Usefulness and feasibility of comprehensive and less comprehensive vocational rehabilitation for patients with chronic musculoskeletal pain: perspectives from patients, professionals, and managers

Figures & data

Table 1. Participants’ characteristics.

Name^a	Gender and age	Years of work experience^b	Number of patients referred to VR per year^c	Participating trial center?	Profession
(a) Managers
Alex	M47	4	N = 123	Yes	Manager
Rudy	M54	11	N = 370	Yes	Manager
Bernard	M58	12	N = 93	Yes	Manager
Peter	M39	6	Unknown	No	Manager
Johan	M72	3	N = 92	Yes	Manager
Megan	F53	1	N = 31	No	Manager
Tim	M45	1	Unknown	No	Manager
Harold	M56	15	Unknown	No	Manager
Simon	M36	3	N = 78	No	Manager

^a Pseudonyms are used for privacy reasons.

^b Work experience of working with the care as usual C-VR program.

^c Mean referred patients over period 2016–2018.

Table 2. Patient-related factors determining the usefulness of C-VR or LC-VR according to professionals.

Category	Patient-related factors determining the usefulness of the C-VR program	Patient-related factors determining the usefulness of the LC-VR program	Participant	Quotation
Intelligence	Low level of education	High level of education	Lynn, PR	LC-VR: The people who are already more proactive, who are slightly more independent, perhaps further on in the process, too, and a bit more highly educated.
	Low level of knowledge	High level of knowledge	Lynn, PR	LC-VR: People who have a lot of knowledge and insight, who can process things more quickly and who are able to change themselves a bit.
	Low level of information uptake	High level of information uptake	Ellen, PR	LC-VR: People, I think, who are also able, yes, to pick things up quickly, who are perhaps more independent in that sense.
Behavioral	Not proactive person	Proactive person	Lea, PR	LC-VR: I think, especially people with a very proactive coping style, who are, um, rapidly encouraged to take charge of things.
	Low level of self-direction	High level of self-direction	Jacob, PR	LC-VR: People who simply find it difficult to take charge of the process, the rehabilitation process, for them, I think 40 hours is too little.
	Low level of discipline	High level of discipline	Karen, PR	LC-VR:… it requires a degree of discipline to pick things up at home or in any case from home, such as sports, and to also apply other things, that takes discipline.
	Low level of willingness to change^a	High level of willingness to change	Carol, PR	LC-VR: Willingness to change, looking at themselves, that kind of factors.
	Patient cannot train independently	Patient can train independently	Jacob, PR	LC-VR: We also see a lot of people who are not really able to work out independently.
Complaints	Fibromyalgia	No fibromyalgia^a	Lea, PR	C-VR: I think for example fibromyalgia or chronic fatigue like …
	Chronic fatigue	No chronic fatigue^a	Lea, PR	C-VR: I think for example fibromyalgia or chronic fatigue like …
	Chronic complaints^a	Subacute complaints	Jill, PR	LC-VR: Someone who hasn’t been out for very long … who’s at a very early stage in the process … yes, the subacute or when C-VR is used as a prevention program.
	Low capacity^b	High capacity	Lynn, PR	C-VR: Those who, when it comes to taking things on, mentally and physically, have so little resilience that they first have to build up a certain degree of strength before they are able to do anything at all meaningful at work.
	High / much psychosocial problems	No / low psychosocial problems	Anna, PR	LC-VR: … where less psychosocial problems play a role.
			Anna, PR	C-VR:… then you see that it really is a very considerable problem and yeah, that it’s therefore not only a work problem, but also a psychosocial problem, one that’s often very, very complicated, too.
	Multi-problems	No multi-problems^a	Jacob, PR	C-VR: … where, for example, there are problems on multiple levels, where there are problems at work and at home, yes, how to put it, intrinsically, so it’s more that people are coming up against their own difficulties, yes, good. On a psychological level, but also in dealing with and accepting their symptoms.
	Complex patients	No complex patients^a	Jill, PR	C-VR:… that people have often tried something else and when that really hasn't worked, then the [name of center] comes up, so yes, if it doesn’t work there anymore, then… you know.
Mental	Movement anxiety	No movement anxiety	Lynn, PR	C-VR: People with a lot of anxiety associated with movement, who just need a little more attention to be able to overcome that anxiety too.
			Lea, PR	LC-VR: If they nevertheless dare to train at the gym, while they are afraid. Still dare to train, even if it’s painful, then some people will conclude more quickly, um, OK, I can do it, so I’ll start working on my development.
	Obstructive thoughts	No obstructive thoughts^a	Lea, PR	C-VR: It depends on the extent of that obstructive thought. As a psychologist, yeah, that’s something you can’t express in numbers, say, but you can talk about certain gradations. Um, let’s think, for example, I now have someone training and, um, now, well, that one frets a little about pain and fatigue, but other people really fret day in, day out, and then it obstructs them much more in their daily life. So there’s a difference of gradation there. And the degree of gradation also determines how much work you have to put in in order, um, to reduce that gradation.
	Uncertain patients	Confident patients^a	Lynn, PR	C-VR: I think people who generally chose the C-VR program, that people are what I just said, who feel pretty insecure.
	Low cognitions	High cognitions^a	Anna, PR	LC-VR: … yet the problem around his pain experience and his cognitions were much stronger, and that we did not get that turned around in the LC-VR program, not even a start with that.
	Low acceptance of complaints	Acceptance of complaints^a	Jacob, PR	LC-VR: … but also in dealing with and accepting their complaints.
Work factors	Work participation not treatment goal^a	Work participation as the treatment goal	Anna, PR	LC-VR: … where it really concerns a work-related question.
	No willingness to return to work^a	Willingness to return to work	Anna, PR	LC-VR: … someone who’s also more open to it… like, I want to do this quickly and I also want to get back to work quickly.
	Has not made steps towards work reintegration^a	Has made steps towards work reintegration	Anna, PR	LC-VR: … who has already taken some steps in the direction of work.
	Bad relationship with employer	Good relationship with employer^a	Lea, PR	C-VR: people who have a worse relationship with the employer.
	Long time off work	≤ one year off work^a	Carel, PR	C-VR: people with more long-term symptoms, that is, people who may have been on sick leave for over a year.
			Anna, PR	C-VR: sometimes they’ve been at home for even longer, meaning they’ve been out of the work environment for longer, perhaps then it all gets worse in their head, so they’re no longer able to pick up the thread, yes, I think that could really be one of the factors.

