Review
Pre-return-to-work medical consultation for low back pain workers.
Good practice recommendations based on systematic review and expert consensus
A. Petit
a,b,*, S. Rozenberg
c, J.B. Fassier
d, S. Rousseau
e, P. Mairiaux
f, Y. Roquelaure
a,baLaboratoired’ergonomieetd’e´pide´miologieensante´ ettravail(LEEST),LUNAM,faculte´ deme´decined’Angers,universite´ d’Angers,Angers,France
bCentredeconsultationsdepathologieprofessionnelle,laboratoired’e´pide´miologieetd’e´tudeensante´ autravail,CHUd’Angers,4,rueLarrey,49933Angers cedex9,France
cServicederhumatologie,hoˆpitalPitie´-Salpeˆtrie`re,Paris,France
dServicedeme´decineetsante´ autravail,hospicescivilsdeLyon,UMRESTTE,universite´ Claude-BernardLyon1,Lyon,France
eMe´decineetsante´ autravail,comite´ interentreprisesd’hygie`neduLoiret,Orle´ans,France
fServicedesante´ autravailete´ducationpourlasante´,universite´ deLie`ge,Lie`ge,Belgium
1. Introduction
Eventhoughmostworkersrecovercompletelyafteranepisode ofbackpain,2to7%candevelopchroniclowbackpain(LBP)with subsequentlong-termsickleave[1].Thiscanhaveagreatimpact on the career path of those workers and lead to major socioeconomicconsequences[2].
Followingalong-termsickleave,theemployeecanrequestto his/heroccupationalphysician(OP),apre-return-to-work(RTW) medicalconsultationwhenstillonsickleave.Thisconsultationcan also be programmed at the initiative of the worker’s general practitionerortheSocialSecurityadvisingphysician.Thepre-RTW consultationisaworker’srightasindicatedintheFrenchlaborlaw texts(Art.R4624-20and21ofthelabourregulation).Itisafree consultation,withtheOP,regardlessofthesickleaveduration;it canberenewedasmanytimesasneededuponthesimplerequest oftheemployee.ContrarilytotheRTWconsultation,atthetimeof thepre-RTWconsultationthephysiciandoesnothavetodeliveran aptitudeornon-aptitudecertificate,butratheritsgoalistoengage inacommunicationwiththeworker’sorganization,inagreement ARTICLE INFO
Articlehistory:
Received8January2015 Accepted11August2015
Keywords:
Guidelines
Pre-return-to-workmedicalconsultation Chroniclowbackpain
Jobretention
ABSTRACT
Objectives:Thepre-return-to-workmedicalconsultationduringsickleaveforlowbackpain(LBP)aimsat assessingtheworker’sabilitytoresumeworkingwithoutriskforhis/herhealth,andanticipatingany difficultiesinherenttoreturningtoworkandjobretention.Thisarticlesummarizesthegoodpractices guidelinesproposedbytheFrenchSocietyofOccupationalMedicine(SFMT)andtheFrenchNational HealthAuthority(HAS),andpublishedinOctober2013.
Methods:Good practices guidelines developed by a multidisciplinary and independent task force (24experts)andpeerreviewcommittee(50experts)basedonaliteraturereviewfrom1990to2012, accordingtotheHASmethodology.
Results:Accordingtothelabourregulations,workerscanrequestamedicalconsultationwiththeir occupationalphysicianatanytime.Thepre-return-to-workconsultationprecedestheeffectivereturn- to-workand canberequestedbytheemployeeregardlessoftheirsickleaveduration.Itmustbe scheduledearlyenoughto:(i)deliverreassuringinformationregardingriskstothelowerbackand managingLBP;(ii)evaluateprognosticfactorsofchronicityandprolongeddisabilityinrelationstoLBP anditsphysical,socialandoccupationalconsequencesinordertoimplementthenecessaryconditions forreturningtowork;(iii)supportandpromotestayingatworkbytakingintoaccountallmedical,social andoccupationalaspectsofthesituationandensurepropercoordinationbetweenthedifferentactors.
