Presented by: Dr Nick Kendall, Health Services Consultant at OHSIG 2014, Thursday 11/9/14, Plenary session, 3.45pm

1. Joining Up Occupational Health
and Safety with Rehabilitation
Dr Nick Kendall
Occupational Health Services Consultant

2. Outline
• Focus = common health problems, minor injury
– Relationship between work and health
• Does the current conceptual framework have limitations?
– Knowledge from primary prevention
– Knowledge from treatment and rehabilitation
• Workplace safety and retention
• Does the biopsychosocial model offer anything?
– Line manager tools
– Dual responsibility - employer & employee

3. Focus: Common Health Problems (CHPs)
and Minor Injuries
• Less severe illnesses/injuries
• Responsible for ~70% of absence
and long-term incapacity
– Mild/moderate mental health problems
– ‘Stress’
– Musculoskeletal conditions
– Cardio-respiratory conditions
Waddell, Burton & Kendall 2008

4. What’s in a Name? ‘Injury’ vs. ‘CHP’
…problem is that legislative definitions and usage
of these terms vary with the context and needs
of each system. For example, in the UK only 39%
of work-related health problems are classified
as injuries and 61% as work-related ill health,
whereas in US 94% are termed injuries and only
6% occupational diseases.
Kendall N. Management and governance of occupational safety and health in five
countries (United Kingdom, United States of America, Finland, Canada, Australia).
Technical Report prepared for the National Occupational Health and Safety Advisory
Committee: NOHSAC Technical Report 8: Wellington, 2006. p.349

5. UK Sickness Absence
• Estimated impact of £100B per year, due
mainly to lost productivity
• Leading causes are mental health,
musculoskeletal, cardiac, pulmonary
• About 10% of those on sick leave account for >
85% total costs
• What percentage could be working?

6. Common Health Problems
– High prevalence across population
– Characterised more by symptoms than disease
or impairment
– Coexisting symptoms common - physical and
mental
– Untidy pattern of symptoms of varying severity
at irregular intervals over life course
– Care seeking for ~10% of episodes - most
episodes settle uneventfully
– Multifactorial causation – work usually only one
contributory factor
– Most people remain at work or return to work
quite quickly
– Essentially whole people, with a manageable
health problem
• given support, opportunities and
encouragement

7. Conceptual Framework Limitations:
Secondary Prevention - Treatment and Rehabilitation
The biomedical model (falsely) predicts
treatment → cure → return to activity & work
What to do when this doesn’t happen?
• More investigation and treatment, over-medicalise
• Fall back on ‘it’s all in the head’ option

8. Paradox
sick leave and disability are driven
primarily by psychosocial factors
Burton & Kendall, Musculoskeletal disorders, BMJ, 348 (2014).

9. Clinical severity is not strongly related
to work disability
• RA: better clinical status ≠ fewer sick leave episodes (Bjork, 2009)
• RTW rates in SCI around 45% at one year independent of
severity (Young and Murphy, 2009)
• LBP: 3-fold international variation in LBP work disability
driven by policy, not care (Anema et al, 2009)
• Common mental health conditions: severity unrelated to
work status (Waddell Burton and Kendall, 2008)

10. Contrast predictors of clinical and work outcomes
Predictors of back pain
symptoms
•Pain severity
•Duration
•Somatic focus
•Coping
•History
Predictors of back pain
work outcomes
•Workplace conflict
•Workplace inflexibility
•Fear of injury
•Lack of autonomy
•Pain severity
•Catastrophic view
Pransky, 2009

11. Conceptual Framework Limitations:
Primary Prevention – Health and Safety
The exposure model (falsely) predicts
hazard → person/worker → harm
What to do when removing or reducing
exposure doesn’t minimise harm?
Increase control?

