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Purpose: Depressive symptoms have been identified as a significant risk factor for prolonged disability, however, little is known about the process by which depression impacts recovery following work-related musculoskeletal disorders (WRMDs). The primary objective of this study was to examine whether recovery expectancies mediate the relation between depression and return-to-work (RTW) status in individuals with WRMDs., Methods: A sample of 109 patients with WRMDs were recruited from 1 of 6 primary care physiotherapy clinics. Participants completed measures of pain severity, depression and recovery expectancies. RTW status was assessed by telephone interview 1 year after the initial assessment., Results: Consistent with previous research, more severe depressive symptoms and lower recovery expectancies were associated with a lower probability of RTW. Logistic regression analyses revealed that recovery expectancies completely mediated the relation between depression and RTW status at 1-year follow-up., Conclusion: The results suggest that interventions specifically targeting recovery expectancies in individuals with WRMDs and depressive symptoms might improve RTW outcomes.

Musculoskeletal disorders are among the leading causes of work-related physical disability in the province of Quebec in Canada. The authors conducted a focus group study with physiotherapists and physical rehabilitation therapists working with patients whose treatments are compensated by the Quebec Workers' Compensation Board with the goal of exploring quality of care and ethical issues. Three main themes were identified: (1) systemic factors, (2) complexity in treatment decisions and (3) inequality of care. Although physiotherapy professionals strive to give these patients the best possible care, patients might not always be provided with optimal or equal treatment. When compared with other patients, there appear to be differences with respect to access to care and types of services offered to injured workers, raising equity concerns. Factors that shape and constrain quality of physiotherapy services for injured workers need to be addressed to improve care for these patients., (Copyright © 2015 Longwoods Publishing.)

Background: Health, illness and treatment representations have been described as key factors for return to work. The Revised Illness Perception Questionnaire (IPQ-R) is a quantitative tool available to assess these factors. However, an adaptation is necessary before its use with workers on prolonged work disability presenting musculoskeletal disorders (MSD)., Methods: Two distinct phases were carried out, firstly, by adapting the IPQ-R for a population of workers in prolonged work disability related to an MSD and, secondly, by conducting a pre-test on the adapted questionnaire to assess item clarity. PHASE 1: The Technique for Research of Information by the Animation of a Group of Experts (TRIAGE) was selected to proceed with the adaptation. TRIAGE is an inductive and structured method aiming at the attainment of group consensus. Consensus was obtained in two steps: for the individual production, each expert had to judge the pertinence of the questioned elements and suggested new elements if needed; for the group production, all suggestions submitted were sorted according to TRIAGE systematic procedure, in order to retain the most pertinent ones by group consensus. Analysis was done simultaneously to data collection, by the attainment of group consensus. The group of experts consisted of six clinicians and two researchers. For the clinicians, selection criteria consisted of: being an occupational therapist or a psychologist and working for at least 2 years in a vocational rehabilitation setting for workers in prolonged work disability; for the researchers, being affiliated to a university and to have pursued a least one research project regarding prolonged work disability following MSD and development/validation of assessment tools. As a result of the adaptation process eight items were excluded because they were not considered pertinent by the experts. The label "illness" was changed for "current health condition" and 26 new items have been added to the questionnaire to better account for the work disability. The adapted questionnaire appears to present good content validity. PHASE 2: The assessment tool was then pre-tested using a widely known method for trans-cultural adaptation of questionnaires. This method adds a 7-point scale following each item in order to assess item clarity. When the questionnaire is filled, questions are asked to the respondent about items with low rating (4 or less on 7) in order to identify potential ambiguities. Inclusion criteria for the respondents consisted of: being between 18 and 64 of age, having more than 3 months of absence from work related to an MSD and being admitted in a rehabilitation program. Workers absent from work for more than a year, unable to understand and/or read French, suffering from an MSD related to a specific pathology, or presenting major psychiatric problems as indicated in their medical record were excluded. Nine workers were recruited using convenience sampling. Average clarity rating was above 4 for each item, suggesting that the adapted questionnaire was clear. Characteristics of participants seem to be representative of the target population., Conclusion: A questionnaire was adapted in order to better assess the representations of workers in a situation of work disability following an MSD. The rigorous process used in this study ensures the quality of the adaptation, but a validation study must be conducted before the implementation of the questionnaire in clinic and research., (Copyright © 2012 L’Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)

