Returning to Work After Sickness Absence Due to Low Back Pain: A Poetic Representation

: The purpose of this project was to capture the voices of clients through a poetic representation of their experiences and perceptions as they shared their stories of returning to work after a period of sickness absence following an episode of LBP. A retrospective evaluation of electronic chart notes of clients at an occupational health clinic in London, United Kingdom presenting with LBP who were returning to work were reviewed over a six-month period from January 2023 to June 2023. Verbatim comments of clients about their experiences and perceptions were extracted from the electronic chart notes and analysed thematically. A total of 68 electronic chart notes were retrieved and reviewed by a senior physical therapist. A poem called “The struggle within” was developed to represent the experiences and perceptions of clients as they shared their stories. Healthcare professionals should engage not only in evidence-based interventions, but also with the narratives and stories of individuals to ensure a more holistic approach. A poetic representation is one way that healthcare professionals can frame these dialogues.


INTRODUCTION
Low back pain (LBP) is pain or discomfort between the costal margin and inferior gluteal folds with or without associated leg pain (Vrbanić, 2011).The categories of low back pain can include non-specific LBP, nerve root problem and serious spinal pathology (Chetty, 2017).About 90-95% of people present with non-specific LBP, 5-10% with nerve root problems and <1% with serious pathology (Chetty, 2017).In addition to the physical and structural pathology of LBP, the social and psychological factors play an important role (Dagenais et al., 2008).The impact of LBP with regards to health and work is considerable.Over 60% of workers in the United Kingdom have taken time off work due to LBP with an estimated 15.5 days per worker (Steenstra et al., 2006).Facilitating early return to work (RTW) following LBP has been shown to improve physical, social and psychological outcomes (Carroll et al., 2010).The process of RTW can include modified, alternative or restricted duties (Carroll et al., 2010).There is strong evidence that remaining at work is good for health and early RTW is beneficial for LBP (Shaw et al., 2002).RTW interventions, such as physical therapy, have been shown to contribute to a rapid and safe RTW in a cost-effective manner (Chetty, 2011;2013;2014;2020).Most of the literature on LBP have been largely quantitative in nature with a focus on outcome measurements.There has been relatively little on the experiences and perceptions of people with LBP returning to work after a period of sickness absence.These experiences and perceptions are important to capture in order to inform vocational rehabilitation programmes.
A poetic representation is a process that captures the narratives and stories of people in order to understand what it is like for them to live with pain and disability (Neilsen, 2004).In addition, it can also seek to capture the struggles and difficulties of returning to work after a period of sickness absence (Corbett et al., 2007).The narratives and stories can be captured in numerous ways, such as personal narratives, expanded life stories or analysis of documentary evidence (Gannon, 2009).The poem presented in this paper is a representation of the experiences and perceptions of clients that was recorded verbatim by healthcare clinicians in their electronic chart notes as they shared their stories of returning to work after a period of sickness absence following an episode of LBP.

METHODS
This project was conducted at an occupational health clinic at a North London NHS Foundation Trust in the United Kingdom.This Trust consists of three designated acute care hospitals serving over 10,000 employees.The employees include both clinical and non-clinical staff providing services to maternity care, accident and emergency, orthopaedics, child heath, and general medicine and surgery.The Trust has educational links through academic partnerships.The occupational health service is an in-house service located on the Trust's premises and comprises doctors, nurses, physical therapists, psychologists and occupational therapists.
A cohort database was used to identify all clients presenting with LBP who were returning to work over a six-month period from January 1 to June 30, 2023.These clients were contacted by email to inform them of the purpose and scope of the project and to seek their permission to access their electronic records.Once permission was given, the electronic chart notes were reviewed by a senior physical therapist and only verbatim comments (i.e., comments recorded in inverted commas by the healthcare clinician) of clients about their experiences and perceptions of returning to work after a period of sickness absence following LBP were extracted and documented on a transcript.The transcript was analysed using the process of thematic analysis so that recurrent accounts from clients of what seemed to be critical to their experiences and perceptions were grouped together.This process involved multiple readings of the transcript until a final set of themes was derived.
To create the poem "The struggle within" relevant phrases from the thematically coded transcript were placed under the relevant theme (which were used to divide the poem into Acts).Throughout this process the senior physical therapist used reflexive engagement which involved meeting with four different disciplines of clinicians (doctors, nurses, psychologists and occupational therapists).These meetings ensured that the poetic reconstruction from the transcript captured the voices of the clients and not those of the healthcare clinicians.This project was classified as a service improvement, and therefore, ethical approval was not required (Health Research Authority, 2017).

RESULTS
A total of 68 electronic chart notes of clients were reviewed.Tables 1 depicts the demographic data of clients presenting with LBP who were returning to work.

DISCUSSION
The purpose of this project was to capture the experiences and perceptions of clients as they shared their stories of returning to work after a period of sickness absence following an episode of LBP.Act 1 related to the guilt and pressure of having to return to work.The pressure to be at work was more of a personal feeling compared to the guilt which was placed on the individual by their colleagues.Individuals tended to mask their personal feelings of the pressure they were under to RTW by expressing a strong keenness to do so.This masking of one's personal feelings is in agreement with the existing literature (Osborn & Smith, 1998).
Act 2 related to the indecisiveness of whether to RTW or not.There is robust data to suggest that early RTW is beneficial for the health and wellbeing of the individual (Shaw et al., 2018).However, it has been argued that this approach is applied too broadly because it does not take into consideration the personal experiences and perceptions of the individual (MacEachen et al., 2007).Individuals that return to work when they are not ready could result in presenteeism (i.e., loss of work productivity when individuals come to work even though they are not well), and this is often more expensive than absenteeism (Dagenais et al., 2008).Act 3 related to having to deal with the views and opinions of others.The dilemma when dealing with the views and opinions of others is that the responsibility of RTW between the individual and their colleagues becomes blurred.While the individual should aim to RTW as soon as realistically possible, external pressure in the form of unhelpful comments by colleagues only makes the individual feel inner tension and guilt (Kendall et al., 1998).A supportive relationship between the individual and their colleagues can contribute to an open discussion and address any conflicts so that the barriers to RTW can be explored (Shaw et al., 2011).A limitation of this project is that it involved clients at only one NHS Trust and therefore the findings cannot be transferable to all Trusts in the United Kingdom.A further project is needed to capture the experiences and perceptions of individuals with LBP returning to work after a period of sickness absence in different work settings to determine if similar themes are identified.

CONCLUSION
In conclusion, this project captured the voices of clients through a poetic representation of their experiences and perceptions as they shared their stories of returning to work after a period of sickness absence following an episode of LBP.Their voices are represented as a single poetic performance text crafted from the analysis of the transcript.The poem "The struggle within" bears witness to the feelings of guilt, pressure, frustration and ultimate resolve of those clients living with low back pain returning to work after a period of sickness absence.A poetic representation is one way that healthcare professionals can frame these dialogues.

Table 1 .
Demographic data of clients presenting with low back pain returning to work EPILOGUEIt would be nice to have a manager that is supportive, Website: https://bjmas.org/index.php/bjmas/indexPublished by European Centre for Research Training and Development UK