Effectiveness of an Interactive Website Aimed at Empowerment of Disability Benefit Claimants: Results of a Pragmatic Randomized Controlled Trial

Introduction The aim of this study was to investigate the effectiveness of an interactive website aimed at empowerment of disability claimants, prior to the assessment of disability by an insurance physician. Methods A randomized controlled trial was conducted. Claimants applying for a work disability pension after being sick-listed for 104 weeks, were randomized into either an intervention group or control group. Participants who were randomized into the intervention group were able to logon to the website , which mainly consisted of five interactive modules aimed at increasing knowledge, self-awareness, expectations, self-efficacy, and active participation. Participants from the control group were directed to a ‘sham’ website with commonly available information only. The primary outcome was empowerment. Secondary outcomes included coping, knowledge, claimant satisfaction, perceived justice, and physician satisfaction. Outcomes were assessed at baseline, 2 days before the disability assessment, as well as 1 day after, 6 weeks, and 4 months after the disability assessment. Results Claimants were randomly assigned to the intervention group (n = 123) or a control group (n = 119). The intervention had no significant short- and long-term effects on empowerment, but the intervention increased claimants’ knowledge significantly compared to the control group. Claimant satisfaction with the disability assessment interview and claimant perceived justice on the outcome of the assessment were lower in the intervention group (statistically not significant). Furthermore, the intervention had a significant negative effect on claimants perceived procedural justice. Conclusion Although knowledge increased significantly, the intervention was not successful in reaching its primary target, that is, to increase levels of empowerment among disability claimants, prior to the assessment of disability.     

On the Effects of a Workplace Fitness Program upon Pain Perception: a Case Study Encompassing Office Workers in a Portuguese Context

Introduction Office workers share several behavioural patterns: they work seated without moving for long times, they use only a few specific muscles of their arms, wrists and hands, and they keep an overall poor body posture. These working patterns generate musculoskeletal disorders, and produce discomfort or pain. Implementation of a work fitness program is thus a low-cost strategy to reduce/prevent body pain derived from work. The aim of this study was to test the benefits of a workplace fitness program, specifically applied to an administrative department of a Portuguese enterprise. Recall that this type of primary prevention level of musculoskeletal disorders has been seldom applied in Portugal, so this research effort materialized an important contribution to overcome such a gap. Methods The participants in this study were office workers (n = 29 in the study group, and n = 21 in the control group)—who consistently had reported pain mostly on their back side (neck, posterior back, and dorsal and lumbar zones), wrists and posterior legs. The workplace fitness program consisted of three sessions per week during an 8-month period, with 15 min per session; emphasis was on stretching exercises for the body regions most affected by workers’ pain perception. Each participant was requested to point out the injured region, as well as the intensity of pain felt, by using a visual analogue scale. Statistical analyses of the perceived pain data from control and study groups resort to non-parametric hypothesis tests. Results There was a strong evidence that the workplace fitness program applied was effective in reducing workers’ pain perception for their posterior back, dorsal and lumbar zones, and for their right wrist (P < 0.05). Conclusions These results generated are rather promising, so they may efficiently serve as an example for other enterprises in that country—while raising awareness on the important issue of quality of life at the workplace.     

Validation of a Risk Factor-Based Intervention Strategy Model Using Data from the Readiness for Return to Work Cohort Study

Background Low back pain (LBP) is a common and in some cases disabling condition. Until recently, workers presenting with non-specific LBP have generally been regarded as a homogeneous population. If this population is not homogeneous, different interventions might be appropriate for different subgroups. We hypothesized that (1) Clusters of individuals could be identified based on risk factors, (2) These clusters would predict duration and recurrences 6 months post-injury. Methods The study focuses on the 442 LBP claimants in the Readiness for Return-to-Work Cohort Study. Claimants (n = 259) who had already returned to work, approximately 1 month post-injury were categorized as the low risk group. A latent class analysis was performed on 183 workers absent from work, categorized as the high risk group. Groups were classified based on: pain, disability, fear avoidance beliefs, physical demands, people-oriented culture and disability management practice at the workplace, and depressive symptoms. Results Three classes were identified; (1) workers with ‘workplace issues’, (2) workers with a ‘no workplace issues, but back pain’, and (3) workers having ‘multiple issues’ (the most negative values on every scale, notably depressive symptoms). Classes 2 and 3 had a similar rate of return to work, both worse than the rate of class 1. Return-to-work status and recurrences at 6 months were similar in all 3 groups. Conclusion This study largely confirms that several subgroups could be identified based on previously defined risk factors as suggested by an earlier theoretical model by Shaw et al. (J Occup Rehab 16(4):591–605, 2006). Different groups of workers might be identified and might benefit from different interventions.     

