A case-control study of Naval rehabilitation patients assessing levels of psychological strain, susceptibility factors and workplace stressors.

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1 A case-control study of Naval rehabilitation patients assessing levels of psychological strain, susceptibility factors and workplace stressors. Dr Lachlan Mackay Brown

4 Rehabilitation in HM Forces 3 tier structure Physiotherapy assessment & treatment Regional Rehabilitation Units (RRUs) Defence Medical Rehab Centre Headley Court

6 biological psychological social

7 chronic pain psychological distress Tunks, E. R. et al. Epidemiology of chronic pain with psychological morbidity: prevalence, risk, course and prognosis. Can J Psychiatry 2008; 53(4):

8 chronic pain psychological distress occupational role disability Gureje, O., Simon, G.E., Von Korff, M. A cross-national study of the course of persistent pain in primary care. Pain. 2001; 92:

9 comorbid psychological distress outcome workplace stressors Lloyd, C., Waghorn, G., McHugh, C. Musculoskeletal disorders and comorbid depression: Implications for practice. Australian Occupational Therapy Journal. 2008; 55: Macfarlane, G.J., Thomas, E., Croft, P.R. et al. Predictors of early improvement in low back pain amongst consulters to general practice: the influence or premorbid and episode-related factors. Pain. 1999; 80:

10 Efficacy of psychological interventions Remains unclear Recent quality reviews show no added benefit Schaafsma, F., Schonstein, E. et al. Physical conditioning programmes for improving work outcomes in workers with back pain. Cochrane Database of Systematic Reviews. 2010; Issue 1. Art. No.: CD Henschke, N., Ostelo, R.W.J.G., van Tulder, M.W. et al. Behavioural treatment for chronic low-back pain. Cochrane Database of Systematic Reviews. 2010; Issue 7. Art No.: CD Difficulties interpreting the literature cloud analysis

12 Current thought Early psychological assessment Maladaptive coping strategies Risk factors for chronicity Tailored CBT approach to the individual Graded in vivo Exposure Acceptance and Commitment Therapy Bailey, K.M., et al. Treatments addressing pain-related fear and anxiety in patients with chronic musculoskeletal pain: a preliminary review. Cognitive Behaviour Therapy. 2009; 39(1): 46 63

13 Naval Stress Surveys (NSS) Strain prevalence c. 32% Identified workplace stressors associated with strain over-commitment effort-reward imbalance organisational commitment work/family conflict role conflict

14 Naval Stress Surveys (NSS) How strain prevalence changes over time Suggested susceptibility factors for job strain cognitive failures Van der Linden, D. et al. Work stress and attentional difficulties: An initial study on burnout and cognitive failures. Work and Stress. 2005; 19: Wadsworth, E.J. et al. Fatigue and health in a seafaring population. Occupational Medicine. 2008; 58:

15 Hypothesis 1 That rehabilitation patients would exhibit higher rates of psychological strain and higher scores on other stress-related factors than matched controls from the general Naval population

16 Hypothesis 2 That Spines patients would exhibit higher strain rates and higher scores on other stress-related factors than Lower Limb patients

17 Subjects Plymouth RRU patients over a 6 month period Spines & Lower Limbs courses Royal Navy & Royal Marines personnel Male & Female X Army & RAF patients X Previous NSS participants

18 Plymouth RRU Stress Survey Questionnaire Derived from modified Work and Wellbeing Questionnaire used in 2007 NSS Included: GHQ-12 5 stressor scales Cognitive Failures Questionnaire

19 Control Matching 2007 NSS data 3 controls per study participant Matched exactly service branch (RN or RM) gender rank As close as possible age length of service

20 Data Collection Day 1 Verbal brief by lead Physiotherapist Information leaflet Day 2 Unique ID code assigned Completed questionnaire in classroom setting (45 mins)

21 Results 8 rehabilitation courses 85 patients invited to participate 53 completed questionnaires 62% response rate

22 RRU patients v. controls 60 Strain Rates (%) RRU Patients 29.6 Contols P = 0.01 Odds Ratio Strain (RRU) = 2.29 (95% CI )

23 RRU patients v. controls Workplace stressors Effort-Reward Imbalance Over-commitment Role Conflict Work-Family Conflict Organisational Commitment No significant difference between RRU patients and controls by ANOVA

24 RRU patients v. controls Mean CFQ score (95% CI) 40.5 ( ) 32.3 ( ) RRU Patients Controls

25 Comparison of Spines & Lower Limbs groups Higher strain rates in Spines patients cf. Lower Limbs but not statistically significant No difference in workplace stressor scales or CFQ score between two groups

26 Strain Level All Patients Spines Lower Limbs Controls Effort/Reward Imbalance ** Over commitment ** Role Conflict 0.321* 0.358* 0.383** Work/Family Conflict ** Organisational C ment ** CFQ ** ** Correlation is significant at the 0.01 level (2-tailed) * Correlation is significant at the 0.05 level (2-tailed)

27 Conclusions Power affected by lower than predicted numbers Cognitive failures score findings tempered by wide CIs direction of relationship remains unclear constant v. variable

28 Conclusions Rehabilitation population more strain than matched controls different correlation patterns between usual stressors and strain levels What else may account for rehab patient strain? chronic pain syndromes occupational role disability? psychological morbidity?

29 Recommendations Further adequately powered research required to confirm findings Potential unmet need in patients at this stage of rehab

Is it useful for chronic pain patients? Therapeutic Patient Education (TPE) Psycho-education Cognitive Behavioral Therapy (CBT) Françoise LAROCHE, MD

Is it useful for chronic pain patients? Therapeutic Patient Education (TPE) Psycho-education Cognitive Behavioral Therapy (CBT) Françoise LAROCHE, MD Pain and Rheumatologic Department Saint-Antoine Hospital