Health status , work limitations , and return-to-work trajectories in injured workers with musculoskeletal disorders Background The purpose of this study was to describe the health status and work limitations in injured workers with musculoskeletal disorders at 1 month post-injury , stratified by return-to-work status , and to document their return-to-work trajectories 6 months post-injury . Introduction Work-related musculoskeletal -LRB- MSK -RRB- disorders are common health problems and a major contributor to disability and costs in working populations . In Canada , MSK disorders are responsible for 10 % of the short-term disability costs and 39 % of the estimated long-term disability costs -LSB- 1 -RSB- . The natural course of low back pain and other MSK disorders is characterized by recurrent disabling symptoms and can be described as chronic-episodic -LSB- 2 -- 6 -RSB- . Similarly , the trajectory of return-to-work -LRB- RTW -RRB- following a period of work absence due to MSK disorders is a complex and dynamic process , frequently involving recurrences of work absence -LSB- 7 , 8 -RSB- . Already a decade ago , it was shown that a first return to work after an injury is frequently followed by one or more recurrences of work absence , making a focus on first return to work a limited and potentially misguiding index of RTW outcomes , and one that does not address the important issue of sustainability of return to work -LSB- 9 , 10 -RSB- . Recently , Pransky et al. -LSB- 7 -RSB- pointed out that `` despite an abundance of RTW research , the concept of RTW is often poorly defined , and there is not substantial agreement about what constitutes a successful RTW outcome . '' Many studies have been focused on -LRB- first -RRB- return to work as the primary outcome measure , e.g. , return to work is used as an indicator for a reduction in disability -- usually with the assumption that workers who return to work are completely recovered from the disabling effects of the injury -LSB- 10 -RSB- . However , several studies have demonstrated that workers who return to work are not fully recovered from their initial complaints or injury -LSB- 10 -- 15 -RSB- . The traditional outcome measures of return to work and time lost from work do not capture important information about the burden of injury that can be shown by self-reported measures of disability and functional limitations . Hence , to obtain a complete picture of the complex RTW process , capturing the recurrences of work absence , the persistence of disability , and their consequences for work performance , it is important to use multiple outcome measures during follow-up . Although a few studies have addressed health outcomes , such as pain , functional status , and general health , in relation to RTW status -LSB- 11 , 12 , 14 -RSB- , little is known about depressive symptoms , which have been suggested to increase the total numbers of days on benefit -LSB- 16 -RSB- and about limitations at work in injured workers . Furthermore , it is largely unclear how injured workers `` transit '' in their RTW status over time . So far , we do know that a substantial proportion of workers with cumulative trauma disorders of the upper extremity -LSB- 15 -RSB- and compensated back pain -LRB- Côté et al. , submitted -RRB- experience multiple episodes of work absence . The purpose of this study was to describe the health status , assessed by multiple outcome measures , and work limitations , in injured workers with MSK disorders 1 month post-injury stratified by RTW status , and to document their RTW trajectories over a period of 6 months post-injury . Materials and methods Study design The present study was conducted within the sampling frame of a prospective study of Ontario workers with a back or upper extremity -LRB- UE -RRB- MSK disorder , who filed a Workplace Safety and Insurance Board -LRB- WSIB -RRB- lost-time injury claim . Data was collected from two sources : self-reports of participants and WSIB administrative data . The participants were interviewed by phone at baseline -LRB- 1 month post-injury -RRB- , and 6 months post-injury . Participants provided information on their RTW experience , workplace , healthcare provider , insurer , and physical and mental health . From the WSIB , administrative information on sociodemographics , workplaces , and claims -LRB- e.g. , site of injury , claim status , time receiving wage replacement benefits -RRB- was obtained . This information was linked to the interview data , when the participants provided written consent for linkage . Ethical approval for the study was granted by the University of Toronto 's Ethics Review Board . Participants were given the option to withdraw from the study at any point and to decline data linkage of their questionnaire responses with their WSIB data . It was made explicit to the respondents that study participation would in no way affect their claim with the insurer . Participant recruitment and final study sample Study eligibility required participants to have a new , accepted or pending , back or UE MSK lost-time claim , be absent from work for at least 5 days within the first 14 calendar days post-injury , and be 15 years of age or older . We excluded claimants with a fracture , amputation , burn , hernia , head injury , concussion , or electrocution , those who were not able to understand or speak English , and those with a security problem , who were incarcerated or received institutional care . From January to July 2005 , a computer program run on WSIB weekly files resulted in the identification of 14,555 potential participants . Eligibility assessment and recruitment were conducted in three stages : at the WSIB tracking level , at the WSIB recruiting level , and the university-based research unit level -LRB- see Fig. 1 -RRB- . Fig. 1Recruitment procedure and flow of participants A total of 632 participants completed the baseline interview 1 month post-injury . The overall response rate was 61 % -LRB- 632 out of 1,038 eligible and contacted potential participants -RRB- . Verbal consent for the interview data was obtained from all participants . The mean time between the date of injury and the date of interview was 29.6 days -LRB- SD 6.2 ; median 29 days , range 15 -- 46 days -RRB- . Approximately 98 % of the participants were interviewed within 6 weeks post-injury . For the linkage with WSIB data , written consent was obtained from 479 participants , for which WSIB wage replacement data was available for 431 participants . A consent-to-linkage analysis showed that consenters -LRB- n = 479 -RRB- and non-consenters were similar in terms of sociodemographic , workplace , health status , and work absence variables . However , consenters were more likely to have a higher level of education , and male consenters were more likely to be older than male non-consenters -LRB- Franche et al. , submitted -RRB- . Definition of the RTW status At baseline , four mutually exclusive RTW status groups were constructed , based on the workers ' responses to the following yes/no questions : `` Have you gone back to work at any point since your injury -LRB- includes part-time or modified work -RRB- ? '' and `` Are you currently working at any job right now ? '' The four groups were : -LRB- 1 -RRB- sustained first return to work -LRB- RTW-S -RRB- , -LRB- 2 -RRB- return to work with recurrence -LRB- s -RRB- of work absence and working at time of interview -LRB- RTW-R working -RRB- , -LRB- 3 -RRB- return to work with recurrence -LRB- s -RRB- of work absence and not working at time of interview -LRB- RTW-R not working -RRB- , and -LRB- 4 -RRB- no return to work -LRB- No RTW -RRB- . In the analyses , we collapsed the two return to work with recurrence -LRB- s -RRB- groups into one group -LRB- RTW-R -RRB- . RTW status was assessed at each follow-up . Measurements : health outcomes and work limitations Pain intensity We used two items from the Von Korff Pain Scale -LSB- 17 , 18 -RSB- to measure pain intensity . On a 10-point numerical rating scale -LRB- 0 = `` no pain '' to 10 = `` pain as bad as could be '' -RRB- , participants were asked to indicate their level of perceived pain from their workplace injury -LRB- 1 -RRB- at the present time and -LRB- 2 -RRB- on average in the past month . Functional status Functional disability associated with back pain was measured using the Roland -- Morris Disability Questionnaire -LSB- 19 -RSB- , a 24-item questionnaire assessing