A Participatory Return-to-Work Intervention for Temporary Agency Workers and Unemployed Workers Sick-Listed Due to Musculoskeletal Disorders: Results of a Randomized Controlled Trial

Introduction Within the labour force workers without an employment contract represent a vulnerable group. In most cases, when sick-listed, these workers have no workplace/employer to return to. Therefore, the aim of this study was to evaluate the effectiveness on return-to-work of a participatory return-to-work program compared to usual care for unemployed workers and temporary agency workers, sick-listed due to musculoskeletal disorders. Methods The workers, sick-listed for 2–8 weeks due to musculoskeletal disorders, were randomly allocated to the participatory return-to-work program (n = 79) or to usual care (n = 84). The new program is a stepwise procedure aimed at making a consensus-based return-to-work plan, with the possibility of a temporary (therapeutic) workplace. Outcomes were measured at baseline, 3, 6, 9 and 12 months. The primary outcome measure was time to sustainable first return-to-work. Secondary outcome measures were duration of sickness benefit, functional status, pain intensity, and perceived health. Results The median duration until sustainable first return-to-work was 161 days in the intervention group, compared to 299 days in the usual care group. The new return-to-work program resulted in a non-significant delay in RTW during the first 90 days, followed by a significant advantage in RTW rate after 90 days (hazard ratio of 2.24 [95% confidence interval 1.28–3.94] P = 0.005). No significant differences were found for the measured secondary outcomes. Conclusions The newly developed participatory return-to-work program seems to be a promising intervention to facilitate work resumption and reduce work disability among temporary agency workers and unemployed workers, sick-listed due to musculoskeletal disorders.     

Work Reintegration and Cardiovascular Disease: Medical and Rehabilitation Influences

Introduction Research into work reintegration following cardiovascular disease onset is limited in its clinical and individual focus. There is no research examining worker experience in context during the return to work process. Methods Qualitative case study method informed by applied ethnography. Worker experience was assessed through longitudinal in-depth interviews with 12 workers returning to work following disabling cardiac illness. Workplace context (Canadian auto manufacturing plant) was assessed through site visits and meetings with stakeholders including occupational health personnel. Data was analyzed using constant comparison and progressive coding. Results Twelve men (43–63 years) participated in the study. Results revealed that unyielding production demands and performance monitoring pushed worker capacities and caused “insidious stress”. Medical reassurance was important in the workers’ decisions to return to work and stay on the job but medical restrictions were viewed as having limited relevance owing to limited understanding of work demands. Medical sanction was important for transient absence from the workplace as well as permanent disability. Cardiac rehabilitation programs were beneficial for lifestyle modification and building exercise capacity, but had limited benefit on work reintegration. Occupational health provided monitoring and support during work reintegration. Conclusions Medical reassurance can be an important influence on worker representations of disease threat. Medical advice as it pertained to work activities was less valued as it lacked considerations of work conditions. Cardiac rehabilitation lacked intensity and relevance to work demands. Occupational health was reassuring for workers and played an important role in developing return to work plans.     

Prevention of Work Disability Due to Musculoskeletal Disorders: The Challenge of Implementing Evidence

Background: The process of returning disabled workers to work presents numerous challenges. In spite of the growing evidence regarding work disability prevention, little uptake of this evidence has been observed. One reason for limited dissemination of evidence is the complexity of the problem, as it is subject to multiple legal, administrative, social, political, and cultural challenges. Purpose and methods: A literature review and collection of experts' opinion is presented, on the current evidence for work disability prevention, and barriers to evidence implementation. Recommendations are presented for enhancing implementation of research results. Conclusion: The current evidence regarding work disability prevention shows that some clinical interventions (advice to return to modified work and graded activity programs) and some non-clinical interventions (at a service and policy/community level but not at a practice level) are effective in reducing work absenteeism. Implementation of evidence in work disability is a major challenge because intervention recommendations are often imprecise and not yet practical for immediate use, many barriers exist, and many stakeholders are involved. Future studies should involve all relevant stakeholders and aim at developing new strategies that are effective, efficient, and have a potential for successful implementation. These studies should be based upon a clearer conceptualization of the broader context and inter-relationships that determine return to work outcomes.     

