1. Research Center for Insurance Medicine AMC-UMCG-UWV- VUmc Limitations to Work-Related Functioning of Medically Unexplained Physical Symptoms (MUPS): A Modified Delphi Study among Physicians Kristel Weerdesteijn, Frederieke Schaafsma, Allard van der Beek and Han Anema

2. Research Center for Insurance Medicine AMC-UMCG-UWV- VUmc Disclosure sheet Affiliations: Department of Public and Occupational Health, and the EMGO+ Institute for Health and Care Research, VU University Medical Center (VUmc), The Netherlands Research Center for Insurance Medicine (KCVG), AMC- UMCG-UWV-VUmc, The Netherlands Department of Social Medical Affairs (SMZ), Dutch Social Security Agency (UWV), The Netherlands Conflicts: The above organizations had no further role in analysis and interpretation of the data; no conflict of interest

3. Research Center for Insurance Medicine AMC-UMCG-UWV- VUmc MUPS & Sick leave MUPS: Cannot be fully explained by a defined organic disease Associated with: o Significant occupational dysfunction o Long duration of sick leave o Work disability Sick leave: In The Netherlands a prevalence of 15% of severe MUPS in employees on long-term sick leave In several European countries 5–8% of all new work disability benefits

4. Research Center for Insurance Medicine AMC-UMCG-UWV- VUmc Assessment of MUPS Complaints and dysfunction → limitations on work-related functioning: o claimant’s eligibility for a work disability o Advice about recovery, participation opportunities, long-term prognosis and treatment options Assessment of MUPS difficult: o lack of objective medical findings o Existing evidence-based recommendations general and not specified Differences in appraisal of work ability and advices → unnecessary obstacle in recovery and return-to-work process → consensus physicians of different specialty fields

5. Research Center for Insurance Medicine AMC-UMCG-UWV- VUmc Modified Delphi technique Preliminary round Four case vignettes: o MUPS of the head° MUPS of the abdomen or genitals o MUPS of the neck and upper extremities° MUPS of the back and lower extremities Summary of existing evidence List of 78 work-related functioning items based on: o The Functional Ability List (FAL) o The International Classification of Functioning (ICF) o National guidelines 15 physicians: o Insurance physicians° General practitioners o Occupational health physicians° Psychiatrists o Rehabilitation physicians

6. Research Center for Insurance Medicine AMC-UMCG-UWV- VUmc Modified Delphi technique → Experts were reported independently any potential limitations in the items per case vignette Bending Definition: Bending the upper body forward from a standing position and return back to the standing position shortly after. Interpretation: The dynamic load of bending concerns a few degrees of bending, normally no more than 90 degrees. When bending, the bended position does not take more than a few seconds. Bending can be necessary to increase the maximal effective personal reaching distance; to touch an object beneath hip height, to pick something up, to put something down, or to manipulate something. The angle of bending will be appraised by drawing a notion line from the hip joint to the shoulder joint. The angle of this line in combination with the lead line is the bending angle. Ability score: 1.Normal: is able to bend over an angle of 90 degrees (able to pick up a piece of paper from the ground) 2.Limited: is able to bend over a maximum angle of 60 degrees (able to pick up a bag from the ground) 3.Highly limited: is able to bend over a maximum angle of 45 degrees (able to pick up something from a chair) Ability score Case 1: MUPS of the head Case 2: MUPS of the neck and upper extremities Case 3: MUPS of the abdomen and/or genitals Case 4: MUPS of the back and lower extremities

7. Research Center for Insurance Medicine AMC-UMCG-UWV- VUmc Modified Delphi technique First and second round Processing and calculating the scoring of each expert → degree of consensus in each item per case vignette All items with ≥75% agreement on the level of limitations were accepted without further rating or discussion