the presence of activity limitations . Responses to individual items -LRB- yes/no -RRB- are summed up and range from 0 -LRB- no disability -RRB- to 24 -LRB- severe disability -RRB- . The score is averaged and -- for a better comparison with scores of other instruments -- transformed to a standardized score of 0 -- 100 -LRB- by multiplying each averaged score by 100 -RRB- , with a higher score indicating greater disability . The Roland -- Morris has been shown to have good psychometric properties -LSB- 20 -- 25 -RSB- . In the baseline sample , the internal consistency -LRB- Cronbachs α -RRB- was 0.92 . The 11-item QuickDASH was used to assess physical function and symptoms in participants with MSK disorders of the upper limb -LSB- 26 -RSB- . The QuickDASH is a shortened version of the DASH Outcome Measure -LSB- 27 -RSB- . The items are scored from 1 to 5 . Responses to the individual items are summed , averaged , and transformed to a standardized score of 0 -- 100 , with a higher score indicating greater disability . Initial testing has shown that the QuickDASH has good psychometric properties -LSB- 26 -RSB- . The internal consistency in the present study was 0.90 . When participants reported pain in both the back and UE , they completed both the Roland -- Morris and the QuickDASH . For these participants , scores from each instrument were converted into a z-score and the highest z-score was used as the index of functional status . For participants completing only one measure of functional status , the z-score of that measure was used as the index of functional status . In addition , for those completing both measures , determination of the main pain site , i.e. , back or UE , was based on the highest z-score on the Roland -- Morris or the QuickDASH . General health The Short Form-12 -LRB- SF-12 -RRB- , a 12-item version of the SF-36 , was used to measure physical -LRB- Physical Component Summary Scale Score ; PCS12 -RRB- and mental -LRB- Mental Component Summary Scale Score ; MCS12 -RRB- health-related quality of life -LSB- 28 , 29 -RSB- . To calculate the PCS12 and MCS12 , test items are scored and transformed in an algorithm to norm-based scores with a mean of 50 and a standard deviation of 10 -LSB- 29 -RSB- . PCS12 and MCS12 scores range from 0 to 100 , a higher score indicating better health . The psychometric properties of the SF-12 are good : coefficients for test -- retest reliability , measured over 2 weeks , are 0.89 -LRB- PCS12 -RRB- and 0.76 -LRB- MCS12 -RRB- -LSB- 28 -RSB- . Moreover , Luo et al. -LSB- 30 -RSB- reported good internal consistency , validity , and responsiveness in patients with low back pain . In the present study , the internal consistency was 0.89 -LRB- PCS12 -RRB- and 0.86 -LRB- MCS12 -RRB- at baseline . Depressive symptoms The 20-item Center for Epidemiologic Studies Depression -LRB- CES-D -RRB- -LSB- 31 -RSB- scale was used to measure depressive symptoms . The items report the frequency of occurrence of symptoms in the past week on a 4-point rating scale ranging from `` rarely or none of the time '' -LRB- < 1 day -RRB- to `` most of the time '' -LRB- 5 -- 7 days -RRB- . The score ranges from 0 to 60 with a higher score denoting more depressive symptoms . CES-D scores ≥ 16 are indicative of individuals at risk for clinical depression -LSB- 31 -RSB- . The internal consistency was 0.92 , measured in the baseline sample . Work limitations We used the 16-item version of the Work Limitations Questionnaire -LRB- WLQ-16 -RRB- to assess limitations at work due to injury or associated treatment -LSB- 32 -- 35 -RSB- . The WLQ-16 covers four domains : output demands -LRB- 4 items -RRB- , mental demands -LRB- 6 items -RRB- , physical demands -LRB- 4 items -RRB- , and time management demands -LRB- 2 items -RRB- . Items are scored on a 5-point scale , ranging from `` none of the time '' to `` all of the time . '' The scores on the individual items are summed , averaged , and transformed to a standardized score of 0 -- 100 , with a higher score indicative of more limitations . The internal consistency Cronbachs α 's were 0.82 -LRB- output demands -RRB- , 0.86 -LRB- mental demands -RRB- , 0.78 -LRB- physical demands -RRB- , and 0.76 -LRB- time management demands -RRB- at baseline . Sociodemographics , days off work , and comorbidity Participants provided information on age , gender , education , living status , number of children under the age of 18 , and personal income . Information on occupational status was obtained from the WSIB database . One self-reported question assessed how many full days of work a participant had missed due to the injury . In addition , data on time receiving wage replacement benefits was obtained from the WSIB database . The Saskatchewan Comorbidity Scale was used to measure comorbidity -LRB- Jaroszynski et al. , unpublished work -RRB- . The 16/14-item -LRB- women/men -RRB- self-report scale assesses the presence and severity of health problems . Participants are instructed to indicate whether they currently have a particular health problem/disease and , if so how much it has affected their health in the last 6 months . The response options range from 1 = `` not at all '' to 4 = `` severe . '' In the present study , two additional items pertaining to gynecological problems and pregnancy status were added for women . Responses were combined and categorized as : no comorbidity , comorbidity with no/mild effect on health , and comorbidity with moderate/severe effect on health . Statistical analyses Univariate statistics -LRB- means , standard deviations , frequency counts -RRB- were used to describe participants , for the total cohort and by RTW status , in terms of their baseline sociodemographics , health outcomes , and work limitations . Differences in baseline characteristics between the three RTW status groups -LRB- RTW-S , RTW-R , and No RTW -RRB- were tested using a χ2 test or analysis of variance . Multiple comparisons , with RTW-S as reference group , were performed with a Tukey correction . Group differences in health outcomes and work limitations , adjusted for identified covariates were tested with GLM analyses , and multiple comparisons were performed with a Bonferroni correction . To describe the RTW trajectories , we used the self-reported RTW status at baseline and 6-month follow-up . All statistical analyses were performed with SPSS 13.0 -LSB- 36 -RSB- . Results Baseline characteristics and selection bias analysis A total of 632 participants , 350 -LRB- 55 % -RRB- men and 282 -LRB- 45 % -RRB- women , completed the baseline interview 1 month post-injury . Table 1 shows the sociodemographic factors for the total sample and by RTW status at baseline . The mean age of the total cohort was 42.2 years -LRB- SD 10.8 -RRB- and approximately 69 % lived with a partner . The mean duration of time receiving wage replacement benefits , based on WSIB data , was 19.1 days -LRB- SD 8.9 ; median 20 days -RRB- . Sixty-six percent of the participants were primarily experiencing back pain and 34 % UE pain . Table 1Baseline -LRB- 1 month post-injury -RRB- sociodemographic characteristics , days off work , pain site , and comorbidity for the total study sample -LRB- n = 632 -RRB- and by return-to-work status groupaTotalRTW-SRTW-RNo RTWN = 632N = 293 -LRB- 46.9 % -RRB- N = 88 -LRB- 14.1 % -RRB- N = 244 -LRB- 39.0 % -RRB- GenderN -LRB- % -RRB- N -LRB- % -RRB- N -LRB- % -RRB- N -LRB- % -RRB- Female282 -LRB- 44.6 -RRB- 123 -LRB- 42.0 -RRB- 48 -LRB- 54.5 -RRB- 110 -LRB- 45.1 -RRB- Male350 -LRB- 55.4 -RRB- 170 -LRB- 58.0 -RRB- 40 -LRB- 45.5 -RRB- 134 -LRB- 54.9 -RRB- Age categories 15 -- 29 years93 -LRB- 14.7 -RRB- 45 -LRB- 15.4 -RRB- 9 -LRB- 10.2 -RRB- 35 -LRB- 14.4 -RRB- 30 -- 39 years137 -LRB- 21.7 -RRB- 58 -LRB- 19.8 -RRB- 29 -LRB- 33.0 -RRB- 48 -LRB- 19.8 -RRB- 40 -- 49 years228 -LRB- 36.1 -RRB- 109 -LRB- 37.2 -RRB- 31 -LRB- 35.2 -RRB- 87 -LRB- 35.8 -RRB- ≥ 50 years173 -LRB- 27.4 -RRB- 81 -LRB- 27.6 -RRB- 19 -LRB- 21.6 -RRB- 73 -LRB- 30.0 -RRB- Living with/without partner Living with partner433 -LRB- 68.5 -RRB- 221 -LRB- 75.4 -RRB- 54 -LRB- 61.4 -RRB- 156 -LRB- 63.9 -RRB- Not living with partner199 -LRB- 31.5 -RRB- 72 -LRB- 24.6 -RRB- 34 -LRB- 38.6 -RRB- 88 -LRB- 36.1 -RRB- Children under age 18 No children 341 -LRB- 54.0 -RRB- 158 -LRB- 53.9 -RRB- 48 -LRB- 54.5 -RRB- 131 -LRB- 53.7 -RRB- 1 child118 -LRB- 18.7 -RRB- 53 -LRB- 18.1 -RRB- 17 -LRB- 19.3 -RRB- 47 -LRB- 19.3 -RRB- 2 children118 -LRB- 18.7 -RRB- 57 -LRB- 