Conclusion:Abetterunderstandingofthepre-return-to-workconsultationwouldimprovecollaboration andcoordinationofactionstofacilitateresumingworkandjobretentionforpatientswithLBP.
ß2015ElsevierMassonSAS.Allrightsreserved.
* Correspondingauthor.Centredeconsultationsdepathologieprofessionnelle, laboratoired’e´pide´miologieetd’e´tudeensante´ autravail,CHUd’Angers,4,rue Larrey,49933Angerscedex9,France.
E-mailaddress:aupetit@chu-angers.fr(A.Petit).
Availableonlineat
ScienceDirect
www.sciencedirect.com
http://dx.doi.org/10.1016/j.rehab.2015.08.001
1877-0657/ß2015ElsevierMassonSAS.Allrightsreserved.
withtheemployee,inordertoimplementthenecessaryconditions forreturningtowork.
Theobjectiveofthepre-RTWconsultation,followingsickleave forLBP,istoevaluatetheabilityoftheemployeestoresumetheir formerjob,withoutanyrisksfortheirhealth,accordingtotheir symptomsandtheirsocialandoccupationalsituation(Art.R4624- 21 labourregulation).Thepre-RTW consultation isa privileged time to talk with the workers regarding the difficulties they anticipate when returning toworkand explorewith them the possibleoptions. Thisconsultation helpsidentifythenecessary accommodationstotheworkstation and workschedule (thera- peuticpart-timereturn-to-work)tobeimplementedinpartner- ship with the worker’s employer, and remind workers of preventionmeasures.
Thelegalframeworksofthemedicalandoccupationalfollow- up by the OP concerns employers, employees, but also their referent primary care physicians and specialists. A better knowledgeofthelegalfeaturesrelatedtothisissueisnecessary to promote an improved partnership between care physicians (primary care physician or specialists) and the occupational physician, especially, via the pre-RTW consultation performed bytheOP.
Thisarticleproposesasynthesisoftheliteratureandthefirst goodpracticesrecommendationsonthepre-RTWconsultationfor LBPemployees, proposedbytheFrenchSocietyofOccupational Medicine(SFMT)andtheFrenchNationalHealthAuthority(HAS), in October 2013 [3]. Eventhough thesegood practices recom- mendationsarefirstofallaimedatoccupationalphysicians,they arealsovaluableforprimarycarephysiciansandspecialistscaring forLBPpatients,aswellastheothermedicalandmedico-social actorsandcompanyrepresentativesinvolved insustainablejob retentionandworkdisabilityprevention.
2. Methods
TheseGPRswereelaboratedaccordingtothe‘‘Clinicalpractice recommendations’’ proposed by the French National Health Authority[4].
TheGPRswereelaboratedbya workgroupandrevisedbya readinggroupof50experts,after10meetingsoftheworkgroup between April 2012 and May 2013. The workgroup was multidisciplinaryandassociateddifferentprofessionals;partici- pants had a good knowledge of professional practices in the domaincorrespondingtothethemeoftherecommendationsand wereabletoassesstherelevanceofthestudiespublishedandthe various clinical situations evaluated. The independence and objectivityoftheexpertsaboutthetopicoftherecommendations wereverifiedviatheconflict ofinterestsdisclosureformsthat eachexpertsenttotheHAS[5].Nodirectorindirectconflictof interestinrelationtothetopicsoftheserecommendationswas evidenced.
AsystematicreviewoftheliteraturebetweenJanuary1990to March2012wasconductedinseveraldatabases(PubMed,Embase, NIOSHtic-2andCochraneLibrary),websites,institutionalreports anddocumentsofthemaininternationalorganizationsincharge ofwork-relatedhealthcare. Thekeywordsused were(lowback pain or backache or sciatica) and (occupational health or occupational medicine or occupational disease or occupational accident)and (interventionsorpreventionorreturn-to-workor absenteeism or sick leave or disability or retirement or job retentionoremploymentorjobchangeorjobadaptationorjob lossorergonomicsorrehabilitationorbackschool).