Accuracy of a Disability Instrument to Identify Workers Likely to Develop Upper Extremity Musculoskeletal Disorders

Background Work related upper extremity musculoskeletal disorders (MSD) result in substantial disability, and expense. Identifying workers or jobs with high risk can trigger intervention before workers are injured or the condition worsens. Methods We investigated a disability instrument, the QuickDASH, as a workplace screening tool to identify workers at high risk of developing upper extremity MSDs. Subjects included workers reporting recurring upper extremity MSD symptoms in the past 7 days (n = 559). Results The QuickDASH was reasonably accurate at baseline with sensitivity of 73% for MSD diagnosis, and 96% for symptom severity. Specificity was 56% for diagnosis, and 53% for symptom severity. At 1-year follow-up sensitivity and specificity for MSD diagnosis was 72% and 54%, respectively, as predicted by the baseline QuickDASH score. For symptom severity, sensitivity and specificity were 86% and 52%. An a priori target sensitivity of 70% and specificity of 50% was met by symptom severity, work pace and quality, and MSD diagnosis. Conclusion The QuickDASH may be useful for identifying jobs or workers with increased risk for upper extremity MSDs. It may provide an efficient health surveillance screening tool useful for targeting early workplace intervention for prevention of upper extremity MSD problems.     

Supporting Return-to-Work in the Face of Legislation: Stakeholders’ Experiences with Return-to-Work After Breast Cancer in Belgium

Background The diagnosis of breast cancer increasingly implies a return-to-work (RTW) challenge as survival rates increase. RTW is regarded as a multidisciplinary process and a country’s legislation affects the degree of involvement of the different stakeholders. We elucidated on bottlenecks and contributing factors and the relationship between policy and practice regarding RTW of employees with breast cancer as perceived by Belgian (Flemish) stakeholders. Methods Three multidisciplinary groups (n = 7, n = 9, n = 10) were interviewed during a breast cancer conference. Treating physicians (n = 4), employers (n = 6), social security physicians (n = 3), occupational physicians (n = 4), survivors (n = 5) and representatives of patient associations (n = 4) were included. The major theme was the legal and practical role in the RTW process as experienced by the participants. Qualitative thematic analysis was performed to analyse stakeholders’ experiences of women’s RTW after breast cancer. Results The stakeholders reported different perspectives. Employees focus on treatment and feel ill-informed about the RTW options. Treating physicians do not feel competent about advising on work-related questions. Employers have to balance the interests of both the business and the employee. Social security physicians assess ability to work and facilitate RTW options. Occupational physicians see opportunities but the legislation does not support their involvement. Stakeholders expressed the need for coordination and reported finding ways to accommodate the employee’s needs by being flexible with the legislation to support the RTW process. Conclusions Two factors might hamper RTW for breast cancer patients: the varying stakeholder perspectives and Belgian legislation which emphasizes the patient or disability role, but not the employee role. When stakeholders are motivated they find ways to support RTW, but improved legislation could support the necessary coordination of RTW for these patients.     

Supervisor and Organizational Factors Associated with Supervisor Support of Job Accommodations for Low Back Injured Workers

Purpose Temporary job accommodations contribute to the prevention of chronic work disability due to low back pain (LBP) through the facilitation of early return to work; yet, workplace dimensions of job accommodation are poorly understood. The objective of this study was to determine supervisor and organizational factors associated with supervisors’ support for temporary job accommodations for LBP injured workers. Methods Supervisors were recruited from 19 workplaces in the USA and Canada and completed an online survey regarding job accommodation practices and potential associated factors with respect to a case vignette of a worker with LBP. Multivariable linear regression was used to identify the most parsimonious set of factors associated with supervisors’ support for accommodations. Results A total of 804 supervisors participated with 796 eligible for inclusion in the analysis. The final set of factors explained 21 % of the variance in supervisors’ support for temporary job accommodations. Considerate leadership style (β = 0.261; 95 % CI 0.212, 0.310), workplace disability management policies and practices (β = 0.243; 95 % CI 0.188, 0.298), and supervisor autonomy for designing and providing workplace accommodations (β = 0.156; 95 % CI 0.071, 0.241) had the largest effect on supervisor support for accommodations. Conclusion Factors predicting supervisors’ likelihood to accommodate LBP injured workers include use of considerate leadership style, workplace disability management policies and practices, and supervisor autonomy. Workplace interventions targeting these factors should be developed and evaluated for their ability to improve work disability prevention outcomes.     