19.5 -RRB- 15 -LRB- 17.0 -RRB- 44 -LRB- 18.0 -RRB- ≥ 3 children 55 -LRB- 8.7 -RRB- 25 -LRB- 8.5 -RRB- 8 -LRB- 9.1 -RRB- 22 -LRB- 9.0 -RRB- Education Some high school112 -LRB- 17.7 -RRB- 46 -LRB- 15.7 -RRB- 16 -LRB- 18.2 -RRB- 49 -LRB- 20.1 -RRB- High school completed177 -LRB- 28.0 -RRB- 75 -LRB- 25.6 -RRB- 30 -LRB- 34.1 -RRB- 69 -LRB- 28.3 -RRB- Some university or college130 -LRB- 20.6 -RRB- 70 -LRB- 23.9 -RRB- 14 -LRB- 15.9 -RRB- 45 -LRB- 18.4 -RRB- University/college completed213 -LRB- 33.7 -RRB- 102 -LRB- 34.8 -RRB- 28 -LRB- 31.8 -RRB- 81 -LRB- 33.2 -RRB- Occupational status -LRB- N = 479 -RRB- b White collar89 -LRB- 18.6 -RRB- 47 -LRB- 20.9 -RRB- 13 -LRB- 17.6 -RRB- 29 -LRB- 16.4 -RRB- Pink collar156 -LRB- 32.6 -RRB- 71 -LRB- 31.6 -RRB- 26 -LRB- 35.1 -RRB- 58 -LRB- 32.8 -RRB- Blue collar-indoor99 -LRB- 20.7 -RRB- 54 -LRB- 24.0 -RRB- 15 -LRB- 20.3 -RRB- 30 -LRB- 16.9 -RRB- Blue collar-outdoor68 -LRB- 14.2 -RRB- 28 -LRB- 12.4 -RRB- 10 -LRB- 13.5 -RRB- 28 -LRB- 15.8 -RRB- Missing67 -LRB- 14.0 -RRB- 25 -LRB- 11.1 -RRB- 10 -LRB- 13.5 -RRB- 32 -LRB- 18.1 -RRB- Personal income < $ 20,00095 -LRB- 15.0 -RRB- 31 -LRB- 10.6 -RRB- 12 -LRB- 13.6 -RRB- 47 -LRB- 19.3 -RRB- $ 20,000 -- 39,999240 -LRB- 38.0 -RRB- 111 -LRB- 37.9 -RRB- 32 -LRB- 36.4 -RRB- 96 -LRB- 39.3 -RRB- $ 40,000 -- 59,999180 -LRB- 28.5 -RRB- 88 -LRB- 30.0 -RRB- 28 -LRB- 31.8 -RRB- 64 -LRB- 26.2 -RRB- > $ 60,00081 -LRB- 12.8 -RRB- 46 -LRB- 15.7 -RRB- 9 -LRB- 10.2 -RRB- 25 -LRB- 10.2 -RRB- Missing36 -LRB- 5.7 -RRB- 17 -LRB- 5.8 -RRB- 7 -LRB- 8.0 -RRB- 12 -LRB- 4.9 -RRB- Number of working hours/week at the time of the injury ; n -LRB- % -RRB- ≤ 37.5179 -LRB- 28.3 -RRB- 84 -LRB- 28.7 -RRB- 24 -LRB- 27.3 -RRB- 69 -LRB- 28.3 -RRB- > 37.5 -- 40.0281 -LRB- 44.5 -RRB- 128 -LRB- 43.7 -RRB- 40 -LRB- 45.5 -RRB- 110 -LRB- 45.1 -RRB- > 40.0172 -LRB- 27.2 -RRB- 81 -LRB- 27.6 -RRB- 24 -LRB- 27.3 -RRB- 65 -LRB- 26.6 -RRB- Duration of receiving full wage replacement benefits within first 30 days post-injurycn = 205n = 67n = 156 Days mean -LRB- SD -RRB- 19.1 -LRB- 8.9 -RRB- 14.2 -LRB- 7.1 -RRB- 18.7 -LRB- 8.4 -RRB- 25.9 -LRB- 6.5 -RRB- Days ; median20.013.019.029.0Self-reported full days off work due to injury Days mean -LRB- SD -RRB- 14.5 -LRB- 7.1 -RRB- 10.5 -LRB- 5.1 -RRB- 14.1 -LRB- 6.9 -RRB- 19.7 -LRB- 6.1 -RRB- Days ; median14 .010.013.519 Pain site ; n -LRB- % -RRB- Back418 -LRB- 66.1 -RRB- 214 -LRB- 73.0 -RRB- 64 -LRB- 72.7 -RRB- 134 -LRB- 54.9 -RRB- Upper extremities214 -LRB- 33.9 -RRB- 79 -LRB- 27.0 -RRB- 24 -LRB- 27.3 -RRB- 110 -LRB- 45.1 -RRB- Comorbidity ; n -LRB- % -RRB- No513 -LRB- 81.2 -RRB- 238 -LRB- 81.2 -RRB- 72 -LRB- 81.8 -RRB- 197 -LRB- 80.7 -RRB- Yes , with no/mild effect on health33 -LRB- 5.2 -RRB- 16 -LRB- 5.5 -RRB- 5 -LRB- 5.7 -RRB- 12 -LRB- 4.9 -RRB- Yes , with moderate/severe effect on health86 -LRB- 13.6 -RRB- 39 -LRB- 13.3 -RRB- 11 -LRB- 12.5 -RRB- 35 -LRB- 14.4 -RRB- a N = 625 classified with regard to RTW status , N = 7 were working at time of the baseline interview , but were not asked item regarding recurrencesb WSIB information available for participants who provided informed consent for linkage of WSIB data with questionnaire datac N = 431 for WSIB temporary total compensation within 30 days of accident ; Missing data due to -LRB- 1 -RRB- no informed consent for linkage of WSIB data with questionnaire data -LRB- N = 153 -RRB- or -LRB- 2 -RRB- absence of data when claim was not a lost-time accepted claim -LRB- N = 48 -RRB- To examine a possible selection bias , we compared the cohort participants -LRB- n = 632 -RRB- to a group of algorithm-selected potential participants -LRB- n = 3,712 -RRB- on characteristics extracted from the WSIB database , where the algorithm mimicked the inclusion criteria of our study .1 The time frame during which their injury occurred was the same as for our study sample . This analysis showed that participants were comparable to potential participants with regards to firm size , industrial sector , and income level -LRB- Table 2 -RRB- . However , participants were more likely to be older and female . Women aged 40 -- 49 were more likely to participate than women in the other age categories , and older men were more likely to participate than younger men . With respect to claim status , we compared only participants with accepted claims and available wage replacement data -LRB- n = 559 -RRB- with potential participants , since this data is not available for participants with pending , denied or abandoned claims . Participants were more likely to have a longer duration on wage replacement benefits at 1 and 6 months post-injury and a higher rate of wage replacement re-instatement at 6 months post-injury than potential participants , suggestive of more severe work disability in our cohort . Table 2Comparison of baseline study participants with algorithm-selected potential study participantsVariableFull baseline cohort -LRB- n = 632 -RRB- Algorithm-selected potential participants -LRB- n = 3,712 -RRB- Gender , n -LRB- % -RRB- Female282 -LRB- 44.6 -RRB- 1,365 -LRB- 36.8 -RRB- Male350 -LRB- 55.4 -RRB- 2,347 -LRB- 63.2 -RRB- Age at baseline interview , mean -LRB- SD -RRB- -LRB- median -RRB- 42.2 -LRB- 10.8 -RRB- -LRB- 43 -RRB- 40.3 -LRB- 11.3 -RRB- -LRB- 40.7 -RRB- Gender × age at baseline interview , n -LRB- % -RRB- Females : 15 -- 29 years40 -LRB- 6.3 -RRB- 262 -LRB- 7.1 -RRB- Females : 30 -- 39 years59 -LRB- 9.3 -RRB- 348 -LRB- 9.4 -RRB- Females : 40 -- 49 years109 -LRB- 17.2 -RRB- 428 -LRB- 11.5 -RRB- Females : ≥ 50 years74 -LRB- 11.7 -RRB- 327 -LRB- 8.8 -RRB- Males : 15 -- 29 years53 -LRB- 8.4 -RRB- 524 -LRB- 14.1 -RRB- Males : 30 -- 39 years78 -LRB- 12.3 -RRB- 630 -LRB- 17.0 -RRB- Males : 40 -- 49 years119 -LRB- 18.8 -RRB- 714 -LRB- 19.2 -RRB- Males : ≥ 50 years99 -LRB- 15.7 -RRB- 479 -LRB- 12.9 -RRB- Firm size , n -LRB- % -RRB- < 20 employees58 -LRB- 9.2 -RRB- 335 -LRB- 9.0 -RRB- 20 -- 99 employees100 -LRB- 15.8 -RRB- 680 -LRB- 18.3 -RRB- 100 -- 999 employees190 -LRB- 30.1 -RRB- 1,166 -LRB- 31.4 -RRB- ≥ 1,000 employees150 -LRB- 23.7 -RRB- 769 -LRB- 20.7 -RRB- Schedule 2134 -LRB- 21.2 -RRB- 761 -LRB- 20.5 -RRB- Industrial sector , n -LRB- % -RRB- Automotive , manufacturing , steel109 -LRB- 17.2 -RRB- 875 -LRB- 23.6 -RRB- Service127 -LRB- 20.1 -RRB- 812 -LRB- 21.9 -RRB- Education , municipal , Schedule 2a146 -LRB- 23.1 -RRB- 817 -LRB- 22.0 -RRB- Healthcare85 -LRB- 13.4 -RRB- 425 -LRB- 11.4 -RRB- Transportation55 -LRB- 8.7 -RRB- 333 -LRB- 9.0 -RRB- Chemical/processing , electrical , food31 -LRB- 4.9 -RRB- 212 -LRB- 5.7 -RRB- Construction14 -LRB- 2.2 -RRB- 154 -LRB- 4.1 -RRB- Agriculture , forest , pulp and paper , mining15 -LRB- 2.4 -RRB- 83 -LRB- 2.2 -RRB- Unknown50 -LRB- 7.9 -RRB- 1 -LRB- 0.0 -RRB- Occupational status , n -LRB- % -RRB- b White collar109 -LRB- 18.7 -RRB- 624 -LRB- 16.8 -RRB- Pink collar209 -LRB- 35.9 -RRB- 1,112 -LRB- 30.0 -RRB- Blue collar-indoor132 -LRB- 22.7 -RRB- 1,026 -LRB- 27.6 -RRB- Blue collar-outdoor86 -LRB- 14.8 -RRB- 631 -LRB- 17.0 -RRB- Missing45 -LRB- 7.7 -RRB- 319 -LRB- 8.6 -RRB- Weekly earnings in tertiles , n -LRB- % -RRB- ≤ $ 447.68116 -LRB- 18.4 -RRB- 819 -LRB- 22.1 -RRB- $ 447.68 -- ≤ $ 880.00281 -LRB- 44.5 -RRB- 1,890 -LRB- 50.9 -RRB- ≥ $ 880.00157 -LRB- 24.8 -RRB- 978 -LRB- 26.3 -RRB- Missing78 -LRB- 12.3 -RRB- 25 -LRB- 0.7 -RRB- Duration of time receiving wage replacement benefits -LRB- 30 days post-injury -RRB- , mean -LRB- SD -RRB- -LRB- median -RRB- c20 .6 -LRB- 9.0 -RRB- -LRB- 25 -RRB- 15.9 -LRB- 9.4 -RRB- -LRB- 13 -RRB- Duration of time receiving wage replacement benefits -LRB- 180 days post-injury -RRB- , mean -LRB- SD -RRB- -LRB- median -RRB- d58 .7 -LRB- 57.2 -RRB- -LRB- 33 -RRB- 37.6 -LRB- 50.2 -RRB- -LRB- 14 -RRB- Occurrence of re-instatement of wage replacement benefits -LRB- 30 days post-injury -RRB- , n -LRB- % -RRB- c No507 -LRB- 90.7 -RRB- 3,481 -LRB- 93.8 -RRB- Yes52 -LRB- 9.3 -RRB- 231 -LRB- 6.2 -RRB- Occurrence of re-instatement of wage replacement benefits -LRB- 180 days post-injury -RRB- , n -LRB- % -RRB- d No463 -LRB- 82.5 -RRB- 3,286 -LRB- 88.5 -RRB- Yes98 -LRB- 17.5 -RRB- 426 -LRB- 11.5 -RRB- Claim status -LRB- 30 days post-injury -RRB- , n -LRB- % -RRB- Lost-time-accepted431 -LRB- 68.2 -RRB- 2,893 -LRB- 77.9 -RRB- Lost-time-pending171 -LRB- 27.1 -RRB- 765 -LRB- 20.6 -RRB- Lost-time-denied19 -LRB- 3.0 -RRB- 43 -LRB- 1.2 -RRB- Lost-time-amalgamated5 -LRB- 0.8 -RRB- 1 -LRB- 0.0 -RRB- No lost-time-accepted6 -LRB- 0.9 -RRB- 6 -LRB- 0.2 -RRB- a Schedule 2 firms do not operate under the collective