Objective: To assess the differential effect of personal and work-related psychosocial, physical and organizational determinants by gender on time to return-to-work (RTW) following long-term disability., Methods: Data come from a larger study conducted in the province of Quebec, Canada. A cohort of 455 adults on long-term disability due to work-related musculoskeletal disorders at the back/neck/upper limb was followed for 5 years through structured interviews and administrative databases. Left-truncated Cox regression modeling stratified by gender was used to assess time to a first partial or full RTW of at least 3 days., Results: Survival curves of time to RTW were similar between men and women on long-term disability (log-rank test p value = 0.920) but many personal and occupational factors influencing RTW differed by gender. Women's risk factors included older age (HR = 0.734--in 10 years unit), poor to very poor perceived economic status (HR = 0.625), working ≥40 h/week and having dependents (HR = 0.508) and awareness of workplace-based occupational health and safety program (HR = 0.598); higher gross annual income (in $10,000 s) was a facilitator (HR = 1.225). In men, being over 55 years old (HR = 0.458), poor perceived economic status (HR = 0.653), working ≥40 h/week and high perceived physical workload (HR = 0.720) and higher job insecurity (HR = 0.825) negatively influenced time to RTW. For both men and women, probabilities of not returning to work varied widely according to workers' specific profile of personal and occupational factors (high or low risk profile)., Conclusion: Results confirm the importance of gender-sensitive strategies to investigate RTW determinants from a gender perspective.

Objective: The Therapeutic Return to Work (TRW) is a comprehensive rehabilitation process that is centralised in the workplace and consists of a worker's progressive return to his or her regular work. A programme impact theory for the TRW and three mechanism hypotheses were developed [12]. The objective of this study was to validate the mechanism hypotheses. participants: Construction workers who received compensation for low back pain., Methods: A multiple-case study was carried out. Data on the programme activities were collected on a repeated basis using validated measurement instruments and semi-structured interviews of the 20 participants and the clinicians responsible for them. Analyses were carried out using the pattern matching technique., Results: The results supported two of the three hypotheses proposed in the impact theory, specifically, that the development of competent work behaviours is a key factor in promoting return to work and appears to be associated with a reduction in work environment constraints, an improvement in work capacities and the presence of concerted action., Conclusion: This study revealed that rehabilitation interventions carried out in the workplace and involving workers with low back pain are both complex and embedded in the social environment, and that the actions taken must be coordinated in collaboration with various stakeholders.

Introduction: Distinctions between disease and illness have been criticized for being too theoretical. In practice, however, it may help explain gaps in understanding and miscommunication between health care professionals and patients/injured workers, since each has their own perception of reality. To reduce the gap between health care professionals and patients in understanding the definition of disease, this paper documents general representations of health, illness and work-related musculoskeletal disorders and their influence on the work rehabilitation program., Methods: A qualitative methodology was used. Semi-structured interviews were conducted with 16 participants (male, female) recruited when they were starting an intensive interdisciplinary work rehabilitation program for chronic pain due to a musculoskeletal disorder. Interviews were performed at three points during the program and 1 month after discharge., Results: First, participants described health and illness in terms of: (1) illness prototype; (2) the absence or presence of symptoms; (3) physical health and capacities; (4) engaging in a healthy lifestyle; (5) maintaining independence; (6) preserving mental well-being; and (7) healing from accidents or injuries. A second observation was that rehabilitation success depended on workers transitioning from a less mechanistic to a more functional view of health., Conclusion: This study highlights the importance of identifying and acknowledging workers' health, illness and WRMSD representations to facilitate their return to work.

Unlabelled: Previous studies have found illness representations to be associated with the degree to which patients adopt health behaviours. Surprisingly, pain representations, especially those in a work rehabilitation context, have rarely been explored., Objective: To conduct a thorough investigation of the pain representations held by workers who were on sick leave due to persistent musculoskeletal pain during the process of an intensive work rehabilitation program., Methods: Qualitative semi-structured interviews were conducted with 16 participants (male, female), three times during the program and one month after discharge. Data analysis was based on a narrative approach., Results: Throughout the process, pain representation was an indicator of the type of action the participants were ready to take to control the immediate or possible consequences of their pain. Using the context of a work rehabilitation trajectory we identified the differential impact of reconstruction or status quo in pain representations that eventually led to a return to work, or not., Discussion: This study highlights the importance of identifying and acknowledging workers' pain representations in facilitating their return to work.