Basedon thedatayielded bytheliteratureand advicefrom professionals in the workgroup, the level of evidence of the proposedrecommendationswasgradedaccordingtothefollowing levels[6]:
gradeA–validatedscientificevidence:basedonstudieswitha highlevelofevidence:randomizedcontrolledvsplaceboclinical trialswithhighstatisticalpowerandwithoutmajorbiasormeta- analysis of randomized comparative clinical trials, decision analysisbasedonwell-conductedstudies;
gradeB–scientificpresumption:basedonscientificpresump- tionusingstudieswithintermediatelevelofevidence,suchas randomizedcomparativetrialswithlowstatisticalpower,well- conductednon-randomizedcomparativetrials,cohortstudies;
gradeC–lowlevelofscientificevidence:basedonstudieswitha lower level of evidence, such as case studies, retrospective studies,seriesofcases,comparativestudieswithmajorbiases.
gradeAE–scientificexpertagreement:intheabsenceofstudies, recommendations have been based on experts’ opinions resultingfrom a workgroup,afterhavingconsulted a reading group.Theabsenceoflevelofevidencegradedoesnotmeanthat the recommendations are not relevant and useful. It must, however,encourageteamstoconductfurtherstudies.
3. Results
3.1. InformationandadvicetoworkerswithLBP
Foremost,‘‘itisrecommendedtoensurethatworkerswithLBP, alongsickleaveorrepeatedsickleaves,havebeeninformedofthe possibilityofbenefitingfromoneormorepre-RTWconsultations (GradeAE)’’.
Common LBP is a pathological model where individual and social representations (‘‘fears’’ and ‘‘beliefs’’) of pain play an importantroleinthegenesisoffunctionalimpairmentsandthe progressiontochronicity[7].Theclinicalexaminationistheideal time to give workers precious information regarding the LBP diagnosis,caremanagementandprognosis.Thisconversationwith thephysiciancan,initself,have atherapeuticimpactsincethe physician addresses thedysfunctional representations or ‘‘false beliefs’’,whichcanthenbeidentifiedandmodified.Itcanalsohelp restore confidence in workers who were given contradictory information ormedicaladvice[8].Thus,‘‘it isrecommendedto deliver information on LBP risk and LBP pathology since it improvesknowledgeandhelpspositivelychangerepresentations (‘fears and beliefs’) and maladaptive behaviors (movement avoidance)relatedtoLBP(GradeB)’’.
3.1.1. Informationmodalities
‘‘Preventionactors,suchashealthcareprofessionals,mustbe awareoftheinfluencethattheirownrepresentations(or‘beliefs’) canhaveonthecontentofthemessagetheyaredeliveringtothe patientorworker(GradeB)’’.Infact,healthcareprofessionalsmust keepinmindthattheirown‘‘beliefs’’areregularlyassociatedto those of their patients [9], and thatover-medicalized and high profilecaremanagementcanhaverealdeleteriouseffects,andthat theattitudeofphysicianstowardsLBPpatients,canbeinitself,a factorpromotingtheprogressiontochronicity[10,11].‘‘Itisalso recommendedtoensurethecoherenceofmessagesdeliveredto patients,becauseofthedeleteriousnatureofdiscordantspeeches, and to ensure that the worker fully understands the essential messages(GradeAE)’’.Asamatteroffacttheinformationgivento theemployeecanbeadouble-edgedswordsincedivergentorpoor qualitymessagescannegativelyimpactthewell-beingoftheLBP patient and delaythereturn tonormal lifeactivities andwork [12].‘‘Ifpossible,theoralmessagewillbesupportedbywritten informationinaccordancewiththelatestguidelines(forexample, the‘backbook’[13](GradeA)’’sincethemessagebecomesmore effective when coupled with a written document underlining similarinformation[12].Furthermore,usingabookletincreases
thelevelofknowledgeandsatisfactionofpatients,aswellastheir confidenceandcompliancetotherecommendations[13–17].
