Background
Musculoskeletal disorders (MSDs) refer to a range of problems affecting the musculoskeletal system due to inflammatory and degenerative disorders, injuries or repetitive movements, forces and postures.1,2 Musculoskeletal disorders are common, with 60-80% of working adults experiencing a MSD at some point which has a direct effect on functional ability, quality of life, medical costs and time off work.3-5 Of 131 million days lost to sickness in 2013, 31 million were attributed to back and neck problems in the United Kingdom.6 The UK Labour Force Survey has reported a work-related MSD prevalence of 553,000 out of 1,243,000 work-related illnesses in 2014/2015.7 This equates to 9.5 million working days lost and 44% of the total days lost. Australia has a similar incidence reported, with around 500,000 workers injured at work in 2013/2014, representing 4.3% of the workforce and a societal cost of musculoskeletal injury estimated to be around $60.6 billion a year (4.8% of the gross domestic product).8,9 Musculoskeletal disorders are also the biggest cause of working days lost in the United States of America, accounting for 29% of days off work in 2012 and an overall cost (direct and indirect) of $949 billion or 7.4% of gross domestic product.10
In addition to MSDs, work-related MSDs have been defined as "impairments of body structures such as muscles, joints, tendons, ligaments, nerves, bones or a localized blood circulation system caused or aggravated primarily by the performance of work and by the effects of the immediate environment where the work is carried out".11(p.7) Therefore, for the purposes of this umbrella review, all MSDs will be considered, including work-related MSDs, to ensure that all applicable evidence is considered.
Vocational rehabilitation has been identified as a solution to address the impact of MSDs in working-age adults, in which vocational rehabilitation is defined as "whatever helps someone with a health problem to stay at, return to, and remain in work",5(p.5) and work is defined as "activity involving mental or physical effort done in order to achieve a result".12(p.1) Vocational rehabilitation is a multi-component approach that includes different interventions specific to a condition that should begin early and address the physical musculoskeletal problem, any psychological disorders and employment factors to facilitate a sustained return to work (RTW).5 Often, the main outcome of interest in vocational rehabilitation is RTW, but as this is complex and can take time, it is acknowledged that sustained RTW is more advantageous. Sustained RTW differs in comparison to the first RTW as it has been acknowledged that there can be multiple episodes of time off work and also failed RTW.13 Additional outcomes that are also commonly reported for vocational rehabilitation are sickness absence, quality of life, pain and mental wellbeing (depending if there are psychological factors involved).14,15
There has been a significant body of research on vocational rehabilitation for MSD conducted since the best evidence synthesis by Waddell et al.,5 including a number of systematic reviews.16-18 A preliminary search of the Joanna Briggs Institute (JBI) Database of Systematic Reviews and Implementation Reports (JBISRIR), the Cochrane Database of Systematic Reviews, Prospero, MEDLINE and CINAHL did not identify any umbrella reviews (completed or in progress) on the topic. An umbrella review on the effectiveness of vocational rehabilitation on work participation for adults with MSD would enable enhanced understanding of which interventions are effective for which MSD. This will provide an up-to-date synthesis of the best available research evidence to inform commissioning and provision of vocational rehabilitation services. This umbrella review will therefore review all systematic reviews on the effectiveness of vocational rehabilitation interventions on RTW for people with MSD.
Inclusion criteria
Types of participants
The current umbrella review will consider systematic reviews that include working age adults aged 18 and over with MSD including, but not limited to, low back pain, neck pain, upper limb disorders (affecting joints and soft tissue around shoulder, elbow, wrist and hand), repetitive strain injuries, arthritis, rheumatic disease and lower limb disorders (affecting joints and soft tissue around hip, knee, ankle and foot) to provide as broad an overview as possible. As this review has a primary focus on MSD vocational rehabilitation, the following exclusion criteria will be employed: any study with participants aged under 18 years as this review is concerned with working age adults and reflects the working age included in published studies,15 and any studies focused on cardiovascular, respiratory, neurological or psychological vocational rehabilitation.
Types of interventions
The current umbrella review will consider systematic reviews that have evaluated vocational rehabilitation and any systematic reviews that have evaluated vocational rehabilitation (as defined above), including:
* Work participation/work place interventions (such as but not limited to ergonomic/postural assessments, modifications to the physical work environment, job modifications, case management and workplace visits), and/or
* Any systematic reviews of studies assessing interventions with the specific stated aim of assisting RTW such as but not limited to physiotherapy, exercise, education, back to school or psychological/behavioral treatment.