liability insurance principle , and , as such , are individually responsible for the full cost of the injury/illness claims filed by their workers . Schedule 2 employers include federal , provincial and municipal governments , railways , airlines , shipping , and telephone companiesb Data on the full baseline cohort is restricted to participants with accepted claims -LRB- n = 582 -RRB- c Data on the full baseline cohort is restricted to participants with accepted claims and available wage replacement data 30 days post-injury -LRB- n = 559 -RRB- d Data on the full baseline cohort is restricted to participants with accepted claims and available wage replacement data 180 days post-injury -LRB- n = 561 -RRB- Note : Italics -- The main differences between the full baseline cohort and the algorithm-selected potential participants Group differences in baseline characteristics A total of 625 participants were categorized into one of the four RTW status groups . The remaining seven participants were working when interviewed at baseline , but not asked about recurrence -LRB- s -RRB- due to an error in a skip pattern of the questionnaire , which was subsequently corrected . At baseline -LRB- approximately 1 month post-injury -RRB- , 47 % of the participants reported a sustained first return to work , 5 % a return to work with recurrence -LRB- s -RRB- of work absence and working at time of interview , almost 9 % a return to work with recurrence -LRB- s -RRB- of work absence and not working at time of interview , and 39 % no return to work . With regards to gender , age , children under age 18 , education , occupational status , and working hours per week at the time of the injury no statistically significant differences were observed across the three RTW groups . However , participants who had a sustained first return to work reported more often that they lived with a partner -LRB- χ2 = 11.0 , p = .004 -RRB- and reported a higher personal income -LRB- χ2 = 11.7 , p = .069 -RRB- than those with a recurrence or no return to work . These variables were used as covariates in subsequent analyses . With respect to the mean duration of time receiving wage replacement benefits , based on WSIB data , significant differences were observed across all three RTW groups -LRB- F = 122.6 , p = .000 -RRB- . Significant differences were also seen with self-reported full days off work due to the injury -LRB- F = 169.7 , p = .0000 -RRB- . With respect to pain site , a statistically significant difference was found across the RTW groups : participants with a sustained first return to work and those who experienced a recurrence reported low back pain more often , and participants who did not return to work reported pain in the UE more often -LRB- χ2 = 21.6 , p = < .0001 -RRB- . A total of 81 % of the participants reported no comorbidity , whereas 5 % reported no/mild effects on health , and 14 % reported moderate/severe effects on health , with no statistically significant group differences . Group differences in health outcomes and work limitations Table 3 presents the adjusted -LRB- for age , gender , living status , and income level -RRB- estimated means for baseline health outcomes and work limitations by RTW status , with multiple comparison results . Participants with a sustained first return to work reported significantly less pain compared to those with a recurrence and no return to work . Moreover , they also reported significantly less pain in the past month compared to those with no return to work . In participants with back pain , those with a sustained first return to work reported significantly less functional disability compared to those with a recurrence and no return to work . In participants with UE pain , we observed that those with a sustained first return to work reported significantly less functional disability compared to those who did not return to work , but not compared to those who experienced a recurrence . With regards to physical and mental health as well as depressive symptoms , participants with a sustained first return to work reported significantly better health and fewer depressive symptoms than those with a recurrence and no return to work . It is interesting to note that high levels of depressive symptomatology , indicative of being at risk for clinical depression , were found in all participants , especially in those with a recurrence and those who did not return to work . For all outcomes , there were no significant differences between participants who experienced a recurrence and those who did not return to work . With regards to limitations at work , those with a sustained first return to work and those with a recurrence , reported limitations in all domains , but mainly for physical demands and time management demands . As expected , participants with a sustained first return to work reported significantly fewer limitations than those with a recurrence . Table 3Estimated means -LRB- 95 % confidence intervals , CI -RRB- of baseline -LRB- 1 month post-injury -RRB- health outcomes and limitations at work by return-to-work status group -LRB- N = 625 -RRB- , adjusted for age , gender , living status , and personal incomeRTW-SaRTW-RNo RTWN = 293 -LRB- 46.9 % -RRB- N = 88 -LRB- 14.1 % -RRB- N = 244 -LRB- 39.0 % -RRB- Estimated mean -LRB- 95 % CI -RRB- Estimated mean -LRB- 95 % CI -RRB- pEstimated mean -LRB- 95 % CI -RRB- pPerceived painRange 0 -- 10 Pain at time of interview3 .84 -LRB- 3.54 -- 4.13 -RRB- 5.19 -LRB- 4.64 -- 5.73 -RRB- .0005.94 -LRB- 5.62 -- 6.27 -RRB- .000 Pain in the past month8 .45 -LRB- 8.25 -- 9.13 -RRB- 8.78 -LRB- 8.40 -- 9.16 -RRB- .4218.90 -LRB- 8.68 -- 9.13 -RRB- .014 Roland Morris Range 0 -- 100 ; N = 41852.73 -LRB- 49.29 -- 56.17 -RRB- 68.14 -LRB- 61.75 -- 74.54 -RRB- .00075.66 -LRB- 71.30 -- 80.03 -RRB- .000 Quick DASH Range 0 -- 100 ; N = 21447.58 -LRB- 42.61 -- 52.55 -RRB- 54.94 -LRB- 46.01 -- 63.87 -RRB- .46963.15 -LRB- 58.98 -- 67.33 -RRB- .000 Physical SF-12 Range 0 -- 10037.03 -LRB- 35.98 -- 38.09 -RRB- 32.75 -LRB- 30.80 -- 34.69 -RRB- .00031.63 -LRB- 30.47 -- 32.78 -RRB- .000 Mental SF-12 Range 0 -- 10048.55 -LRB- 47.18 -- 49.91 -RRB- 44.40 -LRB- 41.88 -- 46.92 -RRB- .01445.58 -LRB- 44.08 -- 47.07 -RRB- .013 Depressive symptoms CES-D ; Range 0 -- 6013.16 -LRB- 11.74 -- 14.59 -RRB- 18.15 -LRB- 15.53 -- 20.78 -RRB- .00318.70 -LRB- 17.14 -- 20.26 -RRB- .000 Work limitationsRange 0 -- 100 Physical demands46 .00 -LRB- 42.79 -- 49.22 -RRB- 62.81 -LRB- 56.80 -- 68.82 -RRB- .000 n.a. Mental demands17 .12 -LRB- 14.70 -- 19.55 -RRB- 29.41 -LRB- 24.88 -- 33.95 -RRB- .000 n.a. Output demands18 .65 -LRB- 15.95 -- 21.35 -RRB- 35.59 -LRB- 30.56 -- 40.61 -RRB- .000 n.a. Time management41 .83 -LRB- 38.43 -- 45.23 -RRB- 61.90 -LRB- 55.61 -- 68.20 -RRB- .000 n.a.a The RTW-S group is the reference group for the multiple comparisons Attrition analysis Six months after injury , the 632 participants who had completed the baseline interview were approached again to complete the follow-up interview . Overall , 446 participants , 238 -LRB- 53 % -RRB- men and 208 -LRB- 47 % -RRB- women , completed the follow-up interview -LRB- retention rate of 70.6 % -RRB- . Reasons for non-response in the follow-up interview were `` unable to contact '' -LRB- n = 92 -RRB- , `` avoided contact '' -LRB- n = 49 -RRB- , and `` refused to participate '' -LRB- n = 45 -RRB- . An attrition analysis , comparing respondents -LRB- n = 446 -RRB- of the 6-month interview with non-respondents -LRB- n = 186 -RRB- , revealed that non-respondents were more likely to be younger , to work longer hours at the time of injury , and to specify `` back '' as their primary pain site . Moreover , male non-respondents tended to be younger than male respondents , whereas in females differences in age were not statistically significant . Otherwise , non-respondents did not differ significantly with respect to other sociodemographic , workplace , health status , and work absence variables tested , including time receiving wage replacement benefits , re-instatement of wage replacement benefits 6 month post-injury , self-reported work absence duration 1 month post-injury , and claim status . Full details of the attrition bias analysis have been reported elsewhere -LRB- Franche et al. , submitted -RRB- . RTW trajectories from baseline to 6 month follow-up Figure 2 shows the RTW trajectories for 439 participants , based on self-reported RTW status at baseline and 6 month follow-up . The majority -LRB- 73 % -RRB- of workers with a sustained first return to work at baseline were still at work 6 months later . However , 27 % had experienced at least one recurrence during that time period . All participants who experienced a recurrence remained , by definition , in this group . Of those participants who had not returned to work at baseline , 59 % had a sustained first return to work 6 months later , 17 % had made a RTW attempt with a recurrence , and 24 % were still off work 6 months post-injury . Six months post-injury , the rate of recurrences of work absence in workers who had made at least one RTW attempt was 38 % -LSB- n = 153 recurrences / -LRB- n = 439 minus n = 40 with no RTW attempt -RRB- -RSB- . Fig. 2Return-to-work trajectories based on self-reported return-to-work status at baseline -LRB- 1 month post-injury -RRB- and 6-month follow-up -LRB- n = 439 -RRB- . aRTW-S , sustained first return to work ; bRTW-R working , return to work with recurrence -LRB- s -RRB- of work absence and working at time of interview ; cRTW-R not working , return to work with recurrence -LRB- s -RRB- of work absence and not working at time of interview ; dNo RTW , no return to work Discussion The findings of this cohort study suggest the presence of a pattern in baseline health states and work limitations specific to RTW status , 1 month post-injury . Workers with a sustained first return to work reported less pain , less functional disability , better physical and mental health , fewer depressive symptoms , and fewer work limitations compared to those who experienced a recurrence of work absence or who never returned to work . The study adds to the literature by demonstrating that depressive symptoms and limitations at work are prevalent in workers 1 month post-injury , including in those with a sustained first return to work . A substantial rate of recurrences of work absence over 6 months was found -LRB- 38 % -RRB- , even in workers who had initially made a sustained first return to work at baseline -LRB- 27 % -RRB- . Moreover , of those workers who did not return to work at baseline , 17 % attempted to return and experienced a recurrence within 6 months of the injury , and 24 % were still off work at 6 months post-injury . Our findings are consistent with previous research suggesting that a return to work does not translate into a complete recovery from a MSK disorder -LSB- 11 , 12 , 14 , 15 -RSB- . For example , in a study among 205 workers with MSK injury , Evanoff et al. -LSB- 14 -RSB- found that 88 % of the workers had returned to work -LRB- with 83 % working at full duty -RRB- at 6 month follow-up , and of these 24 % reported continuing disability due to the injury -LRB- including 20 % of those working at full duty -RRB- . In our study , participants with a sustained first return to work at 1 month post-injury had SF-12 physical and mental health subscales scores below the healthy population average of 50 -LSB- 29 -RSB- , and high levels of work limitations , specifically for physical demands and time management demands . Thus , the results suggest that many workers , while back at work , still have health problems and experience difficulties in meeting their work demands . Furthermore , the importance of measuring multiple health outcomes , in particular depressive symptoms , was shown by the high levels of depressive symptoms , indicative of being at risk for clinical depression , in injured workers suffering from MSK disorders , particularly in those who experienced a recurrence and those who did not return to work . Our finding of high levels of depressive symptoms in injured workers is in line with earlier studies showing that depressive symptoms are prevalent in MSK-injured workers -LSB- 37 , 38 -RSB- and highlights the need to address and examine the mental health of workers suffering a workplace injury . Moreover , 6 months post-injury we found a high rate of recurrences of work absence -LRB- 38 % -RRB- in workers who had made at least one RTW attempt , which is consistent with studies suggesting that there is considerable movement in and out of work after the first return to work -LSB- 15 Côté et al. , submitted -RSB- . In a study among 1,321 US workers who filed a workers compensation claim for back pain , Côté et al. -LRB- submitted -RRB- observed that 23 % and 30 % of the workers , 6 and 12 months post-onset of back pain , respectively , experienced multiple work absences . When interpreting the results , the following methodological issues must be considered . Though reasonable for a study among claimants , the overall participation rate of 61 % raises the question of selective participation , which may have biased the results . However , the cohort was shown to be representative of the most comparable claimant group with regards to basic demographic and workplace variables , but not with regards to duration of time receiving wage replacement benefits and rates of wage replacement re-instatement , suggesting the presence of more severe disability in the cohort . Hence , the generalizability of the results remains limited with respect to workers with less severe work disability . More importantly , the rates of self-reported recurrence of work absence may be inflated in our cohort . A related issue concerns the loss-to-follow-up of 29 % . The attrition analysis demonstrated that non-respondents and respondents were similar with regards to time receiving wage replacement benefits , the occurrence of re-instatement of wage replacement benefits , and self-reported work absence duration . Non-respondents were younger males , worked longer hours , and were more likely to specify `` back '' as their primary pain site compared to respondents . Future research should further explore the relationship between recurrence -LRB- s -RRB- of work absence , health outcomes , and work limitations over an extended period of time . We found that workers who experienced a recurrence after a first return to work clearly report more health problems and work limitations than those with a sustained first return to work , and their health status is often comparable to workers who do not return to work . Our trajectory analyses were based on a 6 months time window and it was not yet possible to examine multiple recurrences and their effects on health outcomes and work limitations over a longer period of time . However , 12 month follow-up data will make such analyses possible in the future . Moreover , we have to examine important and meaningful changes in health outcomes and work limitations between baseline and follow-up across the possible RTW trajectories -LSB- 39 -RSB- , and also study them in relation to a broad range of factors -LRB- e.g. , RTW interventions , disability management strategies -RRB- that might have influenced the RTW process and the outcomes considered . Finally , future research should identify early prognostic factors of the trajectories , particularly focusing on the `` problematic '' trajectories -LRB- recurrences and persistent work absence -RRB- , so that guidance for an optimal reintegration or for recurrence prevention can be provided . To conclude , the results of this prospective study suggest that workers who had a sustained first return to work report a better health status and fewer work limitations than those who experienced a recurrence after a first return to work or who did not return to work . However , it is also demonstrated that a return to work is not equivalent to a complete recovery from MSK disorders . Workers who had a sustained first return to work still reported meaningful health limitations , as compared to the general population and significant work limitations . Given the considerable impact of disability on worker health and costs for the workers , employers , and society , the findings highlight the importance of considering multiple health outcomes , including depressive symptoms and work limitations , when studying the complex process of return to work and when developing RTW interventions and disability management strategies .

