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Fostering shared decision making by occupational therapists and workers involved in accidents resulting… Coutu, Marie-France; Légaré, France; Durand, Marie-José; Corbière, Marc; Stacey, Dawn; Loisel, Patrick; Bainbridge, Lesley Mar 17, 2011

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STUDY PROTOCOL Open AccessFostering shared decision making by occupationaltherapists and workers involved in accidentsresulting in persistent musculoskeletal disorders:A study protocolMarie-France Coutu1*, France Légaré2,3, Marie-José Durand1, Marc Corbière1, Dawn Stacey4, Patrick Loisel5,Lesley Bainbridge6AbstractBackground: From many empirical and theoretical points of view, the implementation of shared decision making(SDM) in work rehabilitation for pain due to a musculoskeletal disorder (MSD) is justified but typically the SDMmodel applies to a one on one encounter between a healthcare provider and a patient and not to aninterdisciplinary team.Objectives: To adapt and implement an SDM program adapted to the realities of work rehabilitation for painassociated with a MSD. More specific objectives are to adapt an SDM program applicable to existing rehabilitationprograms, and to evaluate the extent of implementation of the SDM program in four rehabilitation centres.Method: For objective one, we will use a mixed perspective combining a theory-based development program/intervention and a user-based perspective. The users are the occupational therapists (OTs) and clinical coordinators.The strategies for developing an SDM program will include consulting the scientific literature and group consensuswith clinicians-experts. A sample of convenience of eight OTs, four clinical coordinators and four psychologists allof whom have been working full-time in MSD rehabilitation for more than two years will be recruited from fourcollaborating rehabilitation centres. For objective two, using the same criteria as for objective one, we will first traineight OTs in SDM. Second, using a descriptive design, the extent to which the SDM program has beenimplemented will be assessed through observations of the SDM process. The observation data will be triangulatedwith the dyadic working alliance questionnaire, and findings from a final individual interview with each OT. A totalof five patients per trained OT will be recruited, for a total of 40 patients. Patients will be eligible if they have awork-related disability for more than 12 weeks due to musculoskeletal pain and plan to start their workrehabilitation programs.Discussion: This study will be the first evaluation of the program and it is expected that improvements will bemade prior to a broader-scale implementation. The ultimate aim is to improve the quality of decision making,patients’ quality of life, and reduce the duration of their work-related disability by improving the services offeredduring the rehabilitation process.* Correspondence: Marie-France.Coutu@USherbrooke.ca1Centre for action in work disability prevention and rehabilitation (CAPRIT)and School of Rehabilitation, Université de Sherbrooke, 1111, rue St-Charlesouest, bureau 101, Longueuil (Québec), J4K 5G4C, CanadaFull list of author information is available at the end of the articleCoutu et al. Implementation Science 2011, 6:22© 2011 Coutu et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (, which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.BackgroundFor individuals having a persistent work disability duepain associated with a musculoskeletal disorder (MSD),a return to work (RTW) will depends on the complexinteraction among several types of factors: biological (e.g., medical status, physical capacities), psychological (e.g.,fears, beliefs, self-efficacy), and social (e.g., work environ-ment, interaction among rehabilitation professionals,and management and compensation policies) [1,2].Therefore, interventions will have to focus primarily onthe reduction of the work disability rather than painreduction. However, a qualitative study observed thatwhen referred to an interdisciplinary work rehabilitationprogram injured workers expected complete pain alle-viation [3]. In the absence of agreement, the clinicianand patient were not focused on the same action planand did not use the same criteria for evaluating treat-ment efficacy [3,4]. Consequently, this paradigm changehas important implications for clinical practice and forthe establishment of an alliance with the patient/injuredworker because the gap between workers expectanciesand what is being offered has evidence-based treatmentcan be significant.Shared decision making to prevent clinician-patient gapsThrough shared decision making (SDM), it may be pos-sible to reduce gaps such as in understandings/represen-tations, values, and expectancies between clinicians andpatients. SDM is currently defined by the joint processof decision making of patient and clinician, in whichinformation is exchanged, preferences are expressed anddiscussed, and agreement is reached regarding the goalsand action plan to pursue. Follow-up is also planned forthe purpose of evaluating and, if necessary, readjustingthe goal or the plan in place [5]. A systematic review ofthe barriers and facilitators of implementing SDM, withdata from 39 studies in 15 countries, did not reveal asingle study in rehabilitation, thus