12. Claims ≠ Injuries

13. Epidemiology
High background prevalence of ULDs in general population
– 1-week prevalence ~50% upper limb/neck symptoms
– varies depending on region, population, case definition etc.
• similar to back pain
– higher prevalence of non-specific symptoms v specific diagnoses
– frequently >1 region affected
– symptoms usually recurrent
– often lead to activity limitation, but most workers remain at work
• some go on to long-term incapacity
ULDs can be considered common health problems

14. Epidemiology discussion
• Some jobs do contain hazards with elevated risk
– but, risk for what?
– most entail 'normal' activity  fatigue/strain not major damage
• Distinguish between symptom expression (reports), symptom modulation,
physical damage, disability
– deleterious consequences depend more on psychosocial factors than what has happened
• Work-related - implies causative link - largely inaccurate and misleading
• Work-relevant more appropriate:
– recognises work difficult in face of ULD, irrespective of cause
• People experience pain in course of everyday activity as well as work
• they face a predicament - what should we/they do about it?

15. Occupational factors
• Earlier evidence was equivocal: high proportion of cross-sectional
studies
• Last decade  more longitudinal studies
– Physical exposures are associated with musculoskeletal problems, e.g. ULDs,
but effect sizes modest
• timeline often unclear: symptoms v injury
– true for non-specific and most instances of specific 
• Little evidence for cumulative exposure to typical physical
stressors as cause of most musculoskeletal problems
• Workplace psychosocial factors consistently associated with
symptoms and sickness absence

16. Associations and risks: health v safety
• Despite reduction in physical demands of work,
musculoskeletal problems have not declined
• Preventing accidents is different from preventing ill-health
• prevention strategies can be very successful in making work safe: e.g. falls
from heights;
• but only successful for ill-health when clear link with exposure: e.g.
asbestosis
• Unless clear exposure-response relationship for
workplace physical stresses, the prevention of
incidence is not feasible

17. Safety v Health – conflicting paradigms
• Reduce risks  primary prevention
– paradigm works for safety e.g. falls from height
– paradigm works for occupational disease with
clear cause-effect e.g. hazardous substances
• Hasn’t worked for common health
problems
– no clear cause-effect
• Presumably healthcare has the
answers…….

18. What we have learned:
Secondary Prevention - Treatment and Rehabilitation
• Inadequate case definition, over-inclusive case criteria (e.g. ‘stress’)
• Increased number of cases, despite prevention and treatment
• Proliferation of types of treatments, weak or no effectiveness
• Provision of more healthcare, repeated and multiple types
• Unhelpful myths about work
• Increased direct and indirect costs to society, individuals, families
• Suffering and long-term unemployment and under-employment

19. Diminishing Returns

20. Healthcare is often ineffective in
improving work outcomes
• Once acute conditions are stabilised more treatment is
usually worse for sickness absence
• Back pain
– Spinal fusion, discectomy
– Extended physiotherapy
– Pain clinics
• Post-bypass cardiac rehabilitation
• Common mental health conditions
• Why?
Campbell, Wright et al, Avoiding long-term incapacity for work, 2007

21. Is being off work like a separate
condition?
Is it…
• A psychosocial condition?
• A unique set of causes, associated factors, and
effective treatments?
• Distinct from the underlying medical condition that
it is often attributed to?

22. WORK HEALTH
• Is work actually good for your health
and wellbeing?
(Waddell & Burton, 2006)
Rueda et al 2012
American Journal of
Public Health
Vol. 102(3) 541-556

23. Main Findings
• Work is generally good for physical and mental health and
well-being
• Unemployment and unnecessarily prolonged sickness
absence are generally bad for physical and mental health
and well-being
• Getting work can reverse the adverse health effects of
unemployment
• Findings apply for healthy people of working age, for many
disabled people, for most people with common health
problems, and for social security recipients

24. Provisos
• Beneficial health effects
depend on the nature
and quality of work
• Good Jobs
• pay, security,
support, safety....

25. Work is generally good for health and well-being, so…
• Help people stay, and return
to being, active and working
• People who want to work
should get the help they
need (to overcome obstacles,
but this is not the same as
‘being made to work’)

26. Work is an important health outcome
NICE (UK) guidelines •Participation/work rarely
seen as a health outcome
•25% offer advice on
rehabilitation
• 10% offer advice on RTW
NICE back pain
guidelines
Occupational outcomes
not included
Signs of change!
… but not in clinical
guidelines yet

