they improve work outcomes. There is a lack of scientific clarity about ‘stress’, and little or no evidence on effective interventions for work outcomes. There is an urgent need to improve vocational rehabilitation interventions for mental health problems. Promising approaches include healthcare which incorporates a focus on return to work, workplaces that are accommodating and non-discriminating, and early intervention to support workers to stay in work and so prevent long-term sickness. Current cardiac rehabilitation programmes focus almost exclusively on clinical and disease outcomes, with little evidence on what helps work outcomes: a change of focus is required. Workers with occupational asthma who are unable to return to their previous jobs need better support and if necessary retraining. Practical suggestions Given that vocational rehabilitation is about helping people with health problems stay at, return to and remain in work, the policy question is how to make sure that everyone of working age receives the help they require. Logically, this should start from the needs of people with health problems (at various stages); build on the evidence about effective interventions; and finally consider potential resources and the practicalities of how these interventions might be delivered. From a policy perspective, there are three broad types of clients, who are differentiated mainly by duration out of work, and who have correspondingly different needs: In the first six weeks or so, most people with common health problems can be helped to return to work by following a few basic principles of healthcare and workplace management. This can be done with existing or minimal additional resources, and is low cost or cost-neutral. Policy should be directed to persuading and supporting health professionals and employers to embrace and implement these principles. There is strong evidence on effective vocational rehabilitation interventions for the minority (possibly 5-10%) of workers with common health problems who need additional help to return to work after about six weeks, but there is a need to develop system(s) to deliver these interventions on a national scale. These systems should include both healthcare and workplace elements that take a proactive approach focused on return to work. To operationalise this requires a universal Gateway that a) identifies people after about 6 weeks’ sickness absence, b) directs them to appropriate help, and c) ensures the content and standards of the interventions provided. Pilot studies of service delivery model(s) will be required to improve the evidence base on their effectiveness and costbenefits in the UK context. This will involve investment but the potential benefits far outweigh the expenditure and the enormous costs of doing nothing. For people who are out of work more than about 6 months and on benefits, Pathways to work is the most effective example to date. There is good evidence that Pathways increases the return to work rate of new claimants by 7-9%, with a positive cost-benefit ratio. Continued research and development is required to optimise Pathways for claimants with mental health problems and for long-term benefit recipients. Vocational rehabilitation needs to be underpinned by education to inform the public, health professionals and employers about the value of work for health and recovery, and their part in the return to work process. Conclusion There is broad consensus among all the key stakeholders on the need to improve vocational rehabilitation in the UK. This review has demonstrated that there is now a strong scientific evidence base for many aspects of vocational rehabilitation, and a good business case for action. It has identified what works, for whom, and when and indicated areas where further research and development is required. Vocational rehabilitation should be a fundamental element of Government strategy to improve the health of working age people

Telephonic support to facilitate return to work: what works, how, and when? (Research report No 853)

Summary There is wide acceptance that a timely return to work for people with health problems is a desirable goal. Telephonic approaches have much to offer in supporting work participation for people with common musculoskeletal and mental health problems. When well designed and implemented, and with suitable governance, they compare favourably with face-to-face approaches. Telephonic approaches are not a replacement for standard clinical healthcare: they are a complement. Telephonic contact has a dual role: to identify peoples’ needs, and then signpost them to the right intervention at the right time. The evidence supporting telephonic approaches is generally robust, being based on a synthesis of academic, institutional, and best practice sources. There are several key aspects of telephonic approaches that facilitate early return to work outcomes. They have optimal effect when used in combination: • Assessment: identifies the client’s needs and their obstacles to return to work, which guide the return to work plan. • Triage: allocates cases to the most appropriate rehabilitation pathway using a stepped-care model. • Advice and information: fostering positive beliefs, setting expectations, and giving self-management advice. • Case management: managing the client’s journey has cost benefits: telephonic approaches provide clear advantages through speed and ease of access, shorter waiting times, optimised referrals to face-to-face interventions, efficient use of resources. A well-designed and delivered telephonic service can enable a substantial proportion of cases to entirely self-manage their health problem and work participation. Provision should be made for a tiered component of the service that combines telephone and face-to-face contact in order to accommodate cases with more complex health problems or difficult obstacles to work participation. The effectiveness of telephonic services in achieving positive work outcomes relies heavily on the training and skills of staff, and on the adoption of a strong work focus by all the key players, including support at the workplace. There is robust evidence that, when properly implemented, telephonic case management approaches can speed return to work and reduce overall case costs. Telephonic intervention by appropriately trained professionals has been shown to be safe and acceptable to users

