Making the best of RTW interventions

Multi-faceted programs that package together different components have their advantages

By the time an employee with an injury or health condition calls up Janet Marlin, chances are he has been off work for a long time. The person may be experiencing chronic pain — such as low-back pain, migraine or irritable bowel syndrome — or chronic mental health conditions such as depressed mood or anxiety.

As head of a Burlington, Ont.-based practice, Marlin has worked for nearly 30 years helping these individuals recover their function. She has long believed the most effective approaches are those that bring together different parties to support the injured worker.

At her practice, a kinesiologist or cognitive behavioural therapist working on a client’s file would typically obtain consent to contact the client’s health-care provider, describe the services being offered and ask for feedback. The clinician would also contact the client’s employer and the case manager to get input on a graduated return-to-work (RTW) plan  the client has taken a lead role in developing.

“That’s the approach that we’ve always used,” says Marlin. “There has to be a collaborative approach to getting individuals back to work.”

As a result, Marlin was not surprised to find that a recent systematic review of workplace RTW interventions recommends multi-faceted programs that package together different types of interventions.

The systematic review, an update by the Toronto-based Institute for Work & Health (IWH) and the Institute for Safety, Compensation and Recovery Research (ISCRR) in Melbourne, Australia, found strong evidence for the effectiveness of workplace-based RTW programs in reducing time away from work due to musculoskeletal disorders (MSDs) and other pain-related conditions when they incorporate practices in at least two of the three following areas:

• health services for injured workers provided at work or in settings linked to work (such as physical therapy, occupational therapy, psychological therapy, medical assessments, graded-activity exercises or work hardening)

• RTW co-ordination (such as case management, RTW planning or improved communication with health-care providers)

• work modifications (such as job accommodations, ergonomic or other worksite adjustments or supervisor training on work modifications).

“There’s something about the grouping together of interventions that address different facets that makes the interventions effective,” says Kim Cullen, associate scientist at IWH and lead author of the article “Effectiveness of Workplace Interventions in Return-to-Work for Musculoskeletal, Pain-Related and Mental Health Conditions: An Update of the Evidence and Messages for Practitioners” in the Journal of Occupational Rehabilitation.

Even when workplace RTW programs package together different components that all address the same domain — for example, all relate to health services or work modification — the evidence shows these have no effect, says Cullen. 

The only exceptions to this finding are work accommodation and graded activity — a moderate level of evidence shows these stand-alone interventions have an effect on RTW. (Graded activity is an exercise or occupational therapy aimed at restoring a patient’s function on specific work tasks by modifying the tasks according to levels of difficulty.)

“If a workplace has to implement any one intervention as a stand-alone, I would recommend one of these two interventions — work accommodation or graded activity,” she says.

Cullen has a few theories as to why the multi-faceted programs are effective.

“It may be because the multi-domain programs are about using different perspectives in thinking about what injured individuals need,” she says. “Or it may be that these packages of interventions cover more ground and are more likely to include the interventions that can help.”

Marlin, who makes a point of keeping up on the research in her field of disability management, says the key to success in her team’s approach is the buy-in that results from having different parties provide their input.

“When we develop a draft of a graduated return-to-work plan with the patient, we ask the health-care provider if there’s anything that’s contraindicated from a mental or physical health perspective,” says Marlin.

“And then it goes to the case manager and employer so that each can look at it from their own perspective. For the most part, the claimants whom we work with follow through with that plan. That’s because everyone has been involved in developing it. The claimants are on board because, in fact, they’re the ones that draft it in the first place.”

Uyen Vu is a communications associate at the Institute for Work & Health (IWH), a Toronto-based not-for-profit research organization that conducts research into workplace injury and disability prevention. She is also editor of the institute’s quarterly newsletter At Work, found at




Key findings

In looking at the return-to-work systematic review update, there’s strong evidence that:

• for MSDs and pain disorders, implementing a multi-domain intervention (with components in at least two of the following domains: health services, case co-ordination or work modification) can help reduce lost time

• for mental health conditions, implementing a work-focused cognitive behavioural therapy (CBT) intervention can help reduce lost time and costs associated with work disability

• for mental health conditions, a traditional CBT intervention has no effect on reducing lost time.

There’s moderate evidence that:

• graded activity and work accommodations can help reduce lost time

• for MSD conditions, multi-domain interventions can improve work functioning and lower costs

• for mental health conditions, work-focused CBT can help improve work functioning.

There’s not enough evidence to guide current practices and policies on:

• work hardening alone

• physician training alone

• return-to-work plans alone

• case management alone

• worker education/training alone

• supervisor training alone.

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