underscoring a majorknowledge gap [6]. This review also brought to light thethree main barriers to implementing SDM, namely, timeconstraints and problems in applying the process due tothe patients’ characteristics or to those of the clinicalsetting [6]. These findings therefore highlight the impor-tance of including the practice settings in the differentsteps involved in implementing an SDM process.Through the exchange of information and discussionof preferences, the SDM process seeks to improve bothpatient’s and clinician’s decisional conflict, thus improv-ing the quality of the decision itself and reducing uncer-tainty when the clinician cannot guarantee a specificresult [7]. The level of decisional conflict is defined bythe uncertainty associated with an action, in cases wherea choice must be made among different options (e.g.,options for returning to work) that may involve a risk,loss, or regret, or go against personal values. TheOttawa Decision Support Framework (ODSF) [7] specifi-cally addresses the decisional conflict [7]. This modelwas developed to improve the quality of decisions madein the health context by addressing the determinants ofdecisions and endeavouring to act on the modifiable fac-tors. The determinants of decision-making conflict com-prise the patient’s and clinician’s characteristics, as wellas perceptions of the decision that has to be made,social pressure/support to make a decision, andresources needed to implement the decision [7]. Thesedetermining factors were also observed in prior studieson patients with work disabilities [3,8]. These findingstherefore underscore the need to aid workers having awork disability in order to enhance the quality of thedecisions made by reducing uncertainty and improvingthe decision-making process. In fact, several studieshave noted a significant correlation between reducingpatients’ decisional conflict and an improved under-standing of their problem, as well as a reduction inregrets and blame of the clinicians [9].Conceptual frameworkBased on findings in disability prevention studies, inempirical data in health psychology and psychotherapy,and SDM literature, we therefore propose the generalconceptual framework depicted in Figure 1 as the basisof this study protocol.The objective of this project is to adapt and imple-ment an SDM program adapted to the realities of workrehabilitation for persistent pain associated with anMSD. This will allow for a first evaluation of the pro-gram so that improvements can be made prior to abroader-scale implementation during a second phase.The ultimate aim is to improve the quality of decisionmaking, patients’ quality of life, and reduce the durationof their work-related disability by improving the servicesoffered during the rehabilitation process. To facilitateattainment of the project objective, we will pursue thefollowing two specific objectives: to adapt an SDM pro-gram applicable to existing work rehabilitation pro-grams; and to evaluate the extent of implementation ofthe SDM program in four work rehabilitation clinics.MethodsGeneral methodologyThis study falls into the field of evaluative research [10].Program development requires four iterative phases:needs evaluation; program planning and development;program implementation and evaluation; and programimprovement [11]. Each of these cycles involves a speci-fic methodology and specific analyses to ensure thevalidity and reliability of the data collected [12]. In thefirst cycle, needs were evaluated using a deductiveCoutu et al. Implementation Science 2011, 6:22 2 of 8approach based on our prior studies [3,8]. The currentproject therefore begins in the second cycle, that of pro-gram planning and development.Specific objective one: To adapt an SDM programapplicable to existing work rehabilitation programsDesignA mixed perspective, which we have used successfully inprior studies, will combine a theory-based perspective[13] and a user-based perspective [14]. In this project,the users are occupational therapists (OTs) and clinicalprogram coordinators. The strategies used to adapt theSDM program/intervention will be defined using thescientific literature and a group-consensus method [15].By adopting a mixed perspective, combining those ofrehabilitation theory and users, we will be able to adaptan SDM program/intervention adapted to the realities ofrehabilitation practice. Over and above the users wehave identified (OTs and clinical program coordinators),we believe that the addition of psychologists, with theirexpertise regarding the establishment of a working alli-ance, will significantly contribute to the adaptation ofthe SDM program.ParticipantsA convenience sample comprised of eight OTs, fourcoordinators, and four psychologists will be recruitedfrom the following four large rehabilitation centers thathave agreed to collaborate: the Centre de réadaptation del’Estrie; Centre Montérégien de Réadaptation; Centre deréadaptation Lucie Bruneau; and the Centre Hospitalierde l’Université de Sherbrooke. These centres were chosenbecause they all apply the same work disability evidence-based intervention principles [16]. They will also providea variety of expertise, taking into account the culture andthe context of different referring agencies, such as theQuebec’s workers compensation board, the Québec auto-mobile insurance agency, the public