1. Michiel Reneman REHABILITATION MEDICINE / CENTER FOR REHABILITATION

2. Disclosure Statement of Financial Interest I, Michiel Reneman, DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.

3. Focus of this contribution Chronic non-specific musculoskeletal pain (CMP) Because: Largest subgroup of people with pain Most costly, because of work productivity loss

4. Outline 1.General introduction Impact of pain on work and work on health and well-being 2.Measurement challenges 3.Staying at work with pain

5. Impact of pain on work CMP highly common among the general population ~ 90% at least once in adult life In many cases: rapid improvement / full recovery Recurrent 44-78% relapse of pain 26-37% relapse of work absence Few: long term pain with significant limitations in ADL and work Chronic: > 3 months

6. Societal costs Direct: costs related to medical care Medical: medical, allied, complimentary, … Nonmedical: transportation, meals, house renovations Indirect: costs related to consequences of CLBP Absenteeism and presenteeism Disability Replacement: overtime, recruitment, training Household productivity: replacement by partner or outsider Intangible costs: decreased QoL (often not included)

7. Direct and indirect costs Various countries, various methods USA: LBP 6 th costliest health condition, 3 rd in associated disability … by any standards must be considered a substantial burden on society

8. Direct and indirect costs in The Netherlands €3.5B - €4.3B per year 0.6% - 0.9% GNP Direct – indirect 12/88% …

9. Impact of work on health and well-being Independent review: 'Is Work Good for Health and Well-being?‘ Commissioned by the UK Department for Work and Pensions Examination of scientific evidence on the health benefits of work, focusing on adults of working age and the common health problems that account for two-thirds of sickness absence and long-term incapacity.

10. Impact of work on health and well-being There is strong evidence showing that work is generally good for physical and mental health and well- being. Worklessness is associated with poorer physical and mental health and well being. Work can be therapeutic and can reverse the adverse health effects of unemployment. That is true for healthy people of working age, for many disabled people, for most people with common health problems and for social security beneficiaries. The provisors are that account must be taken of the nature and the quality of work and its social context; jobs must be safe and accommodating. Overall, the beneficial effects of work outweigh the risks of work, and are greater than the harmful effects of long-term unemployment or prolonged sickness absence. Work is generally good for health and well-being.’ Waddell en Burton, 2006

11. Outline 1.General introduction Impact of pain on work and work on health and well-being 2.Measurement challenges 3.Staying at work with pain

12. CLBP: impact on work? Measurement challenges Variability among studies in terminology and methodology Extra complex Mixed – absent AND present Absent: temp AND permanent Part-time work Self-employed Pain research outcome measures: absenteism and presenteism Absenteeism Not / temporary / permanent Modified hours / work / shifts Measured from records: medical, insurance, employer Presenteeism Present at work, but less productive Measurement?

13. Outline 1.General introduction Impact of pain on work and work on health and well-being 2.Measurement challenges 3.Staying at work with pain Results of a study among a large and underreported group of people with CMP: workers who stay at work despite CMP. What went right? Are they just ‘not absent’, or can they still be productive? How are these people or their work different from those with CMP who seek tertiary care? What lessens can we learn from these workers?

14. Relevance: –‘Unknown’ in literature –New reference field –What can we and our patients learn from them? –Why do they SAW? –How can they SAW? What goes right?

15. Systematic review of scientific literature N=120 workers with chronic pain, < 5% absenteeism Controls: n=120 rehab patients / n=702 healthy workers In-depth interviews with participants Measurements: Bio: functional capacity, aerobic capacity, activities Psycho: cognitions, emotions, distress, coping, … etc Social: occupational physician, boss, partner

16. Study 1: Systematic review High level evidence for determinants for SAW is absent Existing knowledge is based on low level of evidence Consistent (low level) evidence low emotional distressSAW  low physical disabilitySAW  duration of painn.s. catastrophizingn.s. self-esteemn.s. marital statusn.s. Inconsistent evidence: self-efficacy age gender educational level physical and mental health pain intensity depressive symptoms coping

17. Study 2: Qualitative study Motivators: why SAW with chronic pain? Success factors: how are they able to SAW? Motivators: work as life value work as income work as responsibility work as therapy Succes factors: personality traits adjustment latitude coping with pain use healthcare services pain beliefs

18. Study 3: Contrast SAW and rehab patients Group status was predicted best by: pain intensity, duration of pain, pain acceptance, perceived workload, mental health, and psychological distress No difference: Self-reported physical activity level, active coping and work satisfaction

19. Study 4: Work ability and work performance (0-10) Pain Self-Efficacy consistently explained high WA and WP!

20. Study 5: Activity level and pattern Level: 30% higher in SAW Pattern: PM higher in SAW

21. Study 6: Functional capacity and deconditioning? Capacity: SL < CMP < Healthy CMP is associated with relevant deconditioning for work SL more often relevantly deconditioned than SAW

22. Study 7: Social determinants of SAW Partner, boss, colleagues, occupational physician Expected Fall 2012

23. Final results expected November 2012 Thesis The results of this study can be used to develop interventions to promote SAW. The knowledge gathered in this study provides a new reference for clinicians working in rehabilitation, occupational, and insurance medicine.

24. Summary / take home 1.Work is generally good for health and well-being 2.Sustained work participation with chronic pain is often possible and desirable. 3.On average, chronic pain is associated with lower WA and WP 4.Higher WA and WP is associated with higher pain self-efficacy. 5.Many determinants of sustained work participation with chronic pain are still unknown 6.Work participation should be a outcome measure for pain management.

25. m.f.reneman@cvr.umcg.nl REHABILITATION MEDICINE / CENTER FOR REHABILITATION