Advertisement

The Vocational Continuum: How to Make Sense of Vocational Outcomes After Group Cognitive Behavioural Therapy for Chronic Pain Sufferers

Abstract

Introduction Vocational outcomes following group CBT programmes for patients with chronic pain are scarcely reported within the literature, despite their importance as measures of function. This study reports vocational, physical and psychological outcomes following a group CBT programme for patients suffering chronic pain. The study aimed to examine the vocational situation of chronic pain patients who completed a group CBT programme, using a scale known as the vocational continuum. The scale was developed to measure changes in RTW intention and work status, in an effort to reconceptualise vocational outcomes for this population with respect to the RTW process. Methods A group of patients referred to a hospital pain clinic that went on to complete a group CBT programme were retrospectively surveyed about their vocational status at various time points. Physical outcomes measured included the 12-min walk test, 2-min sit to stand test, 2-min stair climb test and timed 20-m walk test. Psychological outcomes measured included pain intensity, self-efficacy, psychological distress (depression, anxiety and stress), catastrophising and disability. Responses to vocational items including work status, hours of work, intention to RTW and barriers to RTW were incorporated into the vocational continuum. Results Two hundred and nine (58%) of the 360 patients who completed the group CBT programme between 1998 and 2005 completed the vocational survey. Ninety percent of participants reported that their chronic pain was a barrier to RTW or increasing hours of work pre-CBT. According to the vocational continuum, fifty per cent of the study population advanced toward working full-time (χ2(2, N = 163) = 28.87, < 0.01) and this result was associated with a significant reduction in pain as a reported barrier to RTW or increasing participation in work post-CBT. Significant improvements were seen across all physical and psychological measures for study participants at 1, 6 and 12 month intervals post-CBT. Conclusions The study demonstrates improvements across physical and psychological measures post-CBT, indicating that participants benefited from reduced levels of pain-related distress and disability. Although retrospective, the study also suggests improvements were made across vocational outcomes. By doing so, the study adds to scant literature reporting on vocational outcomes of group CBT programmes for patients with chronic pain and offers a new scale for measuring and interpreting vocational outcomes for this population.

This is a preview of subscription content, log in to check access.

Access options

Buy single article

Instant unlimited access to the full article PDF.

US$ 39.95

Price includes VAT for USA

Subscribe to journal

Immediate online access to all issues from 2019. Subscription will auto renew annually.

US$ 99

This is the net price. Taxes to be calculated in checkout.

Fig. 1
Fig. 2
Fig. 3

References

  1. 1.

    International Association for the Study of Pain (IASP) Clinical Updates. 2003. Available at http://www.iasp-pain.org/AM/AMTemplate.cfm?Section=Home&CONTENTID=2252&TEMPLATE=/CM/ContentDisplay.cfm.

  2. 2.

    Blythe FM, March LM, Brnabic AJM, Jorm LR, Williamson M, Cousins MJ. Chronic pain in Australia: a prevalence study. Pain. 2001;89:127–34. doi:10.1016/S0304-3959(00)00355-9.

  3. 3.

    Access Economics. The high price of pain: the economic impact of persistent pain in Australia. Report for the MBF Foundation, November, Canberra; 2007

  4. 4.

    Morely S, Eccleston C, Williams A. Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain. 1999;80:1–13. doi:10.1016/S0304-3959(98)00255-3.

  5. 5.

    Morley S, et al. Estimating the clinical effectiveness of cognitive behavioural…. Pain. 2008. doi:10.1016/j.pain.2008.02.025.

  6. 6.

    Amick BC, Lerner MS, Rogers WH, Rooney T, Katz JN. A review of health-related work outcome measures and their uses and recommended measures. Spine. 2000;25:3152–60. doi:10.1097/00007632-200012150-00010.

  7. 7.

    Bombardier C. Outcome assessments in the evaluation of treatment of spinal disorders. Spine. 2000;25:3100–3. doi:10.1097/00007632-200012150-00003.

  8. 8.

    Loisel P, Buchbinder R, Hazard R, Keller R, Scheel I, van Tulder M, et al. Prevention of work disability due to musculoskeletal disorders: the challenge of implementing the evidence. J Occup Rehabil. 2005;15:507–24. doi:10.1007/s10926-005-8031-2.

  9. 9.

    World Health Organisation. International Classification of Functioning, Disability and Health (ICF). 2001. Available at http://www.who.int/classifications/icf/site/intros/ICF-Eng-Intro.pdf.

  10. 10.

    Schultz IZ, Stowell AW, Feuerstein M, Gatchel RJ. Models of return to work for musculoskeletal disorders. J Occup Rehabil. 2007;17:327–52. doi:10.1007/s10926-007-9071-6.

  11. 11.

    Guzmán J, Esmail R, Karjalainen K, Malmivaara A, Irvin E, Bombardier C. Multidisciplinary bio-psycho-social rehabilitation for chronic low-back pain. Br Med J. 2001;322:1511–6. doi:10.1136/bmj.322.7301.1511.