health insurance,and the private insurers. The number of experts retainedis representative of their distribution in the practicesettings. The inclusion criteria are as follows: workingfull-time in MSD rehabilitation for more than two yearsas psychologists, OTs, or clinical program coordinators.These inclusion criteria were based on our prior studies[14], as in the past they have permitted recruitment feasi-bility while providing substantial information. Also, thenumber of participant will help achieve data saturation,while maintaining a good dynamic in the group [17].Data collection and analysisFor the theory-based perspective, a first conceptual fra-mework for the SDM process was developed based on aliterature review and our empirical data. Using this con-ceptual framework, a first theoretical version will beoperationalized [13] to define the specific objectives ofthe SDM process. We will then be in a position to drawup a detailed plan [13] relating the objectives to theactivities and resources needed for the SDM program.Using this theoretical version, the users will be con-sulted to allow us to adapt the theory to the realities ofwork rehabilitation. For this purpose, the Technique forResearch of Information by Animation of a Group ofExperts (TRIAGE) method [15] will be used. This groupconsensus method allows data to be studied, compiled,and analyzed by stimulating reflection among experts.First, the experts will individually study the programtheory that has been derived from the literature and willcomplete a questionnaire on the theory. The question-naire will seek first to document their level of agreementregarding some of the statements about the program.Rated on a 4-point scale (totally disagree to totallyagree) [18]. When respondents gives a rating of lessthan 3, which corresponds to disagree and totally dis-agree, they will be asked to make a maximum of fivesuggestions of ways to improve the program. For exam-ple, here are the statements and specific questions thatcould be asked [13,19]:1. The objectives are necessary and essential for ashare decision-making process in work rehabilitation.Figure 1 The project’s conceptual framework seen from a patient perspective.Coutu et al. Implementation Science 2011, 6:22 3 of 8Propose objectives or clarifications of the objectivespresented that you deem essential for a SDM pro-cess in work rehabilitation; Identify the objectivesthat are non-essential and that should be removed.2. The objectives are realistic for a context of SDMin work rehabilitation. Please make the necessarychanges to the objectives that are not realistic.3. The activities are essential, related to the objec-tives, and both realistic and feasible. They are for-mulated in clear and concrete terms. Proposeactivities or clarifications of the activities presentedthat are related to the objectives, realistic, and feasi-ble, formulating them in clear and concrete terms;Identify activities that are non-essential and thatshould be removed.4. The indicators proposed are necessary, sufficient,and appropriate to measure the attainment of theobjectives. Propose essential indicators or clarifica-tions of the essential indicators presented that arerelated to the objectives; Identify the indicators thatare non-essential and should be removed.5. The resources (human and material) proposed willmake it possible to attain the objectives and carryout the activities. They are also sufficient. Proposeresources that are essential to attaining the objec-tives and carrying out the activities.6. Regarding the implementation of the SDM pro-gram, the following questions will be asked [20]: Theprogram fits in with current practices; What factorswill hinder implementation? What factors will facili-tate implementation?The participants’ answers will be compiled in prepara-tion for the group meetings. These answers will be writ-ten on separate cards, and be discussed in a series ofapproximately four meetings of the same participants.Each meeting will be limited to a maximum of threehours. At the outset, the participants will be told not totry to produce a perfect SDM program. The second spe-cific objective (first implementation) will enable certaincomponents of the SDM program to be further clarifiedor possibly modified.The meetings will be recorded to support the notestaken by the research assistant on the group’s decisions.A summary will be written up for each group meetingand the literature may be consulted in order to docu-ment the emerging data. After the group meetings havebeen completed, an SDM program adapted to workrehabilitation will be ready for a first implementation.The study protocol has been approved by all affiliatedresearch ethics committees of the participating rehabili-tation centres. All experts who agreed to participate tothe group consensus will sign an informed consentform. The group consensus session will be held duringworking hours. The research project will therefore pro-vide financial compensation for the loss of clinical activ-ity time.Specific Objective two: Evaluate the extent ofimplementation of the SDM program in four workrehabilitation clinicsDesignIn order to evaluate the extent of implementation, anexploratory study with a descriptive design will be used[21]. The extent of implementation corresponds to thegap between what is planned and what is offered in