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Psychosocial factors related to return to work following rehabilitation of whiplash injuries.


It is well documented that the longer someone remains off work following an injury, the less likely they are to return to work. It is suggested in the literature that individual psychosocial factors are significant determinants of work disability, as well as the workplace or system-related factors. Those who remain off work long term account for the greatest insurer costs, employer costs and human suffering.

Linton (2000) found that psychosocial factors related to the reporting of injury and the transition from acute to chronic status. Clinically, the purpose of psychosocial screening is to allow identification of injured workers specific problems in order to provide appropriate and timely interventions. In reality, screening tools lack sensitivity and specificity and therefore lead to a number of workers who would have returned to work receiving intervention, and vice versa. It is assumed that if we can target the right people at the right time, return to work outcomes will improve in a cost effective manner. Little is known about whether matching interventions to risk profiles provides better outcomes. This study attempted to look at the degree in which psychosocial factors might account for the relationship between chronicity and poor return to work outcomes.

The questionnaires used were standardised assessment tools that have all been validated. Results show that the chronic group differed from the subacute and early chronic groups with significantly higher scores on all questionnaires at all times of testing. This finding appears to answer the original question that chronicity is associated with an increased psychosocial risk profile. The magnitude of change seen with the intervention is also significantly lower, the longer a person remains off work. The authors do highlight a potential weakness in their findings; because the subjects were selected on the basis of meeting certain scores, regression to the mean could account in some way for the observed reductions in the risk factor scores.

Participants were not randomised into groups, but this study was never intended to be a clinical trial, as the authors were not looking at the efficacy of the intervention. Efficacy of the PGAP has been studied previously although not extensively (Sullivan et al 2006). Information was not available for those who were not enrolled in the PGAP although an assumption could be made that as they did not present with a strong psychosocial risk profile (they did not meet the entry criteria) they were more likely to return to work. However, information about return to work rates in this group would have allowed some comparison.

A further weakness of this study is that return to work rates were not collected past 4 weeks, therefore ability to remain at work is unknown. Return to work data was not analysed further (although the modest sample size may have prohibited this being worthwhile) to identify those in full versus part time work.

As with many papers published on return to work outcomes we need to exhibit caution when interpreting the results, as the system within which it operates is a possible confounding factor. This study was carried out in eastern Canada where the worker's compensation differs from our Accident Compensation Corporation (ACC) system. ACC has recently completed training of therapists and is planning to implement the PGAP in New Zealand and follow through with their own research.

The authors conclude that disability beliefs may be resistant to change as work disability increases and this is seen clinically. The potential for changing beliefs and therefore improving outcomes for a group of injured workers with disability beliefs, if that intervention occurs in a timely manner (i.e. within 3-6 months) appears more promising. These findings would benefit from further research within our own compensation system.

Joanne Williams, MHealSci, DipPhty



Question: How much do psychosocial risk factors account for the relationship between chronicity and poor return to work outcomes?

Study design: Questionnaires were used to collect data regarding pain catastrophising, fear of movement/re-injury and perceived disability at pre-intervention, mid-programme, and programme completion. A phone interview was undertaken 4 weeks after programme completion to determine if participants had returned to work.

Participants: Seventy five (39 men, 36 women) participants with a diagnosis of Whiplash Grade II, sustained in a rear end motor vehicle accident. All were employed prior to their accident and were classified from duration out of work as: subacute (4-12 weeks), early chronic (3-6 months) or chronic (6-18 months). All participants were enrolled in a psychosocial intervention (Progressive Goal Attainment Programme [PGAP]) aimed at facilitating return to work. To meet inclusion criteria they had to score above the 50th percentile on at least one of the risk factors targeted by the programme.

Intervention: PGAP was delivered as a standardised intervention. This programme utilises activity involvement to reduce catastrophic thinking, fear of movement and perceived disability. All participants also took part in a functional restoration physiotherapy programme.

Results: Participants in the subacute (80%) and early chronic (72%) groups were significantly more likely to return to work compared to those in the chronic group (32%). Questionnaire scores showed significant group differences for pain catastrophising and fear of movement/re-injury between the chronic group and the subacute/early chronic groups at all three stages of the programme. At completion of the intervention, all three groups demonstrated significant change (reduction) in scores.

Conclusion: Self reported disability is resistant to change as the period of time off work increases. The need for early intervention in order to change disability beliefs in this population is recommended.


Linton SJ (2000): A review of psychological risk factors in back and neck pain. Spine 25: 1148-1156.

Sullivan M, Adams H, Rhodenizer T and Stanish W (2006): A psychosocial risk factor targeted intervention for the prevention of chronic pain and disability following whiplash injury. Physical Therapy 86: 8-18.
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Title Annotation:Critically Appraised Papers
Author:Adams, H.; Ellis, T.; Stanish, W.; Sullivan, M.
Publication:New Zealand Journal of Physiotherapy
Geographic Code:8NEWZ
Date:Nov 1, 2007
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