Introduction: Individualized subjective quality of life (ISQoL) is the appraisal of quality of life according to personal values, desired goal attainment and life priorities. "Gap" is a way to operationalize ISQoL. ISQoL is rarely measured by interdisciplinary work rehabilitation (IWR) programs attended by the musculoskeletal disorder (MSD) population. These programs commonly measure pain intensity, physical capacity, perceived disability, distress and return to work., Objectives: The aims of this study were to compare ISQoL according to work status and reference values and to explore the relationships between ISQoL and common IWR measures., Methods: Six months after completing an IWR program, 40 working and 31 not-working participants completed questionnaires documenting work status, pain, ISQoL gap, health-related quality of life (SF-36, PCS and MCS), perceived disability and distress., Results: No significant difference in global ISQoL gap was found between working and not-working participants. When compared to reference values considerable variability exists but globally, for both groups, ISQoL gap scores were below average. The following clinical variables were related to global ISQoL (P < 0.05): pain (r = -0.42), PCS (r = -0.37), MCS (r = -0.56), perceived disability (r = 0.37) and distress (r = 0.61). High distress, present in both groups, explains 38% of the global ISQoL gap variance and PCS adds 4%., Conclusion: Following IWR programs for the chronic MSD population, global ISQoL gap is not related to work status. The use of a client-centered interactive computerized measure of ISQoL reveals that domains related to emotional well-being are likely the most problematic for the persistently disabled MSD population.

Despite the high costs associated with mental health problems in the workplace, few studies have yet been published on the design and evaluation of return-to-work rehabilitation programs for workers with mental health problems. In fact, the best-documented return-to-work rehabilitation programs concern workers with musculoskeletal disorders (MSKD). For this clientele, a disability paradigm has been adopted which explains the multicausality of work disability. Long-term work disability is no longer seen simply as the consequence of impairment, but rather as the result of interactions between the worker and three main systems: the health care, work environment and financial compensation systems. A return to work is thus influenced by a complex set of interrelated factors that must be taken into account in any intervention. Parallels can inevitably be drawn in the field of mental health in the workplace, where individual and organizational factors are involved and must be taken into account in the return-to-work process. This paper presents the first results of an exploratory study aimed at determining the possible links between work rehabilitation programs for workers with MSKD and those for workers with mental health problems. To this end, the components of a work rehabilitation program for workers with MSKD, the Therapeutic Return to Work (TRW) program which addresses psychological factors, work environmental factors and factors related to the involvement of the various stakeholders in the rehabilitation process, are described through a multiple-case analysis and mapping of interventions. The results support the relevance of adopting the disability paradigm and considering the return-to-work clinical activities conducted with workers with MSKD (and their mechanisms of action) in the design of work rehabilitation programs for workers with mental health problems.

Introduction: Various obstacles to and facilitators of collaboration between an interdisciplinary work rehabilitation team and the stakeholders (workers, insurers, physicians, and employers) exist, but are not well characterized., Methods: An observational study was conducted, using videotapes of interdisciplinary team discussions of ongoing cases involving 22 workers absent from work due to musculoskeletal disorders. The actions taken and strategies adopted by the team in an effort to overcome the obstacles to collaboration were studied., Results: Various factors influence collaboration between the rehabilitation team and the stakeholders. In general, stakeholder endorsement of the team's therapeutic principles and confidence in their approach emerged as particularly important factors. Diverse strategies, most often, education and awareness-raising, were used by the team to foster collaboration among the parties., Conclusions: This study provides greater insight into the factors affecting collaboration among a rehabilitation team, an injured worker and other stakeholders. The results may improve understanding of the actions taken by rehabilitation teams and help to optimize their practices.

Introduction: The Quality of Life Systemic Inventory (QLSI) measures patients' goal attainment based on the system control theory. It quantifies the perceived impact of the disorder and the gap between the present and aspired states., Purpose: To evaluate concurrent validity and responsiveness of the QLSI among workers on sick leave due to musculoskeletal disorders (MSDs)., Methods: Participants (10 women; 29 men) were recruited at a work rehabilitation centre and had more than 4 weeks of absence from work due to MSDs compensated by the Workers' Compensation Board. Concurrent validity and external responsiveness were based on baseline and post-treatment measures of external criteria. Criteria and related instruments were the following: perception of disability (Roland-Morris Disability Questionnaire); health-related quality of life (SF-12); stress (Psychological Stress Measure) and distress (Psychological Distress Index)., Results: Regression analyses revealed significant correlations between QLSI scores and the Psychological Distress Index (r2 = .11 to .19 and .66; p < .001), with either the SF-12 mental component scale (r2 = .18 and .11; p < .01) or the Roland-Morris Disability Questionnaire (r2 = .04 and .10; p < .05). All measures showed highly significant change over time., Conclusion: Results support the concurrent validity and responsiveness of the QLSI, with an MSD population., Significance: This instrument could serve in future research as an outcome measurement instrument in the evaluation of more long-term effects of rehabilitation programs.

