Feasibility and Acceptability of an Evidence-Informed Virtual Intervention to Reduce Perceptions of Injustice Following Work Injury

There is increasing evidence that perceptions of injustice can contribute to adverse recovery outcomes in individuals with disabling musculoskeletal conditions. Individuals who obtain elevated scores on measures of perceived injustice also report more severe pain, reduced participation in important activities of daily living, prolonged work disability, and the persistence of symptoms of mental health problems such as depression and post-traumatic stress disorder. Recent reviews of the literature have concluded that perceptions of injustice are strong predictors of disability and depression in individuals with musculoskeletal conditions. The emerging pattern of findings suggests that perceived injustice triggers a cascade of cognitive (i.e., rumination), emotional (anger, depression) and behavioural (i.e., activity withdrawal, medication overuse) reactions that can impede recovery. The relation between perceived injustice and adverse recovery outcomes has been demonstrated in individuals with work-related low back pain, whiplash injuries, catastrophic injuries, traumatic head injuries, fibromyalgia, sickle cell disease , osteoarthritis, and rheumatoid arthritis.

Although there are currently no intervention programs that have been developed specifically to modify perceptions of injustice following work injury, there are indications that treatment-related reductions in perceptions of injustice are prospectively associated with more positive rehabilitation outcomes. For example, one study reported that reductions in perceptions of injustice predicted occupational re-engagement in work-disabled individuals participating in a 10-week behavioural activation program. In the latter study, reductions in perceived injustice predicted return to work even when controlling for treatment-related reductions in pain severity. In a separate study, treatment-related reductions in perceptions of injustice were found to prospectively predict reductions in depressive symptom severity in work-disabled individuals with Major Depressive Disorder. The research that has accumulated to date suggests that an intervention specifically designed to reduce perceptions of injustice could contribute to more positive recovery outcomes in individuals who have sustained debilitating musculoskeletal injuries.

The purpose of the proposed study is to test the feasibility and impact of a 4-week psychosocial intervention, delivered remotely, designed to reduce perceptions of injustice following occupational injury. The intervention consists of 4 30-minute virtual meetings with a psychologist trained in the delivery of the intervention protocol. The intervention protocol has been termed, 'Managing Post-Injury Challenges' (MPIC). The intervention protocol is manualized and combines several evidence-supported treatment elements including validation, motivational interviewing, acceptance and problem-solving. The intervention protocol will be delivered concurrently with physiotherapy treatment.

Participants

The study sample will consist of 75 individuals who are absent from work due to a musculoskeletal injury. All participants will be receiving primary care physical therapy from one of 4 clinics. Eligibility criteria will include 1) receiving or having applied for time-loss benefits from the WSIB for a musculoskeletal injury to the back or neck, 2) date of injury less than 6 weeks prior to enrolment in the study, 3) a score above risk threshold on a self-report measure of perceived injustice, and 4) working knowledge of French or English. Individuals who are currently receiving psychological treatment will not be considered for participation.

Measures

All self-report measures will be administered through a secure web-based data capture system (RedCap).

Demographic and Injury-Related Variables. Participants will be asked to complete a general information form where they will be asked to respond to questions concerning their age, sex, education, marital status, number of children at home, occupation, previous time loss claims and current medication intake.

Perceived injustice: The Injustice Experiences Questionnaire (IEQ) will be used to measure injury-related perceptions of injustice.

Pain Severity: The McGill Pain Questionnaire Short-Form (MPQ-SF) will be used to measure pain severity.

Depressive symptoms: The Patient Health Questionnaire-9 (PHQ-9) will be used to assess depressive symptom severity. Self-Reported Disability: The WHODAS 2.0 will be used to assess self-rated disability.

Treatment satisfaction will be assessed at treatment termination. Return to Work. Return-to-work status will be assessed by telephone interview at treatment termination and 3-month follow-up.

Procedure

Consecutive referrals meeting the inclusion criteria for the study will be invited to participate. Prospective participants will be provided with a brief description of the intent of the MPIC intervention and will be asked for permission to be contacted by one of the MPIC clinicians. Prospective participants who agree to participate in the MPIC intervention will be provided with a link to a secure portal that will be used to administer all self-report measures used in the proposed research. MPIC sessions will be scheduled at a mutually convenient time for the MPIC clinician and the participants, and will be held weekly for 4 consecutive weeks. All self-report measures will be administered at the time of enrollment in the study (Week 1), at termination of the MPIC intervention (Week 4) and at 3-month follow-up. Treatment satisfaction will only be assessed at termination of the MPIC intervention.

A post-treatment debriefing interview will be conducted at 3-month follow-up. The aim of the post-treatment interview will be to examine participants' reflections on aspects of the intervention that they considered beneficial and aspects of the intervention that they did not consider beneficial. These interviews will provide important information to guide possible modifications to the intervention protocol that could increase its engagement value and impact.

The short-term expected outcome is that we will demonstrate that MPIC will yield clinically significant reductions in perceived injustice. We also expect that the results of the study will show that reductions in perceived injustice predict more positive recovery outcomes.

The next step in the evolution of this program of research would be to confirm the effectiveness of MPIC within the context of a randomized controlled trial. The long-term expected outcome is that there will be interest from the clinical practice community to acquire the skill set required to deliver the MPIC intervention.

The telehealth model of service delivery also has several advantages over face-to-face treatment including ease of incorporation into other health services to which participants might have been referred, physical accessibility, geographical reach, low cost, and feasibility of quality monitoring. The advantages of combining a risk-targeted intervention with an accessible service delivery model, while minimizing displacement challenges for individuals with a disabling health condition might provide the optimal approach for reducing the pain, disability and chronicity that can ensue in the aftermath of work injury.

It is anticipated that the study findings will reveal that the risk-targeted intervention yields meaning reductions in perceived injustice, and in turn, contributes to more positive recovery outcomes. Such findings would support the addition of the risk-targeted intervention to the repertoire of services made available to injured workers. The telehealth delivery model would maximize the scalable potential of the intervention to meet the needs of the target population. Training modules could be developed to disseminate the skill set required to deliver the intervention to the broader clinical practice community.