  12. 12.

    Adams JH, Williams ACdeC. What affects return to work for graduates of a pain management program with chronic upper limb pain. J Occup Rehabil. 2003;13:91–106. doi:10.1023/A:1022599731391.

  13. 13.

    Young AE, Wasiak R, Roessler RT, McPherson KM, Anema JR, van Poppel NM. Return-to-work outcomes following work disability: stakeholder motivations, interests and concerns. J Occup Rehabil. 2005;15:543–56. doi:10.1007/s10926-005-8033-0.

  14. 14.

    Feuerstein M, Menz L, Zastowny T, Barron BA. Chronic back pain and work disability: vocational outcomes following multidisciplinary rehabilitation. J Occup Rehabil. 1994;4:229–51. doi:10.1007/BF02331618.

  15. 15.

    Richardson IH, Richardson PH, Williams ACdeC, Featherstone J, Harding VR. The effects of a cognitive-behavioural pain management programme on the quality of work and employment status of severely impaired chronic pain patients. Disabil Rehabil. 1994;16:26–34.

  16. 16.

    van der Hulst M, Vollenbroek-Hutten MMR, Ijzerman MJ. A systematic review of sociodemographic, physical, and psychological predictors of multidisciplinary rehabilitation—or, back school treatment outcome in patients with chronic low back pain. Spine. 2005;30:813–25. doi:10.1097/01.brs.0000157414.47713.78.

  17. 17.

    Dionne CE, Von Korff M, Koepsell TD, Deyo RA, Barlow WE, Checkoway H. A comparison of pain, functional limitations, and work status indices as outcome measures in back pain research. Spine. 1999;24:2339–45. doi:10.1097/00007632-199911150-00009.

  18. 18.

    Young AE, Roessler RT, Wasiak R, McPherson KM, van Poppel NM, Anema JR. A developmental conceptualization of return to work. J Occup Rehabil. 2005;15:557–68. doi:10.1007/s10926-005-8034-z.

  19. 19.

    Taylor W, Simpson R, Gow D. Rehabilitation that works—vocational outcomes following rehabilitation for occupational musculoskeletal pain. N Z Med J. 2001;114:185–7.

  20. 20.

    Watson PJ, Kerry Booker C, Moores L, Main CJ. Returning the chronically unemployed with low back pain to employment. Eur J Pain. 2004;8:359–69. doi:10.1016/j.ejpain.2003.11.003.

  21. 21.

    Turk DC, Rudy TE, Sorkin BA. Neglected topics in chronic pain treatment outcome studies: determination of success. Pain. 1993;53:3–16. doi:10.1016/0304-3959(93)90049-U.

  22. 22.

    Pransky G, Gatchel R, Linton S, Loisel P. Improving return to work research. J Occup Rehabil. 2005;15:453–7. doi:10.1007/s10926-005-8027-y.

  23. 23.

    Schonstein E, Kenny DT, Keating J, Koes BW. Work conditioning, work hardening and functional restoration for workers with back and neck pain. The Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD001822. doi:10.1002/14651858.CD001822.

  24. 24.

    Franche R, Krause K. Readiness for return to work following injury or illness: conceptualising the interpersonal impact of health care, workplace, and insurance factors. J Occup Rehabil. 2002;12:233–56. doi:10.1023/A:1020270407044.

  25. 25.

    Franche R, Baril R, Shaw W, Nicholas M, Loisel P. Workplace-based return-to-work interventions: optimizing the role of stakeholders in implementation and research. J Occup Rehabil. 2005;15:525–42. doi:10.1007/s10926-005-8032-1.

  26. 26.

    Sullivan MJL, Feuerstein M, Gatchel R, Linton SJ, Pransky G. Integrating psychosocial and behavioural interventions to achieve optimal rehabilitation outcomes. J Occup Rehabil. 2005;15:475–88. doi:10.1007/s10926-005-8029-9.

  27. 27.

    Baldwin ML, Johnson WG, Butler RJ. The error of using returns-to-work to measure the outcomes of health care. Am J Ind Med. 1996;29:632–41. doi :10.1002/(SICI)1097-0274(199606)29:6<632::AID-AJIM7>3.0.CO;2-L.

  28. 28.

    Williams ACdeC, Richardson PH, Nicholas MK, Pither CE, Harding VR, Rideout KL, et al. Inpatient vs. outpatient pain management: Results of a randomised controlled trial. Pain. 1996;66:13–22. doi:10.1016/0304-3959(96)02996-X.

  29. 29.

    Lovibond SH, Lovibond PF. Manual for the Depression Anxiety Stress Scales. 2nd ed. Sydney: Psychology Foundation; 1995.

  30. 30.

    Brown TA, Chorpita BF, Korotitsch W, Barlow DH. Psychometric properties of the Depression Anxiety Stress Scales (DASS) in clinical samples. Behav Res Ther. 1997;35:79–89. doi:10.1016/S0005-7967(96)00068-X.