O O O B I O O O O O O O O B I O O O O O O O O O O O O O B I O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O B I I O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O 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O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O B I O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O B I I O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O B I O O O O O O O O O O O O O O O O O O O O O O B I O B I O O O O O O O O O O O O O O B I I O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O B I I O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O B I I O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O B I I O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O B I O O O O O O O O O O O O O O O O O O B I I O O O O O O B I O O O O O O B I I O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O B I O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O B I O O O O O O O O O B I I O O O O B I I O O O O O O O O O B I I O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O B I O O O O O O O B I I O O O O O O O O O O

health outcomes
musculoskeletal disorders
return to work
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When pharmacotherapeutic recommendations may lead to the reverse effect on physician decision-making For long the medical literature has shown that patients do not always receive appropriate care , including pharmacotherapeutic treatment . To achieve improved patient care , a number of physician-oriented interventions are being delivered internationally in an attempt to implement evidence based medicine in routine daily practice of medical practitioners . The pharmacy profession has taken an active role in the delivery of intervention strategies aimed at promoting evidence based prescribing and improved quality and safety of medicine use . However , the medical literature also supports the notion that valid clinical care recommendations do not always have the desired impact on physician behaviour . We argue that the well-established theory of psychological reactance might at least partially explain instances when physicians do not act upon such recommendations . Reactance theory suggests that when recommended to take a certain action , a motivational state compels us to react in a way that affirms our freedom to choose . Often we choose to do the opposite of what the recommendation is proposing that we do or we just become entrenched in our initial position . The basic concepts of psychological reactance are universal and likely to be applicable to the provision of recommendations to physicians . Making recommendations regarding clinical care , including pharmacotherapy , may carry with it implied threats , as it can be perceived as an attempt to restrict one 's freedom of choice potentially generating reactance and efforts to avoid them . By identifying and taking into account factors likely to promote reactance , physician-oriented interventions could become more effective . It is well known that the use of medicines often results in avoidable complications or adverse events . In the United States a study showed that approximately 60 % of iatrogenically related admissions to intensive care units were drug related and 75 % were preventable -LSB- 1 -RSB- . In Australia , adverse medicine events are responsible for 1.6 % of all hospital admissions -LSB- 2 -RSB- . To achieve improved quality and safety of medicine use , a number of physician-oriented interventions are being delivered internationally in an attempt to improve evidence based prescribing in routine daily practice of medical practitioners -- e.g. , distribution of educational materials , decision support systems , outreach visits , medication reviews , etc. . The pharmacy profession has taken an active role in the delivery of intervention strategies related to pharmacotherapy . For example , in medication review programmes , pharmacists interview patients , conduct assessments of information gathered on patients ' use of medicines and prepare reports for physicians , which may contain pharmacotherapeutic recommendations -LSB- 3 -RSB- . Pharmacists also are typically involved in educational outreach programmes . In such programmes it is common for pharmacists to take up the role of educator , visiting physicians in their office to provide educational interventions on specific pharmacotherapeutic topics . As pharmacists and physicians share expertise in pharmacotherapy , their involvement in intervention strategies aimed at promoting quality and safety of medicine use makes sense . Indeed , the literature has reported positive results on patient health outcomes arising from such interventions -LSB- 4 , 5 -RSB- . However , despite the delivery of interventions designed to foster quality and safety of medicine use , the literature provides support for the notion that , at times , despite physicians agreeing to the value of evidence based clinical recommendations , intervention strategies do not always have an impact on physician behaviour . For example , in a study in which both physicians and community pharmacists had negotiated actions based on medication reviews , the researchers were only able to document a rate of implementation of 42 % of the proposed actions -LSB- 6 -RSB- . These findings are supported by our own experience working with community pharmacists involved in medication management programmes in Australia . Some of these pharmacists report that sometimes their recommendations have the desired impact on physician choice of pharmacotherapy , but at times they have no impact at all and in some instances they even cause physicians to respond negatively . As expected , failure to change physician behaviour is not restricted to the prescribing area . Indeed , non-compliance to evidence based recommendation is a consistent finding in clinical care research -LSB- 7 -RSB- . For example , Grol and Grimshaw -LSB- 7 -RSB- note that hospital-acquired infections affect one in every 11 patients with 13 % mortality rate and that 15 -- 30 % of infections are considered to be preventable by handwashing -LSB- 8 -RSB- . Still , compliance with handwashing by health care providers , in particular medical practitioners , is known to be poor -LSB- 7 -RSB- . Indeed , with surprising frequency , and to the considerable dismay of interventionists , physician-oriented interventions often fail to improve handwashing behaviour -LSB- 7 , 9 -RSB- . Without a doubt while there are certainly circumstances that may lead physicians to justifiably question clinical care recommendations , in general non-compliance to evidence based recommendations proves costly to patients and society alike . Currently , there is a lack of theoretical framework for understanding instances when valid recommendations do not lead to the desired impact on physician behaviour . The key question is : What are the barriers that impede physician acceptance of valid recommendations ? We argue that the theory of psychological reactance -LSB- 10 -RSB- might at least partially explain instances when evidence based recommendations fail to impact on physician behaviour . Psychological reactance Psychological reactance is a tendency to resist perceived attempts by others to control the individual 's behaviour -LSB- 10 -RSB- . Most of us like to perceive ourselves as being in control ; we value our sense of freedom and autonomy and like to project an image of being in control -LSB- 11 -RSB- . In general , when we perceive that our freedom of choice is being restricted by the action of others , we react in a way that affirms our ability to choose . Often we choose to do the opposite of what the recommendation is proposing that we do or we just become entrenched in our initial position . This phenomenon is called psychological reactance -LSB- 10 -RSB- . Reactance is directed towards reattaining the restricted freedom ; a motivational state compels us to reassert that freedom -LSB- 10 -RSB- . In many circumstances , reactance results in an increase in the attractiveness of the constrained behaviour and an increased sense of confidence in the ultimate decision made -LSB- 10 -RSB- . Particular noteworthy is the finding that reactance appears to be a biological tendency , an inherent human characteristic . At the very least , it can be said that reactance manifests itself at a very young age -LSB- 12 -RSB- . For the last four decades the theory of psychological reactance has been widely tested and applied with reactance being widely recognised as a powerful determinant of behaviour . To date , studies across a vast array of behaviours have consistently demonstrated that recommending that individuals take a certain course of action often produces the opposite effect , consistent with this tendency to resist perceived attempts by others to restrict