3.1.2. Informationcontent
‘‘The goal is to deliver essential, coherent and accessible information (Grade A’’; i.e. delivered in a comprehensible and everyday language adapted to patients and their status. The informationshouldbelimitedtoarestrictednumber(3to5)of clearmessages[12].‘‘Thecontentofthemessagemustremindthe subjectthattheonsetofLBPisduetomultiplefactorsandthat occupational factorsare one of themodifiable factorsthat can impactLBPincidence(GradeB)’’.
‘‘Theinformationmustbereassuringregardingtheprognosis (GradeAE),remindingpeoplethatLBPiscommonandfrequently recurrent,but that LBPepisodesare usually short-termed with spontaneous positive resolution (Grade B)’’. A high level of dysfunctional‘‘fearsandbeliefs’’andanxietymightrequiremore explanationtimetoreassureworkersontheprognosis[18].
‘‘Theinformationshouldexplainanddownplaythetechnical andmedicalterms,becauseoftheabsenceofanatomical-clinical similarityforcommonLBP(GradeAE)’’.
‘‘It isalsorecommendedtoencourageworkertocontinueor resumephysicalactivities,andifpossible,returningtoworktaking into account the characteristics of the job context and the possibilities of job accommodations (Grade A)’’. In fact, it is importanttounderlinethatlong-termrestcanpromotechronicity and slow down therehabilitation and that conversely, staying active, continuing normal activities, decreases chronic impair- mentsandtheriskofrecurrencewhilepromotinganearlierRTW [18–20].
Finally, the pre-RTW is the ideal time to ‘‘update the information and heighten awareness on basic principles for preventingoccupationalrisks(GradeAE)’’.
3.2. PrognosticevaluationofLBPworkers
‘‘ItisrecommendedtoreplacetheLBPepisodeinthemedical and occupational history of theperson, lookingspecifically for changesinjobconditionsandthusensuringthattheOPhasthe completeup-to-datedataonthejobcontext(GradeAE).Itisalso recommendedtoevaluatetheimpactofLBPontheoccupational situationandappreciate withpatientstheriskstotheir health, taking into account the risk assessment of the particular job situation, potential accommodations and medical, social and occupational context (Grade AE); in order to determine, in partnership with the worker, the need for job situation/job accommodations and/or medical restrictions or referring the worker to his/her primary care physician and/or change the medicalandoccupationalfollow-upbytheOP(GradeAE)’’.
The purely biomedical model is insufficient to explain the complexityofpersistentLBP.Thus,someso-called‘‘psychosocial’’
factorsseemtobefrequentlyassociatedwithLBPprogressingto chronicity[21].Furthermore,individual,occupationalandorgani- zationalfactorsinfluence therisk ofprogressing towardslong- termincapacityandneverreturningtowork.Thisiswhy,incaseof persistentorrecurrentLBPinaworkeronlong-termsickleaveor goingon repeated sick leaves, ‘‘it is recommendedto evaluate prognostic factors, i.e. psychological and behavioral factors (‘yellowflags’)thatcouldinfluencetheprogressiontochronicity as well as socioeconomic and occupational factors (‘blue’ and
‘black’flags),whichcouldimpactlong-termworkincapacityand delaytheRTW(GradeA)(Fig. 1). Thisassessmentmay require severalconsultationsorinterviewsincomplexcases(GradeA)and mustbecoupledwithathoroughsearchforclinicalsymptomsof LBP severity (‘red flags’) regardless of the LBP stage: acute, subacuteorchronic(GradeA)’’[8,19,22–26].
