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1 Finnish Institute of Occupational Health, Helsinki, Finland;2 NHMRC Centre for Integrated Research and Understanding; of Sleep(CIRUS), Woolcock Institute of Medical Research, Sydney, Australia3 Department of Public Health, University of Helsinki, Finland
Pain andtransitions out ofpaid employment:Tea Lallukka (1,2,3)
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Key take home messages
• Pain is a serious public health andsocietal challenge.
• A notable proportion of working aged peoplesuffer from pain, which can lead to short-term or even permanent work disability.
• The risk of work disability can potentially beshaped e.g. via modifiable risk factors suchas working conditions.
• It is possible to continue working with pain.
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Common, persistent, and recurrent (1,2)Already in childhood and adolescence (3)
(1) Hoy et al. Best Practice & Research Clinical Rheumatology 2010; 24:769–81; (2) Dunn et al. Best Practice & Research ClinicalRheumatology 2013; 27:591–600; (3) Calvo-Munoz I et al. BMC Pediatr 2013;13:14
Pain is
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Pain and premature exitfrom paid employment
Childhood & adolescence Adulthood/worklife Exit from paid employmentØ Sickness absenceØ Disability retirement
Ø Early painØ Other risk factors
Ø Acute and chronic painØ Multisite pain
Determinants of pain during life courseAge, gender, lifecourse socioeconomic position, modifiable riskfactors such as health behaviours, obesity, working conditions
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Social, work-related andbehavioural determinants of pain
https://pixabay.com/photos/employee-worker-work-physical-1694117/, https://pixabay.com/illustrations/slimming-physical-exercise-treadmill-1136637/, https://pixabay.com/photos/addict-addiction-ashtray-bad-burnt-84430/,https://pixabay.com/illustrations/back-pain-pain-doctor-body-back-2292149/
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Social mobility and radiating lowback painPain disproportionally affects people with low socioeconomic position
Modified from: Lallukka T, et al. Eur J Pain. 2014;18:128-38
OR
*statistically significant after adustments
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Cumulative physical heaviness of work andsubsequent primary health care visits due toupper extremity diseases: a 28-year follow-up
Halonen,… Lallukka. Manuscript 2019
*
*
* * Model 1:age and sex† Model 2:age, sex,smoking,BMI, andparentaloccupationalclass
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Halonen, Lallukka et al. Spine 2019, in press
Physical workload and health-related factors asrisk factors of incident low back pain: a follow-up study of Swedish employeesRisk Ratios (RR) and 95% confidence intervals (CI), adjusted model
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Pain leads to sicknessabsence and disabilitypensionMultisite and recurrent pain
https://en.ac-illust.com/clip-art/117810
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NEW: Within-individual analysisof pain and sickness absenceIncidence rate ratios (IRRs) from a hybrid negative binomial regression*
*IRRs adjusted for time-varying and covariatesP-value for all differences in the between-vs. within-individual estimates <0.05)Short-term = within the survey yearLong-term = during two years after the survey year
From: Hiilamo A,…, Lallukka T. BMJ Open, in press 2019
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1.4
1.4
1.8
1.6
1.9
2.3
2.7
2.6
1.2
1.4
1.4
1.4
1.5
1.8
1.8
1.8
Only past multisite pain
Only past single-site pain
Recurrent single-site pain
Only current single-site pain
Past multisite pain, current single-site
Only current multisite pain
Recurrent multisite pain
Past single-site, current multisite pain
1 1.5 2 2.5 3 1 1.5 2 2.5 3
Unadjusted Adjusted
UnadjustedAdjusted
IRR for long SA
Longitudinal multisite pain profilesand long-term sickness absence*
From: Lallukka T, Hiilamo A, Oakman J et al. Manuscript 2019
*more than 14 days
Incidence rate ratios (IRRs)
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1.3
1.3
2
4.6
8.4
8.8
8.9
10
.91
1.4
1.5
2.5
3.9
4
5.2
5.4
Only past multisite pain
Only past single-site pain