Low back pain

After completing this module you should have: * Appreciation of the nature of low back pain (LBP) and its impact in the community * Knowledge of the appropriate investigation pathways for LBP * Awareness of the importance of maintaining activity and confidence in providing reassurance * Confidence in distinguishing "simple" LBP from more complex causes of LBP - triage in primary care * Recognition of the place for imaging studies * Understanding of the psychosocial aspects of back pain: how to identify and tackle obstacles to recovery and participation * Knowledge of how to use a stepped-care approach to treatment and management * Confidence in selecting effective therapeutic interventions * Awareness of the importance of work participation and the confidence to encourage it * Appreciation of when to refer for a specialist opinio

ABC of Occupational and Environmental Medicine, 3rd Edition Musculoskeletal Disorders

• Musculoskeletal symptoms are very common, with lifetime prevalence rates of 75% or more for problems such as low back pain. Causes are frequently assumed, but are actually unpredictable and largely unknown. This makes outright prevention unfeasible. • Explanations and diagnostic labels can negatively influence responses to symptoms,. Care needs to be taken to reassure and emphasise the benefits of maintaining participation, and avoiding prolonged rest and inactivity. • Clinical management should aim at symptomatic relief with maintenance of activity and work. Most interventions exhibit only weak to moderate treatment effects, and combining or repeating them does not seem to enhance effectiveness. • Effective occupational management depends on communication and coordination between the key players, with optimal intervention being a combination of work-focused healthcare and accommodating workplaces. • Psychosocial issues contribute most strongly to absence from work. These obstacles can be identified in three main areas: the person, their workplace, and the everyday context in which they function. Actively tackling obstacles results in improved outcomes

Tackling musculoskeletal problems: a guide for clinic and workplace - identifying obstacles using the psychosocial flags framework

Most people experience musculoskeletal problems some time during their lifetime. The essence of tackling musculoskeletal problems is not so much what has happened, but how to facilitate recovery. People can fail to recover and return to work in a timely fashion because they come up against obstacles. Psychosocial obstacles can be more important than biomedical factors. Tackling Musculoskeletal Problems is about using the psychosocial flags approach to identify obstacles, formulate a plan and take action to overcome them. In identifying the key obstacles across the domains of the person, the workplace, and the context, this guide enables you to develop a plan that addresses specific problems and provides a timeline for recovery. Tackling Musculoskeletal Problems takes a problem solving approach: it sets out the steps that need to be taken and, importantly, who needs to take them and when. The scientific background for Tackling Musculoskeletal Problems was an international Flags Think-Tank, involving 21 experts in the psychosocial aspects of musculoskeletal disorders. Their deliberations and scientific thinking were synthesised into this definitive guide, which is designed to be of interest to all the key players: • Healthcare: primary care practitioners, occupational health professionals, therapists, rehabilitation providers. • Workplace: line managers, senior management, human resources, health and safety advisors. • Context: other groups that will also find this guide essential include claims handlers, insurers, lawyers, case managers, trainers and employment advisors

Management of upper limb disorders and the biopsychosocial model

This review, using a best evidence synthesis, examined the evidence on management strategies for work-relevant upper limb disorders and established the extent to which the biopsychosocial model can be applied. Articles were found through systematic searching of electronic databases together with citation tracking. Information from included articles was extracted into evidence tables. Themes were identified and the information synthesised into high level evidence statements, which were distilled into key messages. The main results are presented in thematic sections covering classification/diagnosis, epidemiology, associations/risks, and management/treatment, focusing on return to work and taking account of distinctions between non-specific complaints and specific diagnoses. Neither medical treatment nor ergonomic workplace interventions alone offer an optimal solution; rather, multimodal interventions show considerable promise, particularly for vocational outcomes. Early return to work, or work retention, is an important goal for most cases and may be facilitated, where necessary, by transitional work arrangements. The emergent evidence indicates that successful management strategies require all the players to be onside and acting in a coordinated fashion; this requires engaging employers and workers to participate. The biopsychosocial model applies: biological considerations should not be ignored, but it is psychosocial factors that are important for vocational and disability outcomes. Implementation of interventions that address the full range of psychosocial issues will require a cultural shift in the way the relationship between upper limb complaints and work is conceived and handled. A number of evidence-based messages emerged, which can contribute to the needed cultural shift