C-VR: comprehensive vocational rehabilitation; LC-VR: less comprehensive vocational rehabilitation; NM: not mentioned.

^a Patient-related factor which was not explicitly mentioned by professionals but rather indirect (implicit). For example: the codes “Low level of willingness to change” and “High level of willingness to change,”¹ were mentioned as useful (i.e., high level) and not useful (i.e., low level) patient factors for the LC-VR program, but were not explicitly mentioned as a patient-related factor determining the usefulness of the C-VR program. The professionals however implicitly mentioned that such not useful patient-related factors for the LC-VR program (in this example low level of willingness to change) was in fact an eligible (useful) patient factor for the C-VR program.

^b General capacity, mental capacity, and physical capacity together.

Table 3. Usefulness of the content of the C-VR and LC-VR programs, as mentioned by patients.

	C-VR		LC-VR
Content	Useful content	Not useful content^a	Useful content	Not useful content^a
Relaxation	x	x	x	x
Fitness	x		x
Psychologist	x	x	X	x
Group education	x	x	X	x
RTW coordination - ergonomic part	x	x	X	x
RTW coordination - communication part	x		X
Movement teacher^b	x		X
Aquatic exercises^c	x		X

C-VR: comprehensive vocational rehabilitation; LC-VR: less comprehensive vocational rehabilitation; RTW: return to work.

^a “Partly useful” and “Not useful” taken together.

^b Undertaken at two centers.

^c Undertaken at one center.

Table 4. Positive and negative effects of the C-VR and LC-VR programs on patients.