Only current single-site pain
Past multisite pain, current single-site
Recurrent multisite pain
Past single-site, current multisite pain
Recurrent single-site pain
Only current multisite pain
0 5 10 15 20 0 5 10 15 20
Unadjusted Adjusted
UnadjustedAdjusted
Sub hazard ratios for disability pension award due to musculoskeltal disorders
Longitudinal multisite pain profilesand disability pension due tomusculoskeletal diseases(M00-99)
From: Lallukka T, Hiilamo A, Oakman J et al. Manuscript 2019
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Routes of exit
IN TOTAL:6038 non-health related exits2330 health-related exits474 exits due to unemployment1036 exits due to other reasons
Lallukka et al. OEM 2018
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Odds ratios (OR) for the different routes ofexit from paid employment by the numberof pain reports
Adjusted for sex, age and study phase, parental education, occupational grade,BMI, job demands and job control (* 95% CI not including 1.00)
OR
1,00
1,20
1,40
1,60
Exit Health-related Retired Unemployment Other
1 vs. 0 times back pain≥2 vs. 0 times back pain
*OR 1.51, 95% CI 1.15-1.99
*
*
Lallukka et al. OEM 2018
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The proportions (%) of participantsleaving paid employment due to health-related reasons by N of pain reports
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So What...
• … can be done?• A Finnish example of success:
• Occupational Health Helsinki introducedrecommendations to prescribe sickness absence in2016-2017‒ 1/2016: low back, shoulder and elbow pain (prevalent and
recurrent, ICD10: M54, M75, M77.1)‒ 1/2017: neck pain (M53.0, M53.1, M54.2), plantar fasciitis
(M77.2)‒ 8/2017: arthritis of the knee (M17-)
Modified from: Helena Miranda, MD
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0
5000
10000
15000
20000
250002015 2016 2017
- 42 %
3 %- 35 %- 73 %
- 46 %
Modified from: Helena Miranda, MD
Sick leave days from theoccupational health (numbers)
Backpain(M54)
Shoulderpain(M75)
Elbowpain(M77.1)
Neckpain(M53.0,M53.1, M54.2)
Plantarfasciitis(M77.2)
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• Roughly 20 000 more days with work ability in 2years (for the City of Helsinki)
• Cost of sickness absence 250 EUR /dayàMonetary savings: 20 000 days * 250 EUR =
5 000 000 €
Modified from: Helena Miranda, MD
Reduction in the number of sickleave days due to back, shoulderand elbow pain
https://pixabay.com/illustrations/euro-bill-currency-ball-round-447214/
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Working with pain?Potentially modifiable determinants
Suomenlinna Unesco World Heritage Site
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Multisite pain with goodwork ability?
0
10
20
30
40
50
60
Men Women 30-44 years 45-64 years
Good work ability
%
Modified from: Pensola T et al. Scand J Public Health. 2016;44:300-10
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Modifiable predictors of sicknessabsence among people withmultisite pain (1096 women and men)
Lower odds for sickness absence• Work-related factors:
• Physically light work• No repetitive hand movements• Workday length adustment
possible• Encouraging atmosphere at work• No mental stress
• Behavioural factors / health-related factors:• Normal body weight• No sleep disorders
Modified from Haukka E et al. Pain 2017;158:220-9
74%
26%
0 20 40 60 80
Low sicknessabsencetrajectory
High sicknessabsencetrajectory
%
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Discussion
• Pain is a notable burden not only onindividuals and public health but alsoat societal level and economics.
• Pain is not a sufficient cause fordisability pension, BUT
• it could be an important trigger, whichhighlights the importance to tackle itsrisk factors at an early phase.
https://pixabay.com/illustrations/back-pain-backache-ache-aching-3318065/
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Future directions to extend workcareers – joint efforts with differentstakeholders?
• Work modifications might make a difference• Early detection and interventions and focus
on also young employees• Narrowing the gap between researchers,
policy makers and other stakeholders• Other suggestions for the Q&A in the
end?