rea-lity [22]. In order to implement the program within therehabilitation programs at the four centres, the OTs willbe offered training on SDM. This training componentwill help standardize the SDM process. The extent ofimplementation will be evaluated on the basis of theaudiotaped observation of the SDM process carried outby the OT/patient dyad. The results of the observationswill be triangulated using both the results of a self-admi-nistered questionnaire completed by the members of thedyad and an individual interview with each OT after heor she has completed follow-up of five patients. Thedesign will make it possible to identify the reasons forthe gap between what is prescribed and what is offered.The program and training offered can then be modifiedaccordingly.ParticipantsA total of eight OTs will be recruited and trainedaccording to the criteria associated with specific objec-tive one. OTs were selected as the relevant professionalsbecause they conduct the initial diagnostic evaluationwhen a patient is referred to the rehabilitation centre.Also, they are frequently the main health professionalinvolved in the rehabilitation process. The OTs will notbe obliged to have participated in the specific objectiveone phase, given that training will be offered. Moreover,since the OTs have already displayed their interest inparticipating in this study, according to the innovationdissemination model, they are considered to be ‘earlyadopters,’ thus facilitating implementation [23].Five patients will be recruited for each OT, for a totalof 40 patients. The patients will have to be of workingage (between the ages of 18 and 64) have been off workfor more than 12 weeks due to pain associated with aMSD, and be starting a work rehabilitation program. Topromote external validity, only patients with a specificMSD (recent fracture, metabolic disease, neoplasia,inflammation, or infection of the spinal column) will beexcluded.Training the OTs in the SDM processSDM training derived from theories on innovative inter-vention implementation [6,24] will be adapted to therehabilitation context. This training will be given in anCoutu et al. Implementation Science 2011, 6:22 4 of 8interactive one and a one-half hour workshop that hasbeen successfully implemented in Quebec [25]. A beforeand after study of the impact of this training has alsoobserved an improvement in physician/patient agree-ment [24]. According to the basic principles of theOttawa Decision Support Framework [7], the objectivesof training are as follows: identify the modifiable deter-minants contributing to decisional conflict; provide deci-sion support to patient needs; and learn to use thevalidated generic decision-aid instrument based on theOttawa Framework [26]. In addition to this training onbasic SDM skills [27,28], advanced training on the work-ing alliance will be offered based on graduate coursetaught by the principal investigator and offered onlinewith a one-day synthesis of the learning done in class.The course was developed with the help of a techno-pedagogue.The rehabilitation programThe SDM program will be implemented in the four par-ticipating centres that currently offer similar evidence-based rehabilitation programs. In work disability preven-tion, evidence-based intervention principles include stay-ing physically active [29], reassuring patients about theirMSD [30,31], reducing both fears and avoidance of painand movement [32,33], implementing a progressiveRTW [16,34,35] and collaboration with stakeholders[36,37]. The main steps in rehabilitation programs arethe initial diagnostic evaluation, the clinical phase, andthe therapeutic RTW, which includes gradual in vivoexposure. The specific moment during the rehabilitationprogram for offering the SDM will be clarified duringthe specific objective one phase. However, it is realisticto think that it will be done at the beginning of therehabilitation program, following the initial evaluationbut prior to establishing the treatment plan. As thepatients are referred by a third party (private or publicinsurers), the referring party expects the goal of therehabilitation to be a RTW. This goal cannot thereforebe modified. In fact, patients who refuse to RTW maylose entitlement to their income replacement indem-nities. Despite this situation, our prior studies show thatother important decisions can be made [8,38]. The SDMprocess will then focus on the options pertaining to ahealthy, safe, and sustainable RTW.The recruitment procedureThe clinical program coordinators at the four centreswill be our key informants, helping us to identify poten-tial participants in light of the patient inclusion andexclusion criteria. Two weeks prior to the initial diag-nostic evaluation, if an OT trained in SDM is asked toevaluate an eligible participant, the coordinator willrequest the patient’s consent to being contacted by aresearch assistant who will describe the research project.The research assistant will then contact the person bytelephone to present the details of the study. Should thepatient be interested in participating, the research assis-tant will meet with the patient before the initial evalua-tion to have the consent form signed and to answer anyquestions the participant may have. This procedure willenable the patient to make a clear distinction betweenthe research process and the usual clinical