Resilience and return-to-work pain interventions: systematic review

Occupational Medicine 2019;69:163–176 Advance Access publication on 21 March 2019 doi:10.1093/occmed/kqz012 SYSTEMATIC REVIEW Resilience and return-to-work pain interventions: systematic review E. Wainwright1, , D. Wainwright2, N. Coghill2, J. Walsh1 and R. Perry3 Department of Psychology, Bath Spa University, Bath BA2 9BN, UK, 2Department of Health, University of Bath, Bath BA2 7AY, UK, 3NIHR Bristol Biomedical Research Centre – Nutrition Theme, Level 3 University Hospitals Bristol Education Centre, Upper Maudlin Street, Bristol BS2 8AE, UK. 1 Background Resilience is a developing concept in relation to pain, but has not yet been reviewed in return-towork (RTW) contexts. Aims To explore the role of resilience enhancement in promoting work participation for chronic pain sufferers, by reviewing the effectiveness of existing interventions. Methods Resilience was operationalized as: self-efficacy, active coping, positive affect, positive growth, positive reinforcement, optimism, purpose in life and acceptance. Five databases were searched for randomized controlled trials (RCTs) whose interventions included an element of resilience designed to help RTW/staying at work for chronic pain sufferers. Study appraisal comprised the Cochrane risk of bias (RoB) tool and additional quality assessment. Findings were synthesized narratively and betweengroup differences of outcomes were reported. Heterogeneous PICO (population, intervention, comparator, outcome) elements precluded meta-analysis. Results Thirty-four papers from 24 RCTs were included. Interventions varied; most were multidisciplinary, combining behavioural, physical and psychological pain management and vocational rehabilitation. Four found RTW/staying at work improved with intensive multidisciplinary interventions compared with less intensive, or no, treatment. Of these, one had low RoB; three scored poorly on allocation concealment and selective outcome reporting. Four trials had mixed results, e.g. interventions enabling reduced sick leave for people on short-term not long-term leave; 16 showed no improvement. Five trials reported resilience outcomes were improved by interventions but these were not always trials in which RTW improved. Conclusions Effectiveness of resilience interventions for chronic pain sufferers on RTW is uncertain and not as helpful as anticipated. Further agreement on its conceptualization and terminology and that of RTW is needed. Key words Chronic pain; occupational health; resilience; return to work. Introduction There is compelling evidence that safe, appropriate work confers economic, bio–psycho–social benefits for workers and their families [1–3] and strong evidence that worklessness is associated with poorer physical and mental health outcomes for working-age adults [4] including those with chronic pain [5,6]. Chronic pain can be defined as pain that fluctuates, lasting over 3 months, which may be intractable [7,8]. It is estimated that one in five Europeans has chronic pain [9] and it was recently reported that 25–35% of adults report chronic pain [5]. Chronic pain can negatively impact on work [5,10]. An observational study review reported that it has substantial deleterious effects on work absenteeism and presenteeism [11]. It is therefore useful to consider what makes a chronic pain sufferer who wants to (re)enter or sustain working life resilient. Defining resilience is complex; it is debated whether it is an outcome, process, state or trait [12–14]. Resilience enhancement arises from positive psychology, n otably the Broaden-and-Build and Self-Determination Theory © The Author(s) 2019. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: Correspondence to: E. Wainwright, Department of Psychology, Bath Spa University, Bath BA2 9BN, UK. Tel: +44 01225 875563; e-mail: 164 OCCUPATIONAL MEDICINE Key learning points What is already known about this subject: • Resilience is a developing concept in relation to interventions designed to promote return to work for people living with chronic pain but this evidence has not been systematically reviewed What impact this may have on practice or policy: • Pain’s multi-faceted nature increases the need for healthcare professionals to enable patient-centred communication when engaged in interventions trying to return pain sufferers to sustainable working lives • Intervention studies which specifically assess key resilience concepts such as self-efficacy concurrently with other psychological variables may assist in deciding if any one resilience enhancing variable contributes uniquely to return to work • If researchers came to consensus about how to measure work participation, this could make study comparison more meaningful, hence further develop the evidence base [15,16]. There is agreement that resilience can be defined as a dynamic process encompassing positive adaptation in the face of adverse experiences that would otherwise lead to poor outcomes [17–19]. Resilience is a complex, multifaceted phenomenon, but it may help us understand why some people seem relatively protected from stress compared to others [14,20,21]. It is thought that having a resilient personality (i.e. having emotional flexibility and availability to problem-solve) can protect older adults against adverse effects of chronic pain and may help explain individual differences in pain acceptance if considered a stable trait involving the ability to adapt to adversity [22]. A recent review has conceptualized resilience when one is in pain as being able to recover from disability and depression, and sustaining functioning in the presence of pain [23]. This psychological flexibility model, which includes acceptance, mindfulness and committed action, could be important to consider when conceptualizing resilience in pain [24]. These authors also suggest that acceptance and commitment therapy (ACT), which promotes behaviour change rather than symptom reduction, may be key. There is a growing evidence for the utility of these models in reducing pain-related suffering [25]. The authors argue that promoting resilience mechanisms may be useful for both interventions and prevention strategies. It is methodologically challenging to operationalize and measure the dynamic characteristics of resilience mechanisms such as psychological flexibility. We need to know more about resilience when one is in pain [23]. Another recent review demonstrated overlap between pain resilience, pain acceptance, psychological flexibility and pain self-efficacy [26] and concluded that pain resilience is a ‘dynamic process related to both stable individual characteristics and contextual and state factors, such as goal contexts and affective states’. We have synthesized key factors from the research above, and from communications with leading resilience and pain researchers, to inform our search strategy (App (...truncated)