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Thank you and welcome toFinland!
Autumn Winter Spring Summer
latrobe.edu.au
La Trobe University CRICOS Provider Code Number 00115M
Working with persistent pain - an exploration of strategies used to stay
productive at work
Associate Professor Jodi OakmanMarch 13th, 2019
latrobe.edu.au
Workplace accommodations are an important part of enabling individuals to remain at work
Supportive employers are key to ensuring the effectiveness of workplace accommodations
Resources to support both employers and employees for managing persistent pain are needed to support what is needed and where to access services.
Key messages
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Musculoskeletal (MSK) pain is highly prevalent, with nearly 7 million Australians impacted by arthroses and other MSK pain (Australian Institute of Health and Welfare, 2017).
A growing body of evidence suggests that those with chronic conditions, which includes MSK pain, will find it more difficult to maintain employment across an extended life course
Why is persistent musculoskeletal pain a
problem?
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Musculoskeletal pain common in older adults.
Low Back Pain increases with age
• CUPID study: 12,000 workers across 47 occupational groups from 18 countries, LBP was 55% more prevalent at 50-59 than 20-29 years
• British study: 12 month prevalence about double for same age groups as above
Ref: Coggin et al (2013); Palmer et al (2015)
Ageing workers and musculoskeletal
health
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Good quality work better than not working
Sick leave a good predictor of future disability pensioning
More severe or extensive symptoms appear to consistently carry a higher risk of poor employment outcome
Work and pain
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Person environment fit
According to macroergonomicstheory, worker productivity is improved when individuals are well matched to the inherent requirements of their work with better outcomes at an individual and organisational level, often referred to as person-environment fit.
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A systematic analysis of the literature was undertaken to determine which characteristics of workplace interventions are most effective in assisting people with persistent musculoskeletal pain (PMP) to remain productively employed.
Ref: Oakman et al 2016
What is needed to stay at work?
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No high-level evidence for workplace interventions to
assist people with PMP were identified.
Low numbers of participants and limited studies
resulted in downgrading of evidence.
However, individually focused interventions will probably
reduce job loss and sick leave, but are unlikely to reduce
pain.
Multilevel focused interventions will probably result in
decreased sick leave and provide some cost benefit.
The evidence on productivity was limited and of poor
quality.
And, the results
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Study 1:
To explore supports—work and non-work— used by employees to assist them in maintaining productive employment
Study 2:
What resources and supports do people with non-work-related lower back and neck pain need to maintain productive employment?
How should resources to support people with non-work-related lower back and neck pain be provided, implemented and communicated?
What strategies and resources are required to facilitate communication with employers to assist them in managing people with non-work-related lower back and neck pain, to maintain employment?
(see Oakman et al, 2017/unpublished report)
What do people with persistent pain say…….
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I'm the breadwinner in the family and my job pays quite well. There's a lot of people down at my work who'll never work again because of the repetitiveness of our work. So that crosses your mind, gee, am I going to be all right or am I going to be that next statistic? For me, it's - having a young family, it's a scary prospect … it gets to you where you're like, I could be in trouble here … it scares me because I've got nothing - I've got nothing to fall back on. (Crane Driver, 43 yrs)
People’s concerns
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Disclosure
But occasionally you don’t, I do feel like I don’t want to give too much information
that might be used against me as well…If I stigmatise myself as the guy with the bad
back it might, maybe it will cost me some work days or they might look at someone
else. These sort of things go through my head. (Teacher, 48 yrs)
See Oakman et al. 2016
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Barriers
See Oakman et al 2016
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Enablers
See Oakman et al. 2016
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Resources
• Main source of condition/pain management information was GPs, friends & family.
• Some searched internet but were overwhelmed and reported a lack of readily available reputable resources.
• Particularly difficult for people from non-English speaking background
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Resources
Community Organisational Individual
What is needed?