3.2.1. Riskfactorsassociatedwithchronicity
In the literature, psychosocial factors are considered as importantfactorstoidentifyworkersatriskofdevelopingchronic pain and work disability. Socio-demographic and psychosocial dataareintertwinedandtheirusefulnessmayvarywiththeLBP stage.Theirassessmentmustbecombinedaccordingtoalogical and practical screening sequence [19]. The main factors are commonly grouped under the term ‘‘yellow flags’’ (term used todaytodescribepsychosocialbarrierstorecovery)(Fig.1).They encompassemotionalissues,inappropriateattitudesandbehavior towards pain, as well as inappropriate pain-coping behaviors [19,27–29].Theycanbeidentifiedduring theanamnesisofthe worker.Theirpresenceand,evenmoresotheirpluralityareboth associatedtoagreaterriskofdevelopingormaintainingchronic LBPanddevelopingpersistentdisability[8,19,24,30].Otherfactors arealsonotedsuchasinitialfunctionalincapacity,generalhealth status,presenceofpsychiatriccomorbidities,oreven,thenegative opinionofpatientsregardingthehopeofrecoveringortheirRTW capacity [27,28]. Regarding socio-demographic factors, some authors have identified some negative prognostic factors: i.e.
loweducationalattainment,dissatisfactionduringleisureactivi- ties,numerouschildren,beingasingleparent,beingdivorcedor widowedwithoutchildrenandalargeamountofdomesticchores [10]. Conversely,a low levelof fearand avoidance,initialmild functionalincapacityand thehopeforrecoveryseemtobethe mostpredictiveelementsforrecoveringonthemiddleandlong term[27,28].
3.2.2. Work-relatedfactorsincreasingtheriskofprogressiontowards long-termincapacityanddelayedreturn-to-work
Datafromtheliteratureshowthatbarrierstoreturningtowork arelessrelatedtotheLBPitselfbutrathertoitscontext.Thus,the determinantsoftheLBPincapacity(anddelayedreturn-to-work) areintegratedwithinadynamicbiopsychosocialincapacitymodel [31–33].Thisbiopsychosocialmodelunderlinesfactorsrelatedto theindividual,workplacesystem,healthcaresystemaswellasthe financialcompensationsystem.Allthesepreviousfactorscanbe groupedintoprognosticfactors[27,31,34]relatedtotheworker’s perceived representationsof workand theenvironment (‘‘blue flags’’) and prognostic factors related to company policy, care systems and healthcare insurance (‘‘black flags’’) (Fig. 1) [35–
41].‘‘Long-termincapacitywork-relatedfactorscanberesearched viaseveraltools,whicharedifficulttoimplementindailypractice andthosetoolsarerarelyvalidatedinFrench,besidestheOMPSQ (O¨ rebro Musculoskeletal Pain Screening Questionnaire) (GradeAE)’’[42,43].
It has been demonstrated that the negative representations workershaveregardingpainandtheir‘‘fearsandbeliefs’’regarding consequencesoncontinuingworkingaremajordeterminingfactors of LBP incapacity, just like ‘‘fears and beliefs’’ from healthcare professionalsandhumanresourcesinthecompany[44–47].Thisis thereasonwhysomeauthorshavedevelopedthenotionof‘‘work disabilitydiagnosis’’toidentify,foranemployeeonsickleave,the determinantsoftheLBPincapacityinthevarioussystemsinvolved [48].‘‘Incaseofrepeatedand/orlong-termsickleave>4weeks,itis recommended to explicitly address with the employee the representations or ‘beliefs’regarding thelink between LBPand work(GradeAE).Ifaquestionnaireapproachisused,theassessment ofLBP-relatedbeliefscanbedoneviatheFABQ(Fear-Avoidance Belief Questionnaire), especially with theFABW-work subscale, whichisavalidatedtool(GradeAE)’’[49,50](Table1).