  31. 31.

    Roland M, Morris R. Study of the natural history of back pain. Part I. Development of a reliable and sensitive measure of disability in low back pain. Spine. 1983;8:141–4. doi:10.1097/00007632-198303000-00004.

  32. 32.

    Nicholas MK. Self-efficacy and chronic pain. Paper presented at the annual conference of the British Psychological Society. St. Andrews; 1989.

  33. 33.

    Flor H, Behle DJ, Birbaumer N. Assessment of pain-related cognitions in chronic pain patients. Behav Res Ther. 1993;31:63–73. doi:10.1016/0005-7967(93)90044-U.

  34. 34.

    Price DD, Harkins SW. Psychophysiological approaches to pain measurement and assessment. In: Turk DC, editor. Handbook of pain assessment. New York: Guilford Press; 1992. p. 111–34.

  35. 35.

    Harding VR, Williams ACdeC, Richardson PH, Nicholas MK, Jackson JL, Richardson IH, et al. The development of a battery of measures for assessing physical functioning of chronic pain patients. Pain. 1994;58:367–75. doi:10.1016/0304-3959(94)90131-7.

  36. 36.

    ACDeC Williams, Nicholas MK, Richardson PH, Pither CE, Justins DM, Chamberlain JH, et al. Evaluation of a cognitive behavioural programme for rehabilitating patients with chronic pain. Br J Gen Pract. 1993;43:513–8.

  37. 37.

    Verbeek JH. How can doctors help their patients to return to work? PLoS Med. 2006;3:e88. doi:10.1371/journal.pmed.0030088.

  38. 38.

    Fishbain DA, Cutler RB, Rosomoff HL, Khalil T, Abdel-Moty E, Sadek S, et al. “Movement” in work status after pain facility treatment. Spine. 1996;21:2662–9. doi:10.1097/00007632-199611150-00016.

Download references

Acknowledgements

The authors would like to thank the patients and Dr. Andrew Muir of the Barbara Walker Centre for Pain Management at St Vincent’s Hospital, Melbourne for supporting this project. We also wish to offer our thanks to the anonymous reviewer for their helpful suggestions.

Author information

Correspondence to Darren C. White.

Appendices

Appendix A

Eligibility for START

Patients are offered the START Programme after completing a comprehensive multidisciplinary assessment process. Providing they meet none of the specified exclusion criteria (see below) and at least two of the inclusion criteria (see below) the patient is offered a position in the programme.

Exclusion criteria:

  1. 1.

    Unmotivated or unwilling to participate in the Programme

  2. 2.

    Unable to understand English and/or relevant concepts

  3. 3.

    Active major psychiatric illness (e.g. psychosis, clear suicide risk)

  4. 4.

    Eligible/require further medical/surgical treatment or investigations

  5. 5.

    Pain less than 3-months duration

  6. 6.

    Primary substance dependence

  7. 7.

    Use of injectable medication aimed at managing pain

  8. 8.

    Unable to perform programme activities due to specific illness (e.g. cardiac conditions)

Inclusion criteria:

  1. 1.

    Widespread reduction in normal activities due to pain

  2. 2.

    Habitual overactivity leading to increased pain

  3. 3.

    Excessive or inappropriate medication intake

  4. 4.

    High levels of pain behaviour (e.g. excessive pain focus)

  5. 5.

    Work reduced or ceased due to pain

  6. 6.

    Distressed mood (e.g. anxiety, depression) secondary to pain-related problems

  7. 7.

    Based upon staff assessment, the patient is highly likely to benefit from START

Appendix B

  • Return to work (RTW): Refers to an individual resuming work (paid or unpaid) after a period of absence.

  • RTW intention (RTWI): Refers to an individual’s intention to RTW.

  • RTWI o : Refers to an individual who has no intention to RTW.

  • RTWI i : Refers to an individual who intends on RTW but is not seeking work (i.e. behaviourally inactive).

  • RTWI a : Refers to an individual who intends on RTW and is seeking work (i.e. behaviourally active)

  • Work Status (W): Refers to an individual’s labour force status (i.e. where an individual is regarded as either not working or working in a paid and/or unpaid capacity).

  • Hours working (HW): Refers to the number of hours per week an individual spends working.

  • Vocational Continuum (VC): A scale comprising RTWI and work status.

  • Retired: A term study participants used to define their vocational situation.

  • Barriers to RTW: Impediments to an individual’s progress in RTW.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

White, D.C., Beecham, R. & Kirkwood, K. The Vocational Continuum: How to Make Sense of Vocational Outcomes After Group Cognitive Behavioural Therapy for Chronic Pain Sufferers. J Occup Rehabil 18, 307–317 (2008) doi:10.1007/s10926-008-9141-4

Download citation

Keywords

  • Vocational
  • Outcomes
  • Cognitive behavioural therapy
  • Chronic
  • Pain