27. What we have learned:
Primary Prevention – Health and Safety
• Based mostly on associations, not causal (e.g. absence of dose-response)
• Over-inclusion unconfirmed risk factors factors (e.g. lifting)
• Multiple approaches to prevention, weak or no effectiveness
• Insufficiently effective prevention
• Myths about work and causation, and need for healthcare
• Increased burden on compliance (with costs), leading to potential
lack of adherence, and potential devaluing OHS (Lord Young, 2010)

28. Does the biopsychosocial model
have anything to offer?

29. Work-Relevant Symptoms
• Primary prevention of most
common health problems is
unfeasible
• Symptoms may affect workability
 symptoms may be more pronounced at work
 work may be difficult because of symptoms
 Health problems may be highly
work-relevant, whatever the cause

30. Uncomfortable
Unpleasant

31. Truly dangerous

32. For treatment and rehabilitation –
obstacle (‘flags’) model
Kendall, Burton, Main, & Watson (2009)
Tackling musculoskeletal problems: a
guide for the clinic and workplace -
identifying obstacles using the
psychosocial flags framework
www.tsoshop.co.uk/flags
PERSON
WORKPLACE
CONTEXT

33. Initial Concept
Work should be comfortable
when we are well, and
accommodating when we are
ill or injured Nortin Hadler (1997)

34. Research commissioned by HSE
Developing an intervention toolbox common
health problems in the workplace
Kendall, Burton, Lunt, Daniels, & Mellor (in press). Developing an Intervention
Toolbox for the Common Health Problems in the Workplace. HSE Books

35. Relationships and intervention levels for good work,
comfortable jobs, and accommodating workplaces

36. What does a biopsychosocial
approach to OHS look like?
What should we call it?
‘comprehensive’, ‘smarter’, or …

38. Accommodation is the key element for
RTW across a range of health problems
• 30 % reduction in LBP sickness absence
• Therapeutic, supportive, valued contribution
• Time limited, with periodic review
• Uses adjustments and transition
• Usually self-arranged, but use outside expertise
when needed
(Shaw and Pransky, 2005)

39. Integrated approach
• SAW and RTW don’t just
happen – action needed!
• Healthcare alone not enough
– vocational rehab not something to try after
healthcare has finished/failed
• Workplace must be involved
• from day #1
• working whilst recovering option
Waddell, Burton & Kendall 2008

40. The employee has the most power to
determine the eventual outcome of work
disability by deciding how much
discretionary effort to make to get better
and get life back to normal
* given the right support they can help drive the
process, but they face obstacles
Adapted from Pransky, 2009

41. The employer plays the second most
powerful role in determining outcome
by deciding whether to manage the
employees situation actively passively,
hostilely, supportively and whether to
provide for on-the-job recovery
* can be facilitator or obstacle creator – they
need some help to do the right thing
Adapted from Pransky, 2009

42. Myths
Beliefs are central to our
responses to injury & disease
influence what we do about it
Health & Injury myths abound
held by clinicians, employers,
policy-makers, and the public
Myths are major obstacles to
being active and working

43. MYTHS Rest is always needed
until symptoms go
It's a health problem, so
there must be a cure....
It hurts at work, so I
was damaged by work
Working whilst ill or
‘injured’ will just
make matters
worse
Contacting absent
worker is intrusive
No return to work
until 100% fit

44. Workplace Policy Affects Work Outcomes

45. Line Manager Training
• Immediate contact
• No blame/inquiry
• Positive, empathic
• “Want you back”
• Safety focus
• Problem-solving
• Regular follow-up
• Accommodations
• Workplace update
• Functional inquiry
Effective Training
• Two 2-hour sessions
• Interactive
• Management support
• During regular hours
(Shaw, Robertson, McLellan, 2006)

46. Early Line Manager Response is Key
There is an
independent
additive effect of
negative line
manager responses
Practical implication – line managers should avoid being
unsupportive, blaming, angry, or expressing disbelief

47. Some Conclusions
• Differentiate ‘uncomfortable’ and ‘unpleasant’
from the ‘truly dangerous’
• Avoid perpetuating the pervasive myths about
work and health
• Good Jobs come from good management and
help people be more resilient
• Supportive workplaces help people overcome
obstacles to staying at and returning to work

48. thank you for you attention
nick@kendallburton.com