3.3. FunctionalevaluationofLBPworkers
Patients’perceptionoftheirincapacityiscloselyrelatedtothe barriersinvolved in resumingactivities, especially returning to
work.Anabsenceorlow progressionofthepatient’s incapacity perceptionmightmeanthatobstaclestoresumingactivitiesand returningtoworkdoexistandneedtobeidentifiedinordertobe dealtwith.Therefore‘‘itisrecommendedtoevaluateearlyonand repeatedly:pain,functionalincapacityandtheirimpact,aswellas themainfactorsofwork-relatedlong-termincapacity(GradeB)’’.
EvaluatingthefunctionalpainstatusofLBPpatientsenables, notonlytoquantifyphysical,socialandoccupationalconsequen- ces of LBP, but also helps appreciate treatment effectiveness [51].Theimpactofnon-specificLBPcanbeidentifiedviapainself- evaluationandperceivedfunctionalincapacityquestionnaires,but alsousingfunctionalcapacitiesassessmenttests(Table1).Ofnote, theseparametersarerelatedtoeachotherinasubtlemannerand areinfluencedbymultiplefactorsandonlyacompleteevaluation ofthedifferentpaincomponentscanleadtoaglobalvisionofthe painitself[12,21].Therefore‘‘itisrecommendedtousetheVAS (VisualAnalogScale)(GradeA)’’[52](Table1).Itisalsoimportant toperiodicallyassesstheworkers’progress,givetheminformation backandaboveallsupportandencouragethem[12].
There is great variability in the objectives and content of questionnairesevaluatingthefunctionalimpactandqualityoflife alterations related to LBP, but only some are acceptable and validatedinFrench:theRoland-Morrisquestionnaire(orEIFELin itsFrenchversion),theOswestryand Dallasquestionnaires, the QuebecscaleandSF-36qualityoflifequestionnaire[21,49–51,53–
59](Table1).
Finally, the evaluation of functional capacities validated by physicaltestscanhelpwriteappropriateadviceinregardstothe righttimewhenpatientsmayresumeworkand/orwhichadvice should be shared with them [60]. This functional capacity assessmentshouldbeconductedeachtimeasignificantdecrease inactivityorabsenteeismcanbesuspectedduringtheprogression ofLBP[12].Severalspecifictoolshavebeendevelopedbutonlya limited number of them have been scientifically studied to documenttheirmetrologicalproperties,whichvaryaccordingto
eachtool(BlankenshipSystem,ERGOSWorkSimulator,Ergo-Kit, IsernhagenWorkSystem)[60].
3.4. JobretentionforLBPworkers 3.4.1. Medicalandoccupationalsynthesis
In the context of the pre-RTW consultation, elements of returning to workand the necessary conditionsfor ensuringa successful return (temporaryor permanentaccommodations of workingconditions)dependon themedical,social and occupa- tionalsynthesis.Inordertodothis,‘‘itisrecommendedontheone hand,toevaluatethecapacityoftheemployeetoresumeworking and the conditions for a successful RTW according to the previously evaluated impact of the LBP on the worker’s job (GradeAE)andontheotherhand,toassessthemainlong-term work-related incapacity factors, i.e. job-related physical cons- traints,qualityofworkrelationshipsandsocialconditionsinthe worker’sorganization,pain-relatedbeliefsandbehaviors(adjust- ments, avoidance), collective organization policy of managing workincapacity(GradeAE).Thepre-RTWconsultationisalsothe perfecttimetoremindworkersthatitisnotnecessarytowaitfor thecompletedisappearanceofthesymptomstoRTWandthatan early RTWdoes actually improve theprognosis, given that job accommodations are made when necessary (Grade A) and to evaluate,inpartnershipwiththeemployeetheeventualneedto implementajobretentionapproach(GradeAE)’’.
Theimplementationoftheprocessofgettingbacktoworkcan leadtoresumingworkatthesameposition,jobretentioninthe samecompanybutatanotherposition,orvocationalrehabilitation toworkinanothercompany.Toensuremaximumeffectiveness,it is important to inform the occupational physician, as early as possibleafter6weeksofsickleave,ofapotentialsituationthat couldleadtoprogressiveexclusionfromtheworkplace[19].Early care management,recommended inthe literature,includesthe coordinationofmedicalcare,changesinbehaviorsforallactors Fig.1.Synthesisofred,yellow,blueandblackflagsforlowbackpainworkers.