8. Research Center for Insurance Medicine AMC-UMCG-UWV- VUmc Modified Delphi technique Third round

9. Research Center for Insurance Medicine AMC-UMCG-UWV- VUmcResults The experts reached consensus on 49 out of 78 items for the level of limitations to work-related functioning in all four cases No consensus on any of the cases for 2 items that were related to the category of working hours Number of items with consensus, per number of cases (©) Round 3 Category of items Total itemsone ©two ©three ©four © Personal functioning140068 Social functioning1200210 Dynamic movements2904916 Static postures91026 Adjusting to environment80017 Working hours and time61012 Total78242149

10. Research Center for Insurance Medicine AMC-UMCG-UWV- VUmcResults Category of items Total items MUPS of the head MUPS of the neck and upper extremities MUPS of the abdomen and/or genitals MUPS of the back and lower extremities Personal functioning 1411131412 Social functioning121012 Dynamic movements 2928222623 Static postures98797 Adjusting to environment 88887 Working hours and time 63333 Total7868657264

11. Research Center for Insurance Medicine AMC-UMCG-UWV- VUmcResults MUPS of the back and lower extremities Items per category: Level of limitations Personal functioning; High working tempo on the working place 1 a Increased personal risk on the working place1 Dynamic movements; Pulling or pushing 2b 2b Lifting2 Handle heavy objects frequently1 Turning/twisting round1 Kneeling or squatting1 Walking time per day on work2 Walking on different surfaces1 Walking stairs2 Moving around using transportation1 Static postures; Maintaining a sitting position2 Maintaining a standing position2 Maintaining a kneeling or squatting position1 Maintaining a bending and/or twisting position1 Need for possibility to change body position1 Adjusting to environment; Wearing protection gear1 Vibration1 MUPS of the neck and upper extremities Items per category: Level of limitations Dynamic movements; Turning or twisting hands or arms1 Reaching out1 Pulling or pushing1 Handle heavy objects frequently1 Climbing1 Static postures; Working above shoulders1 Maintaining head in one position1 Adjusting to environment; Wearing protection gear1 Vibration1

12. Research Center for Insurance Medicine AMC-UMCG-UWV- VUmcResults MUPS of the head Items per category: Level of limitations Personal functioning; Focusing attention1 Solving problems1 Handling stress and other psychological demands1 Distraction from others during work1 Need for predictable working situation1 Frequent disruptions on the working place1 Frequent deadlines and/or production peaks1 High working tempo on the working place1 Social functioning; Dealing with conflicts1 Cooperating with someone else1 Contact with clients1 Management tasks1 Dynamic movements; Duration time of using a keyboard and/or mouse1 Adjusting to environment; Sound intensity1 Vibration1 Working hours and working time; Working during the night (between 00:00-06:00)1 MUPS of the abdomen and/or genitals Items per category: Level of limitations Static postures; Standing time per day on work1 Adjusting to environment; Vibration1 Possibility to use a toilet quickly1

13. Research Center for Insurance Medicine AMC-UMCG-UWV- VUmcConclusion Physicians from several medical specialties were able to reach agreement for a substantial number of limitations to work-related functioning for people with MUPS People with MUPS can have functional limitations, but still have possibilities to work functioning despite these limitations Although the cases were all considered MUPS, the assessment of functioning seems to be based more on the specific impairment than on the disease.

14. Research Center for Insurance Medicine AMC-UMCG-UWV- VUmcConclusion Items with consensus: → Assessing work ability for people with MUPS → Better communication between physicians → better inter-rater reliability and less conflicting advice → better understanding of patients about their possibilities and work abilities → may help the return-to-work process Still some items did not reach agreement, especially in the category limitations in working hours → achieve further agreement among physicians, and study the effectiveness of a temporary or permanent limitation in working hours

15. Research Center for Insurance Medicine AMC-UMCG-UWV- VUmcQuestions

16. Number of items with consensus, per number of cases (©) Round 1Round 2Round 3 Category of items Total items one © two © three © four © one © two © three © four © one © two © three © four © Personal functioning14524213450068 Social functioning123171025500210 Dynamic movements29231182781204916 Static postures9033111331026 Adjusting to environment 8023300260017 Working hours and time 6000210121012 Total78101128175132333242149