interventions.Data collection procedureThe patients who agree to participate will undergo theirinitial diagnostic evaluation as planned in the clinicalprocedures. Toward the end of this meeting, the SDMprocess will be launched. This last segment of the meet-ing will be audiotaped by the OT to avoid bringing athird person into the meeting and possibly changing thedyadic dynamic. At the end of the meeting, the researchassistant will take the recording to be transcribed andwill invite the participant and OT to complete a self-administered questionnaire independently andconfidentially.Once an OT has completed this procedure with fiveparticipants, he or she will be asked to participate in asemi-structured individual interview for the purpose ofdocumenting the factors hindering and facilitatingimplementation of the SDM process. The same researchassistant will conduct the interviews.Informed consent will be sought from the injuredworkers. The OTs will have to sign a new consent formeach time a patient agrees to be involved in the SDMprocess. The training in SDM will be held during work-ing hours. The research project will therefore providefinancial compensation for the loss of clinical activitytime.Variables and measurementsSDM-related activities The SDM activities carried outby the OT/patient dyad will be recorded and evaluatedusing the OPTION observation scale [39], for which avalidated French language translation already exists [40].Using this scale and audiotaped recordings of the SDM,it is possible to rate the 12 basic skills needed for SDMon a five-point scale from 0 (behaviour not observed) to4 (skill observed and exhibited to a high standard). Thescale has good construct validity and [41] and hasyielded very high inter-rater agreement, with intra-classcorrelation coefficient scores of 0.77 [39]. High internalconsistency has also been observed [41]. A systematicreview of SDM observation instruments shows this scaleto have the best psychometric qualities [42].Working alliance To triangulate the observational data,a validated dyadic questionnaire on the working alliance[43] will be filled out by each member of the dyad. Itwill allow the evaluation of each person’s perception ofthe quality of the relationship established. The question-naire has 12 items rated on a Likert scale and measuringthe perception of the relationship established, of the taskCoutu et al. Implementation Science 2011, 6:22 5 of 8performed, and of the goals pursued. High Cronbach’salphas have been observed [43] for each of the threeconstructs, and ranged from 0.83 to 0.98.Barriers to and facilitators of implementation ofSDM Semi-structured individual interviews will serve todocument the OTs’ perception of the factors hinderingand facilitating SDM implementation. The followingquestions will be asked: Are there typical cases in whichthe SDM process worked particularly well? What werethe characteristics of these cases (e.g., patient-related,legal or administrative context, et al.)? Are there typicalcases in which the SDM process did not work particu-larly well? What were the characteristics of these cases(e.g., patient-related, legal or administrative context, etal.)? Which prescribed objectives or activities in theSDM program theory did you feel most comfortableusing? With which ones did you feel least comfortable?Why? Can you make any suggestions to improve theprogram theory?At the end of these questions, the interviewer will pre-sent the interviewee with the aggregate results of theOPTION scale ratings for the five cases he or she ismanaging, to maintain the confidentiality of the indivi-dual results. These results will be presented in a respect-ful manner to avoid blame and to promote theemergence of explanations and theories as to the differ-ences between what was done and what was prescribed.Data analysisDescriptive analysis will be performed on the scores ofthe questionnaire completed by each member of thedyads. The transcript of the 40 SDM processes will beanalyzed by two independent evaluators using theOPTION rating scale to obtain a score for implementa-tion. Qualitative data analysis of the individual inter-views with the OTs will be done to determine whetherthe OTs carried out the SDM process successfully asprescribed in the program theory. For this purpose, con-tent analysis will be performed using a list of a prioricodes. These codes will come from a taxonomy of bar-riers and facilitators of implementation of SDM [6].However, the emergence of new codes in light of thedata obtained will be possible, in an effort to remain asfaithful as possible to the transcript. Qualitative dataanalyses will be done using ATLAS-TI analysis software[44]. The interviews will be coded by a research assis-tant and the principal investigator to obtain inter-rateragreement using the Landry method [45]. The codesassigned to the excerpts will then be compared anddivergences discussed in order to clarify any ambiguities.This process will be carried out until inter-rater agree-ment of 90% [46] is obtained. A summary will be pre-pared of the barriers and facilitators identified by eachOT, and the summaries then compared to identifypoints of convergence and divergence between cases.Following this step, discussion groups will be held withall the researchers and the research assistant for thepurpose of reaching a consensus on