Integrating Psychosocial and Behavioral Interventions to Achieve Optimal Rehabilitation Outcomes

Introduction: Psychosocial factors are important contributors to work disability associated with musculoskeletal conditions. The primary objectives of this paper were 1) to describe different psychosocial interventions that have been developed to prevent prolonged work disability, and 2) to identify future research directions that might enhance the impact of programs targeting psychosocial risk factors for work disability. Methods: Selective review of scientific literature on psychosocial and behavioral interventions and work disability. Results: Most prior interventions focused on psychosocial risk factors that exist primarily within the individual (e.g., pain catastrophizing, beliefs, expectancies). Successful disability prevention will require methods to assess and target psychosocial risk factors “outside” of the individual (e.g., interpersonal conflict in the workplace, job stress, etc.) using cost-effective, multipronged approaches. Research to explore interactions among different domains of psychosocial risk factors in relation to RTW outcomes is needed. Challenges to effective secondary prevention of work disability include developing competencies to enable a range of providers to deliver interventions, standardization of psychosocial interventions, and maximizing adherence to intervention protocols. Conclusion: Effective secondary prevention of work disability will require research to develop cost-effective, multipronged approaches that concurrently target both worker-related and workplace psychosocial risk factors.     

Workplace-Based Return-to-Work Interventions: A Systematic Review of the Quantitative Literature

Introduction: A systematic review was conducted to review the effectiveness of workplace-based return-to-work (RTW) interventions. Method: Seven databases were searched, in English and French, between January 1990 and December 2003 for peer-reviewed studies of RTW interventions provided at the workplace to workers with work disability associated with musculoskeletal or other pain-related conditions. Methodological quality appraisal and data extraction were conducted by pairs of reviewers. Results: Of a total of 4124 papers identified by the search, 10 studies were of sufficient quality to be included in the review. There was strong evidence that work disability duration is significantly reduced by work accommodation offers and contact between healthcare provider and workplace; and moderate evidence that it is reduced by interventions which include early contact with worker by workplace, ergonomic work site visits, and presence of a RTW coordinator. For these five intervention components, there was moderate evidence that they reduce costs associated with work disability duration. Evidence for sustainability of these effects was insufficient or limited. Evidence regarding the impact of supernumerary replacements was insufficient. Evidence levels regarding the impact of the intervention components on quality-of-life was insufficient or mixed. Conclusions: Our systematic review provides the evidence base supporting that workplace-based RTW interventions can reduce work disability duration and associated costs, however the evidence regarding their impact on quality-of-life outcomes was much weaker. Donald Cole, Jeremy Dacombe, Jaime Guzman, Sheilah Hogg-Johnson, Ellen MacEachen, Victoria Pennick, Anusha Raj, Rhoda Reardon, Dwayne Van Eerd.     

Absenteeism Screening Questionnaire (ASQ): A New Tool for Predicting Long-term Absenteeism Among Workers with Low Back Pain

Introduction: Over the last decades, psychosocial factors were identified by many studies as significant predictive variables in the development of disability related to common low back disorders, which thus contributed to the development of biopsychosocial prevention interventions. Biopsychosocial interventions were supposed to be more effective than usual interventions in improving different outcomes. Unfortunately, most of these interventions show inconclusive results. The use of screening questionnaires was proposed as a solution to improve their efficacy. The aim of this study was to validate a new screening questionnaire to identify workers at risk of being absent from work for more than 182 cumulative days and who are more susceptible to benefit from prevention interventions. Methods: Injured workers receiving income replacement benefits from the Quebec Compensation Board (n = 535) completed a 67-item questionnaire in the sub-acute stage of pain and provided information about work-related events 6 and 12 months later. Reliability and validity of the 67-item questionnaire were determined respectively by test–retest reliability and internal consistency analysis, as well as by construct validity analyses. The Cox regression model and the maximum likelihood method were used to fix a model allowing calculation of a probability of absence of more than 182 days. Criterion validity and discriminative capacity of this model were calculated. Results: Sub-sections from the 67-item questionnaire were moderately to highly correlated 2 weeks later (r = 0.52–0.80) and showed moderate to good internal consistency (0.70–0.94). Among the 67-item questionnaire, six sub-sections and variables (22 items) were predictive of long-term absence from work: fear-avoidance beliefs related to work, return to work expectations, annual family income before-taxes, last level of education attained, work schedule and work concerns. The area under the ROC curve was 73%. Conclusions: The significant predictive variables of long-term absence from work were dominated by workplace conditions and individual perceptions about work. In association with individual psychosocial variables, these variables could contribute to identify potentially useful prevention interventions and to reduce the significant costs associated with LBP long-term absenteeism.     

