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  • Title: Individualised placement and support programme for people unemployed because of chronic pain: a feasibility study and the InSTEP pilot RCT.
    Author: Linaker C, Fraser S, Price C, Maguire N, Little P, Madan I, Pinedo-Villanueva R, Coggon D, Cooper C, Ntani G, Walker-Bone K.
    Journal: Health Technol Assess; 2021 Jan; 25(5):1-72. PubMed ID: 33501902.
    Abstract:
    BACKGROUND: Chronic pain is a common cause of health-related incapacity for work among people in the UK. Individualised placement and support is a systematic approach to rehabilitation, with emphasis on early supported work placement. It is effective in helping people with severe mental illness to gain employment, but has not been tested for chronic pain. OBJECTIVE: To inform the design of a definitive randomised controlled trial to assess the clinical effectiveness of individualised placement and support for people unemployed because of chronic pain. METHODS: A mixed-methods feasibility study comprising qualitative interviews and focus groups with key stakeholders, alongside a pilot trial. STUDY PARTICIPANTS: Primary care-based health-care professionals, employment support workers, employers, clients who participated in an individualised placement and support programme, and individuals aged 18-64 years with chronic pain who were unemployed for at least 3 months. INTERVENTION: An individualised placement and support programme integrated with a personalised, responsive pain management plan, backed up by communication with a general practitioner and rapid access to community-based pain services. OUTCOMES: Outcomes included stakeholder views about a trial and methods of recruitment; the feasibility and acceptability of the individualised placement and support intervention; study processes (including methods to recruit participants from primary care, training and support needs of the employment support workers to integrate with pain services, acceptability of randomisation and the treatment-as-usual comparator); and scoping of outcome measures for a definitive trial. RESULTS: All stakeholders viewed a trial as feasible and important, and saw the relevance of employment interventions in this group. Using all suggested methods, recruitment was feasible through primary care, but it was slow and resource intensive. Recruitment through pain services was more efficient. Fifty people with chronic pain were recruited (37 from primary care and 13 from pain services). Randomisation was acceptable, and 22 participants were allocated to individualised placement and support, and 28 participants were allocated to treatment as usual. Treatment as usual was found acceptable. Retention of treatment-as-usual participants was acceptable throughout the 12 months. However, follow-up of individualised placement and support recipients using postal questionnaires proved challenging, especially when the participant started paid work, and new approaches would be needed for a trial. Clients, employment support workers, primary care-based health-care professionals and employers contributed to manualisation of the intervention. No adverse events were reported. CONCLUSION: Unless accurate and up-to-date employment status information can be collected in primary care health records, or linkage can be established with employment records, research such as this relating to employment will be impracticable in primary care. The trial may be possible through pain services; however, clients may differ. Retention of participants proved challenging and methods for achieving this would need to be developed. The intervention has been manualised. TRIAL REGISTRATION: Current Controlled Trials ISRCTN30094062. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 5. See the NIHR Journals Library website for further project information. Chronic pain is a common cause of disability and unemployment. Individualised placement and support is a package of care that aims to rehabilitate people and get them back into paid employment. It is effective for people with severe mental health conditions, but no one knows if it works for patients with chronic pain. This research aimed to determine the feasibility of a future randomised trial to test if individualised placement and support improves quality of life or other health outcomes in this group. We conducted in-depth interviews with patients, doctors, nurses, employment support workers and employers, as well as a small-scale pilot trial. All of the groups interviewed supported the value of the intervention and the pilot trial. The Patient Advisory Group helped review trial documentation and produced a standardised treatment-as-usual booklet for comparison with individualised placement and support. However, despite experimenting with a range of methods, recruiting patients proved challenging, particularly from general practices, where employment status is not recorded systematically. More efficient recruitment was achieved through pain services. Overall, we recruited and randomised 50 participants, 22 of whom received individualised placement and support and 28 of whom received treatment as usual. There were no adverse events and both groups found their ‘intervention’ acceptable. Returned questionnaires were completed well by all participants; however, we experienced significant levels of non-returns, particularly among those receiving the individualised placement and support, possibly related to starting work. Overall, we believe that a trial would not be feasible if recruiting through general practices, but may be feasible via pain services. Challenges would be complex clients, retention over 12 months in both arms, integrating individualised placement and support with pain services and ensuring that the intervention was delivered as intended across multiple sites. The full report comments on how such challenges might be addressed.
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