Outcomes
The current umbrella review will consider systematic reviews that include the following outcome measures:
* The primary outcome of interest is RTW - systematic reviews that use outcomes to measure return to paid work (including part-time and full-time work) such as sick leave duration, time to RTW, time until a lasting/sustained RTW,19 mean days of sick leave/month over follow-up or percentage population resumed work will be included.
* The secondary outcomes of interest for disability are patient-reported outcomes - mean or median change in overall function/disability (such as Roland Morris Functional Disability Questionnaire),20 quality of life (such as Short form 36)21 and pain (pain-rating scales).
Any studies focusing on presenteeism (reflecting people in work with an injury or illness that impacts on their work productivity)22 will be excluded as this review is focused on work participation in terms of RTW.
Types of studies
The current umbrella review will consider quantitative systematic reviews, meta-analyses and pooled analyses identifying relevant international scientific evidence on the effectiveness of vocational rehabilitation for working age adults with MSD. This umbrella review will not consider critical reviews, integrative reviews, general literature reviews, primary research or qualitative reviews.
Search strategy
The search strategy aims to find both published and unpublished systematic reviews and meta-analyses. A three-step search strategy will be utilized in this umbrella review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe each article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Third, the reference lists of all identified reports and articles will be searched for additional studies. Studies published in English will be considered for inclusion in this umbrella review. To ensure relevance, all studies published from 2006 onwards will be considered for inclusion in this umbrella review.
The sources to be searched include: MEDLINE, CINAHL, AMED, Cochrane Database of Systematic Reviews, Centre for Reviews and Dissemination Databases (Database of Reviews of Effects), PROSPERO register, JBISRIR, PEDro database and OTseeker.
The search for unpublished studies will include: Google Scholar, Grey Literature Report (The New York Academy of Medicine), National Institute for Occupational Safety and Health (USA), National Rehabilitation Information Centre (USA), National Institute of Disability Management and Research (Canada), Database of International Rehabilitation Research, Vocational Rehabilitation Association (UK), the UK Rehabilitation Council and British Society for Rehabilitation Medicine.
Initial keywords to be used will be: systematic review, meta-analysis, vocational rehabilitation, occupational rehabilitation, work rehabilitation, return to work, RTW, work retention, work status, sick leave, sickness absence, intervention and absence management.
Papers will be assessed for relevance based on the title, abstract and index terms, including papers found from searching reference lists of relevant papers. Screening will be conducted independently by two reviewers.
Assessment of methodological quality
Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized JBI critical appraisal tool for systematic reviews and research syntheses.23 Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.
Data extraction
Data will be extracted from papers included in the review by two independent reviewers using the standardized JBI data extraction tool for systematic reviews and research syntheses.23 The data extracted will include specific details about the type of review, countries where the studies were conducted, number of studies included in the review, participants (numbers, age group), type/s of intervention/s, outcomes identified (type/characteristics), length and completeness of follow-up and primary outcome measures. In the event of missing information or to seek clarity, the authors of this umbrella review will endeavor to contact the authors of the paper in question to seek clarification. Any disagreements between the two reviewers will be resolved through discussion, or with a third reviewer.
Data summary
The above data extracted from selected reviews related to the effectiveness of vocational rehabilitation for musculoskeletal conditions will be tabulated and accompanied by a narrative to address the review objective and specific questions. Tabular presentation of quantitative results describing overall effect sizes and a clear description of the vocational rehabilitation intervention will be presented with supporting interpretation. Tables will include a high level of detail for each included systematic review including number of studies, total number of participants, MSD, heterogeneity of results, setting, age and information on the vocational rehabilitation itself.
The results of the review will be provided in tabular format in a "Summary of Evidence" table that includes the vocational rehabilitation, musculoskeletal condition/s and a simple visual indicator of the effectiveness of the vocational rehabilitation using a "stop-light" indicator.24 The criteria that will be evaluated include methodological limitations, consistency, risk of bias and relevance to the study population.
Acknowledgements
The current umbrella review protocol is part of a mixed methods study funded by the Police Treatment Centres, UK.
References