	Barrier / Facilitator	Participant	Quotation
C-VR
Not forced to think critically about dose	Barrier	Ellen, PR	I think that you could look more critically at whether it’s always necessary to have 100 hours, does someone really need those 15 weeks or could they stop sooner, could more re-integration take place sooner?
Program is too uniform	Barrier	Karen, PR	At present, it’s all very standard. I think that at the least, we could look at making the content more tailored, and get away from the kind of one-size-fits-all that we have now.
	Barrier	Tim, MA	At present, it’s really a hit-and-miss approach and I’d want to use interventions in a more targeted way.
Redundant care	Barrier	Rudy, MA	At the same time, we also see clients who we’re currently putting in the full program, of whom we say, actually, a little less would also have been fine.
Therapy dependency	Barrier	Jacob, PR	What we do see in the longer program, or in any case the normal one^b, is that people do build up a certain degree of dependence on the guidance, on the therapy and all.
Tailored care	Facilitator	Karen, PR	Look, if we’re not sure whether certain parts will be feasible, then I also think yes, you know, we do want to have a go, say, a certain part that might be too much for someone, we can leave that bit out, it’s not the case that the program per se has to run the way it was conceived, we can make adjustments to it, and if we want to stop earlier or even keep going for a bit longer, then we have that option.
	Facilitator	Izzy, PT	Because it is really clearly focused on the individual, personally. And yes, that the assumption is that they look at what you can do, not at what you can’t do.
Rehabilitation in a group	Facilitator	Tess, PT	You recognize a huge number of things that in the beginning, you always thought yourself, that it was to do with you and only you feel that, but that’s not the case at all. Everyone is dealing with the same problem, in fact. So that was great, being able to recognize things in other people.
LC-VR
Time schedule (dosage)	Facilitator	Ron, PT	It’s really nice to be able to do those exercises at home, I was shown how to do all of them and then I was able to do them all by myself, yeah, I enjoyed that, then I didn’t need to spend whole days there, say, four or five hours at a time, but normally just two or three hours.
	Facilitator	Lea, PR	Due to having less contact time, well, I think you’re more concentrated as a result, I think that’s the general added value. Clients and coaches and trainers are less able to – now, how to put it – delay things for you, wait for you.
Less time spent absent from work	Facilitator	Kim, PT	There came a time when, more like the rest, I was already at work more and was also coming up against things, and in that way, yeah, you could share that with the group, also with the people from the [name of the rehabilitation center], in order to look at how best to deal with things if you found yourself in that kind of situation.
	Facilitator	Lynn, PR	People have a bit more time to reintegrate, so you can make more time and space for that.
Prevention of therapy dependency	Facilitator	Lea, PR	… and also, that you simply empower people that way, yeah, that you can simply keep living your own life and you also have to keep on doing sports as normal, you establish a framework in that way. That they have to do it themselves. Less dependence is created.
Increase self-management	Facilitator	Kim, PT	I also learned to still do quite a lot myself.
	Facilitator	Ellen, PR	Well, what I also found useful was that the client takes charge of doing things at an earlier stage, which means that we’re spoon-feeding them a bit less.
Tailored care	Facilitator	Ava, PT	They looked specifically at what would suit me in terms of group training, because I didn’t have to take part in everything. So, I did find that positive, because why should you take part in things that might not be suitable or meant for you? That might be a waste of your time.
	Facilitator	Karen, PR	The advantages were that it’s a shorter program that’s much more tailored to the individual, from the Quickscan^a you’re looking at what the person needs and how we’re going to do that.
Rehabilitation in a group	Facilitator	June, PT	I think that it’s very good that it’s in a group and I was lucky that there were two girls of my age, who I could get along with very well. I think that all ensures that, yeah, we supported each other a lot and, you know, if someone was having a bad day, the others cheered them up, and that was really nice.

C-VR: comprehensive vocational rehabilitation; LC-VR: less comprehensive vocational rehabilitation; PT: patient; PR: professional; MA: manager.

^a Quickscan is the center name for the multidisciplinary screening.

^b C-VR was meant here.

Table

(b) Professionals
Name^a	Gender and age	Years of work experience^b	Experience with N LC-VR patients	Participating trial center?	Profession
Jacob	M30	4	N = 1	Yes	Physiotherapist
Karen	F40	4	N = 1	Yes	Reintegration specialist
Jill	F39	18	N = 2	Yes	Physiotherapist & reintegration specialist
Anna	F59	5	N = 2	Yes	Psychologist
Ellen	F35	6	N = 3	Yes	Psychologist
Lynn	F42	6	N = 3	Yes	Reintegration specialist
Lea	F33	4	N = 1	Yes	Psychologist
Carol	F43	9	N = 1	Yes	Physiotherapist

^a Pseudonyms are used for privacy reasons.

^b Years of work experience of working with the care as usual (i.e., C-VR) program.

Table

(c) Patients
Name^a	Gender and age	Treatment allocation	Work status	Pain status	Civil status	Educational status^b
Owen	M63	LC-VR	Full sick leave	CMP	Single	Low
Ava	F31	LC-VR	Part sick leave	SMP	In a relationship	Medium
June	F28	LC-VR	Part sick leave	SMP	In a relationship	High
Kim	F35	LC-VR	Full sick leave	SMP	In a relationship	High
Alice	F46	C-VR	Full sick leave	CMP	In a relationship	High
Stan	M50	LC-VR	Full sick leave	SMP	In a relationship	Other
Izzy	F51	C-VR	Full sick leave	CMP	In a relationship	Medium
Mike	M54	LC-VR	Full at work	CMP	In a relationship	Low
Rose	F45	C-VR	Full sick leave	CMP	In a relationship	Other
Britt	F65	C-VR	Part sick leave	SMP	In a relationship	Low
Tess	F52	C-VR	Part sick leave	CMP	In a relationship	Other
Ron	M59	LC-VR	Full sick leave	CMP	In a relationship	Medium
Lauren	F33	C-VR	Part sick leave	CMP	In a relationship	Medium

^a Pseudonyms are used for privacy reasons.

^b Low: primary school, lower vocational education, and lower secondary school, medium: intermediate vocational education and upper secondary school, high: upper vocational education or university.

CMP: chronic musculoskeletal pain; SMP: subacute musculoskeletal pain.

Data availability

The data that support the findings of this study are available from the corresponding author, MFR, upon reasonable request.