http://hstaskforce.govt.nz/consultation/consultation-submissions/Kirsten%20Bendix%20Olsen%20(Part%20B).pdf

Occupational musculoskeletal and mental health: Significance of rationalization and opportunities to create sustainable production systems ― A systematic review

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.

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

Background A variety of therapeutic interventions is available for restoring motion and diminishing pain in patients with frozen shoulder. An overview article concerning the evidence for the effectiveness of these interventions is lacking. Objective To provide an evidence-based overview regarding the effectiveness of conservative and surgical interventions to treat the frozen shoulder. Methods The Cochrane Library, PubMed, Embase, Cinahl and Pedro were searched for relevant systematic reviews and randomised clinical trials (RCTs). Two reviewers independently selected relevant studies, assessed the methodological quality and extracted data. A best-evidence synthesis was used to summarise the results. Results Five Cochrane reviews and 18 RCTs were included studying the effectiveness of oral medication, injection therapy, physiotherapy, acupuncture, arthrographic distension and suprascapular nerve block (SSNB). Conclusions We found strong evidence for the effectiveness of steroid injections and laser therapy in short-term and moderate evidence for steroid injections in mid-term follow-up. Moderate evidence was found in favour of mobilisation techniques in the short and long term, for the effectiveness of arthrographic distension alone and as an addition to active physiotherapy in the short term, for the effectiveness of oral steroids compared with no treatment or placebo in the short term, and for the effectiveness of SSNB compared with acupuncture, placebo or steroid injections. For other commonly used interventions no or only limited evidence of effectiveness was found. Most of the included studies reported short-term results, whereas symptoms of frozen shoulder may last up to 4 years. High quality RCTs studying long-term results are clearly needed in this field.

https://bjsm.bmj.com/content/bjsports/45/1/49.full.pdf

Frozen shoulder: the effectiveness of conservative and surgical interventions--systematic review.

Shoulder pain is very common, and it causes substantial morbidity. Standardised classification systems based upon presumed patho-anatomical origins have proved poorly reproducible and hampered epidemiological research. Despite this, there is evidence that exposure to combinations of physical workplace strains such as overhead working, heavy lifting and forceful work as well as working in an awkward posture increases the risk of shoulder disorders. Psychosocial risk factors are also associated. There is currently little evidence to suggest that either primary prevention or treatment strategies in the workplace are very effective, and more research is required, particularly around the cost-effectiveness of different strategies.

Shoulder disorders and occupation.

Background Little is known about the most effective occupational health and safety (OHS) interventions to reduce upper extremity musculoskeletal disorders (MSDs) and injuries. Methods A systematic review used a best evidence synthesis approach to address the question: “do occupational health and safety interventions have an effect on upper extremity musculoskeletal symptoms, signs, disorders, injuries, claims and lost time?” Results The search identified 36 studies of sufficient methodological quality to be included in data extraction and evidence synthesis. Overall, a mixed level of evidence was found for OHS interventions. Levels of evidence for interventions associated with positive effects were: Moderate evidence for arm supports; and Limited evidence for ergonomics training plus workstation adjustments, new chair and rest breaks. Levels of evidence for interventions associated with “no effect” were: Strong evidence for workstation adjustment alone; Moderate evidence for biofeedback training and job stress management training; and Limited evidence for cognitive behavioral training. No interventions were associated with “negative effects”. Conclusion It is difficult to make strong evidenced-based recommendations about what practitioners should do to prevent or manage upper extremity MSDs. There is a paucity of high quality OHS interventions evaluating upper extremity MSDs and none focused on traumatic injury outcomes or workplace mandated pre-placement screening exams. We recommend that worksites not engage in OHS activities that include only workstation adjustments. However, when combined with ergonomics training, there is limited evidence that workstation adjustments are beneficial. A practice to consider is using arm supports to reduce upper extremity MSDs.

Systematic review of the role of occupational health and safety interventions in the prevention of upper extremity musculoskeletal symptoms, signs, disorders, injuries, claims and lost time.

Considered from medical, social or economic perspectives, the cost of musculoskeletal injuries experienced in the workplace is substantial, and there is a need to identify the most efficacious interventions for their effective prevention, management and rehabilitation. Previous reviews have highlighted the limited number of studies that focus on upper extremity intervention programmes. The aim of this study was to evaluate the findings of primary, secondary and/or tertiary intervention studies for neck/upper extremity conditions undertaken between 1999 and 2004 and to compare these results with those of previous reviews. Relevant studies were retrieved through the use of a systematic approach to literature searching and evaluated using a standardised tool. Evidence was then classified according to a "pattern of evidence" approach. Studies were categorised into subgroups depending on the type of intervention: mechanical exposure interventions; production systems/organisational culture interventions and modifier interventions. 31 intervention studies met the inclusion criteria. The findings provided evidence to support the use of some mechanical and modifier interventions as approaches for preventing and managing neck/upper extremity musculoskeletal conditions and fibromyalgia. Evidence to support the benefits of production systems/organisational culture interventions was found to be lacking. This review identified no single-dimensional or multi-dimensional strategy for intervention that was considered effective across occupational settings. There is limited information to support the establishment of evidence-based guidelines applicable to a number of industrial sectors.

/pdf/interventions-for-the-prevention-and-management-of-neck-5nl1c6khvk.pdf

Marian Simmonds

Papers

Interventions for the prevention and management of neck/upper extremity musculoskeletal conditions: a systematic review

A Framework for the Classification and Diagnosis of Work-Related Upper Extremity Conditions: Systematic Review