freedom of choice . For example : in the marketing area research indicates that expert recommendations are desirable as long as they are consistent with the choice tendency of individuals . When expert recommendations contradict the consumer 's choice tendencies , a reactant state is activated on the part of the decision maker leading to a behavioral `` backlash '' that results not only in consumers ignoring the recommendations but in intentionally contradicting them -LSB- 13 -RSB- . Not only there is an increase in choice of the non-recommended option , but also a significant increase in confidence in the non-recommended option -LSB- 13 -RSB- . In the healthcare literature , psychological reactance has been primarily used to explain patient non-compliance , i.e. , why some patients refuse to cooperate with medical treatment -LSB- 14 , 15 -RSB- . Fogarty and Young -LSB- 15 -RSB- conducted research that indicates that individual variability in compliance to a medication regimen is related to individual variability in reactance as a personality trait -LSB- 15 -RSB- . Psychological reactance has also for long been observed in the natural setting in response to perceived attempts to restrict one 's freedom of choice . A classic example of psychological reactance in the everyday life took place when a city in the United States banned the possession and use of laundry detergents containing phosphates for environmental reasons . It was found that residents stockpiled an enormous quantity of detergents containing phosphates before the ban went into effect . Others organised carpools to neighbouring counties to purchase detergents containing phosphates -LSB- 16 , 17 -RSB- . As a result of the ban , the perceived value of the prohibited products was increased ; compared with residents in neighbouring counties , who were free to choose whatever detergent they liked , residents subjected to the ban rated phosphate detergents as gentler , easier to pour , better whiteners and stain removers , and more effective in cold water . It is noted that phosphates have no impact whatsoever on the cleaning effectiveness of detergents . Psychological reactance and physician-oriented interventions The long history of successful support for reactance theory in diverse settings and areas of behaviour may also have implications for physician-oriented interventions in which evidence based clinical recommendations are provided , as health care providers may not be immune to the phenomenon of psychological reactance . It is true that the basic concepts of psychological reactance are universal and likely also to be applicable to the provision of evidence based clinical recommendations to physicians . In the context of physician-oriented interventions , the theory and research on psychological reactance would predict that at times when opposing recommendations are provided , physicians ' perceptions of threats to their freedom to select an appropriate course of action could produce the opposite reaction leading them to become more likely to ignore the recommendation or to choose the non-recommended option . This would be the case even in circumstances where physicians may agree , in essence , to the value of the recommendation ... to the extent that it is perceived by the individual that the communicator is trying to make him change , his freedom to decide for himself will be threatened and he will experience reactance ... Information and arguments can be quite helpful to the individual and may result in positive influence , but the perception that the communicator is attempting to influence will tend to be seen as a threat to one 's freedom to decide for oneself -LRB- -LSB- 10 -RSB- , p. 94 cited in -LSB- 14 -RSB- -RRB- . Indeed , making recommendations regarding clinical care , including pharmacotherapy , may carry with it implied threats , as it can be perceived as an attempt to restrict one 's freedom of choice generating reactance and efforts to avoid them . Furthermore , the inherent `` veto '' power that physicians have over the treatment regimen may facilitate manifestation of reactant-style responses making non-compliance to evidence based recommendations more likely to occur . It is also important to recognise that even in circumstances where physicians agree to participate in interventions , they may not necessarily expect their practice to be challenged . For example , there are several possible reasons for a physicians agreeing to a medication review . In some cases , physicians may wish to monitor the individual patient 's self-medication habits or they may be concerned about possible patient non-compliance with the medication regimen . It is also true that physicians have for long subscribed to a body of ethical rules created above all for the benefit of the patient -LSB- 18 -RSB- . Professional behaviour of medical practitioners is guided by these ethical rules , which dictate what is morally approved and disapproved conduct specifying what ought to be done -LSB- 18 -RSB- . It is reasonable to expect medical ethics to have a considerable impact on physician decision-making in situations that involve potential harm to the patient . For example , the use of a non-steroidal anti-inflammatory drug -LRB- NSAID -RRB- in a patient taking the anticoagulant warfarin puts the patient at an increased risk of bleeding . In such situations , which involve potential harm to the patient , recommendations arising from intervention strategies most certainly will be recognised by the physician as an injunctive professional norm -LRB- a norm of `` what ought to be done '' -RRB- and most certainly will be implemented . However , it is possible that providing physicians with valid opposing clinical care recommendations that do not involve potential harm to the patient may at times be counterproductive . For example , in a patient with low gastrointestinal and cardiovascular risk , recommendation to use a non-selective NSAID if the patient is responding well to a COX-2 selective NSAID , may be perceived as an unwarranted attempt to restrict one 's action , increasing the likelihood of a reactant-style response . Although no study appears to have specifically addressed reactance from a health care providers ' perspective , a recent qualitative study has provided some indication that reactance might play a role in physician decision-making in response to pharmacotherapeutic recommendations -LSB- 19 -RSB- . This study investigated determinants of successful collaboration between community pharmacists and physicians in medication review . Participating pharmacists discussed the need to be diplomatic in their recommendations , as they believed physicians ' misperception that they were `` telling them what to do '' could induce dismissal of their recommendations . Possible determinants of reactance It is possible that reactant responses may be more likely to occur in situations where the physician has not requested the information/recommendation . Experiments outside the medicines area have demonstrated that unsolicited information can evoke psychological reactance even when recommendations provide a substantial amount of information beyond what the decision maker knows -LSB- 20 -RSB- . Interestingly enough , in situations where the recommended action went contrary to the individual 's choice tendency , this reactance to unsolicited information was significantly more likely to occur when recommendations came from a source perceived to be an expert -LSB- 20 -RSB- . The authors suggest that unsolicited recommendations may be perceived as more of a threat or an intrusion when they come from credible sources . It is noted that although unsolicited information is typically provided to physicians through written materials and computerised decision support systems , in some programmes medicines use review can be initiated by the pharmacist and report sent to the patient 's physician in an unsolicited fashion -LSB- 21 -RSB- . It is also possible that the perception that the particular interventionist is directing recommendations specifically to the particular physician , as opposed to the treatment of the patient 's condition in general , also could make reactance more likely to occur . Brehm -LSB- 10 -RSB- demonstrated that reactant responses are more likely to occur when individuals perceive the constraint as being specifically directed at them as opposed to when it is perceived to be impersonal -LSB- 10 -RSB- . If indeed , this is found also to apply to physician-oriented interventions , it may have implications for how pharmacists and other health care professionals provide recommendations to physicians . Sense of medical professionalism might also be implicated in reactant responses . We do value our sense of freedom and autonomy and we like to project an image of being in control -LSB- 11 -RSB- . Indeed , physicians are trained to make sound decisions with regard to treatment regimen and it is reasonable to expect them to believe that they are in control and have the knowledge and skills required to make the best possible decisions . The acceptance of a contrary recommendation to what is being used to treat the patient 's illness could undermine the physician 's own sense of competence , reducing the cognitive basis of professionalism . On the other hand , dismissal of the recommended option could have the opposite effect reinforcing physician 's ability to choose the most appropriate treatment . We also know that once aroused , reactance may heighten individual 's sensitisation to additional threats to freedom of control -LSB- 22 -RSB- . It is also reasonable to believe that at a time when governments are encouraging greater involvement of allied healthcare professionals in patient care , issues related to professional territoriality may sensitise physicians to reactance in response to recommendations from allied healthcare professionals , including the pharmacist . Although the literature reports positive medical profession 's attitudes to pharmacists and their clinical role , some sentiments of encroachment are supported by studies that found that not all physicians view favourably greater involvement of pharmacists in patient care -LSB- 23 -- 25 -RSB- . Thus , the physician-pharmacist interaction in the intervention process could be burdened with social and personal pressures , which can increase the possibility of a reactant response . Indeed , psychological reactance may offer a theoretical framework that could enhance our understanding of the , at times , difficult relationship between pharmacists and physicians . It is also possible that the nature of the physician relationship with the allied healthcare professional is also a determinant of reactance . For example , it has been argued that the most successful pharmacist interventions have been those in which the pharmacist works in close liaison with the physician -LSB- 26 -RSB- . Indeed , in the United States much of the evidence supporting pharmacist involvement in collaborative drug therapy management is derived from the ambulatory care setting -LSB- 27 -RSB- where routine contact with physicians may allow for the development of the trusting relationship needed for interprofessional collaboration -LSB- 28 -RSB- . Finally , another factor that may determine reactant responses to recommendations include individual differences , as some people are more likely to have a reactant response in general to any perceived constraint -LSB- 29 -RSB- . Individual variations in susceptibility to reactance can explain why identical situations may lead to markedly different perceptions of threat and magnitudes of reactant responses in different persons . Indeed , scales developed to measure reactance as a trait demonstrate that individual reactance levels lie along a continuum from very low to very high -LSB- 29 -RSB- . Naturally , in the context of physician-oriented interventions , the nature and intensity of the reactant response is also likely to be a function of how much the particular physician values his/her freedom to select the treatment option him/herself . Again , a recent qualitative study provides some support to the notion that some physicians are more prone to psychological reactance than others -LSB- 19 -RSB- . In this study , personality of medical practitioners was discussed as a factor influencing the outcome of medication review . Participating pharmacists distinguished between physicians who they thought were amenable to discussing their prescribing decisions and those who were not . These results indicate that interventionists do assess the reactance potential of the individual physician although it is unlikely that they label the assessment as such . It is noteworthy that when interventionists sense reactance in their interaction with the physician , they may be faced with a difficult dilemma , as they are aware of the possibility that the provision of evidence based clinical recommendation may trigger the opposite response . What can the interventionist do in such situation ? Dealing with reactance A phenomenon like psychological reactance , which is likely to impede the desired outcome of physician-oriented interventions , needs to be adequately addressed when training healthcare professionals to deliver such interventions . We must be mindful that the process of delivering physician-oriented interventions can be difficult as psychological reactance is not a reasonable or rational response ; it can cause people to become highly emotional and motivated to defend their behaviour . Prior research on reactance suggests that individuals ' ability to exercise some choice -LRB- freedom -RRB- in relation to recommendations may impact on compliance to the advice provided . That is , maximising the individual 's perception of free choice can minimise reactance -LSB- 22 -RSB- . It is possible that the degree to which the physician is incorporated in the selection of evidence based clinical care practices may affect the extent to which the intervention will induce reactance . Indeed , it is possible that intervention strategies which give physicians the impression they have little or no say on their own clinical practices will be less likely to be effective , as they are perceived as more threatening , compared to those where physicians perceive themselves as exercising some choice . We are now training pharmacists on how to deal with psychological reaction in the context of medication review . We also expect such training to enhance commitment to the pharmacy lead intervention from the interventionist 's perspective , as after being equipped with tools for dealing with reactance , pharmacists may experience a greater sense of self-efficacy in dealing with all types of physicians , including those who are highly reactant . In addition , awareness of reactant responses and its causes may assist pharmacists and other healthcare professionals in altering their emotional response to reactant behaviour avoiding a decreased sense of self-efficacy . Concluding remarks The current paper addressed an intrinsic human characteristic , psychological reactance , as a factor that may influence the outcome of physician-oriented intervention strategies , including those typically delivered by pharmacists . Although psychological reactance has not been tested from a healthcare provider 's perspective , there is enough research to suggest the basic cognitive process represented is universal and also valid in the context of clinical care recommendations in the healthcare setting . Indeed , reactance theory fits well as it offers some explanation of why at times valid recommendations fail to have the desired impact on physician behaviour . It is possible that as human beings , even healthcare professionals are subjected to the same human emotions and weaknesses as humans in general . However , a role for reactance in clinical care recommendations needs to be investigated empirically . If this role is established , factors likely to increase the potential for reactance may need to be taken into account when implementing intervention strategies that attempt to influence physician behaviour . It also is acknowledged that physician non-compliance to valid recommendations is more likely to be a complex , multi-faceted phenomenon . Physicians may not adhere to evidence based recommendations for a number of reasons unique to the individual patient , and the circumstance . It is most likely that reactance , although a powerful determinant of behaviour in general , is only one of the many factors that influence decision-making in relation to clinical care/pharmacotherapeutic recommendations .

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pharmacist
physician
psychological reactance
medication review
interventions
decision support systems

professional behavior change
continuing medical education
health psychology