Policy and Practice of Work Ability: A Negotiation of Responsibility in Organizing Return to Work

Purpose In welfare policy and practical work it is unclear what the concept of work ability involves and assessments may be different among involved actors, partly due to a lack of theoretical research in relation to regulations and practice. Based on theoretical and legal aspects of work ability the aim of the study is to analyze stakeholders?? perspectives on work ability in local practice by studying multi-stakeholder meetings. Methods The material comprises nine digitally recorded multi-stakeholder meetings. Apart from the sick-listed individual, representatives from the public Social Insurance Agency, health care, employers, public employment service and the union participated in the meeting. The material was analyzed using qualitative content analysis. Results Three perspectives on work ability were identified: a medical perspective, a workplace perspective and a regulatory perspective. The meetings developed into negotiations of responsibility concerning workplace adjustments, rehabilitation efforts and financial support. Medical assessments served as objective expert statements to legitimize stakeholders?? perspectives on work ability and return to work. Conclusions Although the formal goal of the status meeting was to facilitate stakeholder collaboration, the results demonstrates an unequal distribution of power among cooperating actors where the employers had the ??trump card?? due to their possibilities to offer workplace adjustments. The employer perspective often determined whether or not persons could return to work and if they had work ability.     

Comparison of the Psychometric Properties of Four At-Work Disability Measures in Workers with Shoulder or Elbow Disorders

Introduction To better capture the extent of work disability following an occupational injury, clinical researchers are beginning to recognize the importance of considering not only levels of absenteeism, but also disabilities experienced while “at-work”. Although at-work disability measures are available in the literature, currently there is little insight on the selection of specific measures that may be best suited for a given population or situation. The objective of this study is to assess and compare the measurement properties of four self-report at-work disability measures in workers with shoulder or elbow disorders. Methods Study sample consisted of 80 patients attending a shoulder and elbow specialty clinic operated by the Worker Safety Insurance Board of Ontario. Internal consistency reliability, validity, and patient preference of four at-work disability measures were compared in a cross-sectional design. Selected measures included the work module of the Disabilities of the Arm, Shoulder and Hand Outcome Measure, Work Limitations Questionnaire (WLQ-16), Work Instability Scale for Rheumatoid Arthritis (RA-WIS), and Stanford Presenteeism Scale. Results All four measures demonstrated evidence of internal consistency reliability (alpha = 0.76–0.90) and construct validity, although only modest correlations against work-oriented constructs (r = 0.37–0.60) were observed. The RA-WIS was most preferred by respondents (44.6%) over the other measures. Conclusions Although no single scale stood out as clearly superior, the WLQ-16 was considered the best overall performer. Variable performance between the scales suggests some divergence in the way these measures conceptualize “at-work disability”, which may be important to consider when selecting instruments for future studies.     

The Nature and Impact of Stigma Towards Injured Workers

Introduction Many injured workers experience high levels of stigma and discrimination, which compound their physical injuries and cause social and psychological harm. Despite a growing awareness of the prevalence of such stigma, there is little research that focuses on the sources, nature and consequences of stigma with respect to the lives of injured workers. The purpose of this paper is to advance knowledge related to stigma towards injured workers, specifically to explain the nature and processes of stigma and their influence on injured workers’ lives. Methods Using a constructivist grounded theory approach, data from focus groups (n = 28 participants) and individual interviews (n = 18) were analyzed to discern how stigma is exhibited and perpetuated, and its impact on the lives of injured workers. Results The study culminated in a preliminary theoretical framework that delineates the key components of the manifestations and impacts of stigma that includes stereotypes, unethical practices and maltreatment negatively affecting work, relationships and the mental health of injured workers. Conclusions The development of sound conceptualizations in this area can advance our understanding of stigma processes and provide a framework for anti-stigma efforts. The findings have implications for public education, workplace interventions and services for injured workers.     