Table1
Recommendedtoolsfortheassessmentoflowbackpain-relatedfunctionalincapacity.
Assessedparameters Recommendedtools
Pain VisualAnalogScale(VAS)
Occupationalfactorsofprolongedincapacity O¨ rebroMusculoskeletalPainScreeningQuestionnaire(O¨ MPQ)
Functionalincapacity Roland-MorrisDisabilityQuestionnaire(orEIFELFrenchversions)andDallasPainQuestionnaire Lowbackpainworker’sbeliefs WorksubscaleoftheFear-AvoidanceBeliefsQuestionnaire
involved and higher RTW rate for patients thanks to muscle strengtheningrehabilitationprograms,therapeuticeducationand/
orformalandinformaladviceinregardstopreparingtheRTWand pain management [61–65]. Therefore, ‘‘it is recommended to promote the transition of the worker from a medicalized environmenttoa workingenvironmentbyincitingandhelping him/hertakeanactivepartintheRTWprocess,byevaluatingthe perceived physical demands of the job and the social support perceivedbythepatientwhileidentifyingthemainwork-related difficultiesandpossiblejobaccommodations,toplanatransition periodforaprogressiveandorganizedRTW,andhelpemployees improvetheirabilitiestomanagetheirresidualsymptomsatwork (GradeC).Inordertodothis,thepre-RTWconsultationmustbe planned sufficiently ahead of thescheduled return-to-work, in ordertomakesurethatallnecessaryapproachesforjobretention havebeenmadebeforeeffectivelyresumingwork.Furthermore,it isrecommendedthatactionsin theworkplaceincludea multi- organizationaldimension andtoensuretheinvolvementof the concerned workers into a ‘participative’ approach (Grade C).
Severalpre-RTWconsultationsmaybenecessary(GradeAE)’’.
Furthermore, ‘‘it is recommended to evaluate the medical, administrative,socialandoccupationalsituationofemployeesand informthem of the advantages and drawbacksof having their chronicLBPrecognizedasanoccupationaldisease,iftheprocess wasnotalreadystarted(GradeAE)’’.
3.4.2. Coordinationofinterventionsandactorsinvolved
Severalactorscanbeinvolvedinresearchingasolutionforjob retentionandthesuccessofthissearchliesinthequalityofthe partnershipandcoordinationbetweenthevariousactors.Thefirst actor in this job retention is the employee, whose active participationisessentialtotheRTWprocessandinthesharing of health-related information between the different actors [66]. The pre-RTW consultation promotes partnership between all playersand the coordination of their differentactions. The involvementoftheorganizationoritsrepresentative,healthand safetymanagersandworkerrepresentativesarealsoessentialto the success of RTW or job retention [67,68]. Therefore, ‘‘it is recommendedtoevaluate,infullagreementwiththeemployee,an eventualneedforcollaboratingwiththeprimarycarephysician, specialist(s)and,possibly,theOPand/oractorsinvolvedinRTW, butalsotoinformtheemployer,infullagreementwiththeworker, ofthenecessaryconditionsforasuccessfulRTW(GradeAE)’’.
Thecoordinationofthemedical,socialandoccupationalactors hasapositiveinfluenceontheRTWrateaswellasonincapacityand painin workers who resume working [69–71]. Therefore, ‘‘it is recommendedtoensurethemutualcomprehensionofthesituation and care management objectives between the worker, care physicians(primarycareandspecialist[s])andtheOP(GradeAE)’’.