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Co
mm
un
ity Increased publicity of MSK Australia website and resources
Implementation of guidance material where jobs are outlined and described according to a set of criteria, e.g. whether the job involves lifting, long
periods of sitting etc. so that individual’s can make informed decision about their careers and future transitions to different jobs which match their
capacities
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Org
anis
atio
nal
emp
loye
r
•Information/web pages for employers about appropriate accommodations
Resources to direct workplace managers and supervisors about how to access services for advice on workplace
accommodations
•Short recorded presentations on topics to educate employers about accommodations, availability of supports,
and other relevant information
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Ind
ivid
ual
Wo
rkp
lace
•Case study videos of people who are managing employment with a range of conditions, e.g. what accommodations at work are useful, how to
negotiate workplace modifications
Provision of resources to inform individuals about their rights and responsibilities in relation to disclosure of an MSK condition.
•Online case studies, written and video, of exemplar employment situations
Online resources with information on workplace supports and advocates –professionals who are able to conduct workstation assessments and
recommendations and liaise with management
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Ind
ivid
ual
Car
eer
Pla
nn
ing
Online resources to assist in identifying suitable jobs/careers for people with LBP and/or NP, e.g. an app to support people in
identifying their limitations and matching this with appropriate careers/jobs
•Information about training opportunities to facilitate career/job changes
Information about where to seek career advice, e.g. appropriate counselling services
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Additional note for employers
• Despite health difficulties, many individuals with arthritis and/or diabetes reported relatively low levels of accommodation use. (Gignac et al 2018)
• Having a variety of workplace practices available and the intermittent nature of symptoms also may mean that workers are able to find different ways to manage their health at work with very few accommodations. (Gignac et al 2018)
• Flexibility is key, but useful for all workers to manage work life interaction and improve sustainability of employment
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Research Gaps
• More intervention studies required, with a particular focus on what enables sustainable employment
• Greater guidance for employers on the benefits of managing/supporting individuals with MSK pain.
• Longitudinal research to establish cause and effect of accommodation provision
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About us
• For further information about our research in the Centre for Ergonomics and Human Factors see:
https://www.aphirm.org.au
• We also run training course in risk management of musculoskeletal disorders, please see our website for more details and to register for future programs.
For all other information please contact:
j.oakman@latrobe.edu.au
latrobe.edu.au
References• Coggon, D., Ntani, G., Palmer, K. T., Felli, V. E., Harari, R., Barrero, L. H., ... & Bonzini, M. (2013).
Disabling musculoskeletal pain in working populations: is it the job, the person, or the culture?. PAIN®, 154(6), 856-863.
• Gignac, M. A., Kristman, V., Smith, P. M., Beaton, D. E., Badley, E. M., Ibrahim, S., & Mustard, C. A. (2018). Are There Differences in Workplace Accommodation Needs, Use and Unmet Needs Among Older Workers With Arthritis, Diabetes and No Chronic Conditions? Examining the Role of Health and Work Context. Work, aging and retirement, 4(4), 381-398.
• Krause, N., Lynch, J., Kaplan, G. A., Cohen, R. D., Goldberg, D. E., & Salonen, J. T. (1997). Predictors of disability retirement. Scandinavian journal of work, environment & health, 403-413.
• Oakman, J., Kinsman, N., & Briggs, A. M. (2017). Working with persistent pain: an exploration of strategies utilised to stay productive at work. Journal of occupational rehabilitation, 27(1), 4-14.
• Oakman, J., Keegel, T., Kinsman, N., & Briggs, A. M. (2016). Persistent musculoskeletal pain and productive employment; a systematic review of interventions. Occup Environ Med, 73(3), 206-214.
• Palmer, K. T., & Goodson, N. (2015). Ageing, musculoskeletal health and work. Best practice & research Clinical rheumatology, 29(3), 391-404.rnal of Epidemiology & Community Health, 46(3), 227-230.
• Walsh, K., Cruddas, M., & Coggon, D. (1992). Low back pain in eight areas of Britain. Jou
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