the extent of imple-mentation, and on the barriers to and facilitators ofimplementation. Depending on the findings, the pro-gram theory will be improved and/or additional traininggiven.DiscussionCurrent studies across the various health fields in SDMonly offer objectives or general recommendations [47].To the best of our knowledge, no SDM program existsthat presents an operationalized conceptual frameworkrelating objectives to specific activities and resources.The findings of our project will make it possible to fillthis gap in the literature.This is a pragmatic study involving a limited numberof clinicians. Therefore, further generalization and con-firmation of the findings will be necessary with addi-tional clinical environments and larger subject groups.This study, however, is a necessary step because thecontent of the innovative SDM process must be adaptedto work in the disability prevention field. We realizethat the conceptual framework is a simplified modeladdressing only a portion of the complex interactionsbetween the stakeholders and patients in the work dis-ability process.The design and multiple theory-driven basis of thisstudy will help prevent the problem that frequently arisesduring the evaluation of complex interventions: that theprogram was not clearly defined or not thoroughly devel-oped [48]. We will also have gathered information fromthree sources (observation, patients, and OTs) to increasethe reliability of the evaluation of the extent of imple-mentation. We have previously validated and used thesetriangulation measures [3,40,43,49]. Combining theory-driven and user-based perspectives will also reduce themain barriers to SDM implementation: lack of applicabil-ity due to the clinical situation, and lack of applicabilitydue to patient characteristics [6]. Therefore, in-depthdocumentation of the implementation process with aview to improving the program will contribute to thesuccess of a future, broader-scale implementation duringa second phase. In addition, this project will facilitateimplementation of the shared decision-making programin the context of other problems generating work disabil-ity, such as mental health problems.AcknowledgementsThis study is supported by a grant from the Fonds de la Recherche en Santédu Québec.Author details1Centre for action in work disability prevention and rehabilitation (CAPRIT)and School of Rehabilitation, Université de Sherbrooke, 1111, rue St-CharlesCoutu et al. Implementation Science 2011, 6:22 6 of 8ouest, bureau 101, Longueuil (Québec), J4K 5G4C, Canada. 2Research Centerof Centre Hospitalier Universitaire de Québec, Hospital St-François d’Assise,CHUQ, 10 rue Espinay Québec (Québec), G1L 3L5, Canada. 3Department ofFamily Medicine and Emergency Medicine, Faculty of medicine, UniversitéLaval, Pavillon Landry, avenue de la medicine, Québec (Québec), G1K 7P4,Canada. 4School of Nursing, Faculty of Health Sciences, University of Ottawa,Guindon Hall, 451 Smyth Road, Ottawa, ON, K1H 8M5, Canada. 5Dalla LanaSchool of Public Health, University of Toronto 155 College Sreet, 5th Floor,Toronto (Ontario), M5T 3M7, Canada. 6Faculty of Medicine, College of HealthDisciplines 400 - 2194 Health Sciences Mall, Vancouver (British Colombia),V6T 1Z3, Canada.Authors’ contributionsMFC wrote the study protocol and conceived the study. FL contributed withher expertise and in the writing on SDM concept and training, as well asidentifying the assessment of the SDM activities. MJD brought her expertisein the methods section on program evaluation, she contributed to theelaboration of the interdisciplinary work rehabilitation program and actedhas a mentor to MFC. MC participated with his expertise in working allianceconcept and its assessment. DS contributed with her expertise on SDMconcepts and training. PL participated with his expertise on work disabilityprevention he contributed to the elaboration of the interdisciplinary workrehabilitation program and acted has a mentor to MFC. LB brought herexpertise in interprofessional education and knowledge transfer expertise inclinical settings. MFC is its guarantor. All authors contributed in obtainingthe funding. All authors read, edited, and approved the final manuscript.Competing interestsThe authors declare that they have no competing interests.Received: 19 January 2011 Accepted: 17 March 2011Published: 17 March 2011References1. Waddell G, Burton AK, Main CJ: Screening to identify people at risk of long-term incapacity for work London UK: Royal Society of Medicine Press; 2003.2. Loisel P, Durand MJ, Berthelette D, Vezina N, Baril R, Gagnon D, Lariviere C,Tremblay C: Disability prevention - New paradigm for the managementof occupational back pain. Disease Management & Health Outcomes 2001,9:351-360.3. Coutu MF, Baril R, Durand MJ, Côté D, Rouleau A, Cadieux G: Transformingthe Meaning of Pain: an Important Step for the Return to Work. WORK: AJournal of Prevention, Assessment, & Rehabilitation 2010, 35:209-219.4. Turk DC, Holzman AD, Kerns RD: Chronic pain. In Self-Management ofChronic Disease. Edited by: Holroyd KA, Creer TL. London: Academic Press;1986:441-456.5. 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ImplementationScience 2011 6:22.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at et al. Implementation Science 2011, 6:22 8 of 8


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