The implementation of effective work disability prevention strategiesrequiresthecreationofmultidisciplinaryteamsor,at least,thecooperation of several healthcare fields: occupational medicine,physicalmedicineandrehabilitation,workandmedical psychology,physicaltherapy,occupationaltherapy,ergonomics... Mostrecently,theinterventionshavefocusedontheworkplace environmentwiththeobjectiveofimprovingthesupportofupper management and colleagues or reduce work-related physical constraints[67,68,71].Thiscoordination canbefacilitated by a contact between all healthcare actors and the occupational physician, especially by requesting a pre-RTW consultation, maintaininga relationshipbetween theworkplaceenvironment and the employee during his or her sick leave, workplace evaluation and potential proposals for accommodations, the collaboration of actors in the workplace, as well as solving eventual medical, administrative and social issues [69–71]. In ordertoachievethis,‘‘itisrecommendedtoprogramanevaluation
oftheworkstation,ifpossibleinthepresenceoftheworker,and organize a meeting between the worker, themanagement, the employerandpossiblycolleaguesdirectlyintheworkplacesetting (Grade AE)’’. For otherauthors,the main coordinationaxes for promotingRTWresidemainlyinworkstationevaluation,planning progressiveRTWrequestsandfacilitatingthecommunicationand agreement of all partners. Most probably, a successful RTW coordinationseemsmorebasedonergonomicsjobaccommoda- tion, communication and conflict resolution rather than on medical orpurelybiomechanical knowledge[72].Thepre-RTW consultation(s)arepreciselytherightmeantopromotedialogue betweenallactorsandthecoordinationoftheiractions.
4. Conclusion
In France,occupationalhealth servicesandmultidisciplinary occupational teams,coordinatedby theoccupational physician, contribute,inaccordancewiththelaw,tothepreventionofspine- related risks and to the promotion of job retention. The July 2012occupationalmedicineamendmentwidensthemissionsof the occupational physician, as an advisor to the employers, workers, and their representatives, in terms of accommodating workstations,techniquesandworkratesinordertopromotejob retentionforworkers(Art.R.4623-1labourregulation).
Atthescaleoftheindividualworker’sfollow-upthepre-RTW consultationisakeysteptothemedical,socialandoccupational evaluation of the employee’s situation and the actions to be implementedfortheRTWandjobretention.Forbetterefficacy, this consultation and subsequent related actions must be implementedearlyon.Themainrecommendationsare:
deliveringtoLBPworkersreassuringinformationregardingback riskandLBP;
evaluating the prognostic factors regarding progression to chronicityandlong-termincapacityrelatedtotheLBP;
assessingthephysical,socialandoccupationalimpactoftheLBP aswellasthefunctionalcapacitiesoftheLBPworker;
supportingandpromotingjobretentionbyathoroughsynthesis ofthemedical,socialandoccupationalelementsofthesituation andcoordinationofallactors.
Eventhough theseguidelines areforemost dedicated toOP, whoareresponsibleforthemedicalandoccupationalfollow-upof workersandthecoordinationofthemultidisciplinaryteam,these recommendationsarealsoaimedatmedicalactors(primarycare physicians,specialists,socialsecurityadvisorphysicians),health- care professionals (physical therapists, occupational therapists) medico-socialprofessionals(thoseincharge ofvocationalreha- bilitation and job retention, social workers, ...) and company representatives (employers, upper management, employees’
representatives).In fact,betterknowledgeoftherelevanceand theobjectivesofthepre-RTWconsultationbytheworkersaswell associalandmedicalactorssupportingthem,couldimprovethe collaborationofallactorsandcoordinationofactionstopromotea successful RTWand job retentionof workersduring long-term and/orrepeatedsickleaveforLBP.
Disclosureofinterest
The authors declare that they have no conflicts of interest concerningthisarticle.
Acknowledgments
Authorsthankthe24membersoftheworkinggroupandthe 50 membersof thereadinggroupfor their participationtothe
elaborationoftheserecommendations.AuthorsthanktheSocie´te´
franc¸aisedeme´decinedutravailandtheHauteAutorite´ desante´
(KarinePetitprez)fortheirmethodologicalandlogisticsupport,as wellastheDirectionge´ne´raledutravailfortheirfinancialsupport.
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