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) worker's internal motivation, (4) worker's adherence to the program, (5) worker's 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.

In this qualitative research project, researchers in three Canadian provinces explored the perceptions of many different actors involved in return-to-work (RTW) programs for injured workers, studying their views on successful RTW strategies and barriers to/facilitators of the RTW process, then analyzing the underlying dynamics driving their different experiences. Each research team recruited actors in a variety of different workplaces and key informants in the RTW system, and used a combination of in-depth, semi-structured interviews and focus groups to collect data, which were coded using an open coding system. Analysis took a social constructionist perspective. The roles and mandates of the different groups of actors (injured workers; other workplace actors; actors outside the workplace), while sometimes complementary, could also differ, leading to tension and conflict. Characteristics of injured workers described as influencing RTW success included personal and sociodemographic factors, beliefs and attitudes, and motivation. Human resources managers and health care professionals tended to attribute workers' motivation to their individual characteristics, whereas injured workers, worker representatives and health and safety managers described workplace culture and the degree to which workers' well-being was considered as having a strong influence on workers' motivation. Some supervisors experienced role conflict when responsible for both production quotas and RTW programs, but difficulties were alleviated by innovations such as consideration of RTW program responsibilities in the determination of production quotas and in performance evaluations. RTW program success seemed related to labor-management relations and top management commitment to Health and Safety. Non-workplace issues included confusion stemming from the compensation system itself, communication difficulties with some treating physicians, and role conflict on the part of physicians wishing to advocate for patients whose problems were non-compensable. Several common themes emerged from the experiences related by the wide range of actors including the importance of trust, respect, communication and labor relations in the failure or success of RTW programs for injured workers.

Background: The causes of prolonged disability due to back pain are multiply determined, involving medical, social, and environmental factors. Possible solutions to the problem of prolonged back pain disability have emerged from recent research but few efforts have been made to transfer evidence-based programs to large community settings., Objective: This article describes three phases of the process of transfer of evidence from rehabilitation research to community practice in the province of Quebec., Methods and Results: Phase A: Based on literature review and expert knowledge, the Sherbrooke model was developed and assessed through a population-based, randomized clinical trial. Results at 1-year follow-up showed quicker return to regular work and improvement of quality of life; the 6-year follow-up showed the cost-effectiveness of the method. Phase B: Based on the Sherbrooke model experience and recent evidence, a new program addressing the disability paradigm was developed and implemented in the province of Quebec (Canada). Results at 1- and 3-year follow-ups showed that only 24% of workers were not working owing to their musculoskeletal disorder. The program is presently being tested through a population-based, randomized clinical trial in a population of construction workers. Phase C: To implement the program at a provincial level, a network for management, research and education in work rehabilitation was developed. An external assessment is presently planned to evaluate return to work and economic outcomes and quality of implementation of the program in various settings.

This study examined the comparability of estimates of functional status elicited through a telephone interview and a face-to-face interview. The Barthel Index, a commonly used measure to assess activities of daily living, was administered over the telephone and then again in the home to 366 individuals, up to 5 yr after their discharge from a rehabilitation hospital. One-half of the telephone interviews were performed by health professionals and the other half by trained lay interviewers; all of the home interviews were performed by health professionals. Proxy-respondents provided information for those unable to respond for themselves. The percent agreement between the scores on the telephone and on the home interview was always greater than 90%; the intraclass correlation coefficient for the telephone/home comparison was 0.89. Responses between the modes of interview were more consistent when provided by self-respondents than when provided by proxies. The telephone assessment worked well in identifying those who did not have functional disabilities; all individuals who scored 100 on the home interview, scored 95 or better on the telephone. When differences arose, they were always in those considered to have moderate to severe impairment and were most often (23 of 29 times) in the direction of higher scores, indicative of less disability, on the telephone. The results of this study suggest that, with the exception of a small subgroup of patients, functional status can be elicited reliably over the telephone by both lay persons and health professionals.