Prognostic factors of long-term disability in a workers' compensation system

OBJECTIVE: We identified predictive factors of long-term disability in new workers' compensation claims to guide secondary prevention research and target interventions for high-risk claims. METHODS: Workers with 4 or more days of work disability resulting from workplace injuries were followed for approximately 6 years in a population-based retrospective inception cohort study of 81,077 workers. RESULTS: Predictors of long-term disability included delay between injury and first medical treatment, older age, construction industry, logging occupation, longer time from medical treatment to claim filing, back injury, smaller firm size, female gender, higher unemployment rate, and having dependents. We used logistic and quantile regression to investigate predictors of disability. These models produced consistent information regarding predictors. CONCLUSION: These factors can be used to identify jobs or workers at increased risk for long-term disability that warrant prevention intervention.     

Investigating the JD‐R occupational stress model with Australian direct‐care workers: A focus group approach

This study aimed to explore the use of a contemporary workplace stress model, the Job Demands‐Resources model, with direct‐care workers using a qualitative approach. The JD‐R model has successfully been used to predict health outcomes across different occupations using quantitative methods. However, the use of the generic questionnaire developed for this model may not always be appropriate. Direct‐care workers (n = 19) attended two focus groups and reported on their job demands, job resources and personal resources. Six themes relating to demands across the two groups: funding insecurity, time pressure, hindrance demands, poor systems, emotional engagement and dealing with client crises were identified. Participants identified clinical supervision, social support and progressive workplace resources as job resources. Finally, the personal resources identified by participants were professional behaviours, disposition and self‐care. The JD‐R model and its standard questionnaire captures some of these aspects of direct‐care work, but many were not assessed. As such, future investigations with direct‐care workers should ensure items related to poor systems, progressive workplace resources, disposition and professional behaviours are included. Alternatively, a qualitative approach should be used as a first step in the development of valid questionnaires when investigating workplace stress with this group to ensure their experience is accurately quantified.     

Understanding key worker experiences at an Australian Early Childhood Intervention Service

The delivery of family-centred practice (FCP) within Early Childhood Intervention Services (ECISs) for young children with a disability or development delay conceptualises that children's learning environments, parenting, family and community supports intersect to have the greatest impact on the developing child. The transdisciplinary key worker model is considered a best-practice approach within ECISs whereby staff work collaboratively across disciplinary boundaries to plan and implement services for children and their families. Research suggests families who have a key worker have better relationships with services, fewer unmet needs, better morale, more information about services, higher parental satisfaction and more parental involvement than those not receiving this service. Using a phenomenological qualitative design this study sought to understand transdisciplinary key workers’ perspectives regarding the strengths and challenges to undertaking their role in providing services to children and families accessing an ECIS at a major disability service organisation, in light of the changing policy reform during the roll out of the National Disability Insurance Scheme in Australia. Purposive sampling was used to recruit key workers (n = 13) to participate in semi-structured interviews during 2015. Data were analysed using an inductive, thematic approach. Results revealed four main themes that impact on the effectiveness of key workers’ service provision. These are broadly categorised as (a) Engagement with the workplace, (b) Engagement with clients, (c) Professional capacity and (d) Staff Wellbeing. The findings aligned with previous studies identifying sources of support and stress for disability services staff. They also provided new insights into key workers’ lack of confidence in addressing parental mental health issues, despite operating under a family-centred approach. These findings informed the development of an intervention trial and evaluation to improve support for parent and staff wellbeing within a Victorian Disability Service with the aim of building their capacity to support children with a disability.     

The “Toxic Dose” of System Problems: Why Some Injured Workers Don’t Return to Work as Expected

Introduction Most workers who incur an injury on the job follow a relatively straightforward path through a workers’ compensation claim, recovery and return to work. However, a minority of compensation claims is prolonged and can be disproportionately costly. We conducted this qualitative study in order to gain an understanding of systemic, process-related problems affecting injured workers who had failed to return to work as expected. Method A total of 69 in-depth interviews were conducted with injured workers with complex and extended workers’ compensation claims and with return-to-work (RTW) providers such as health care providers, insurers, legal advisors, and workplaces. The study was based in Ontario, Canada. A modified grounded theory analysis led to the identification of common mechanisms in RTW problems. Results We identify problems with return to work and extended workers’ compensation claims in dysfunctions in organizational dynamics across RTW systems including the workplace, healthcare, vocational rehabilitation and workers’ compensation. These system problems are difficult to identify because they appear as relatively mundane and bureaucratic. These appeared to have damaging effects on workers in the form of a ‘toxic dose’ affecting the worker beyond the initial injury. Conclusions Worker’s problems with extended claims were linked to RTW policies that did not easily accommodate conflict or power imbalances among RTW parties and by social relations and processes that impeded communication about RTW situations and problems. Avenues for intervention are located in a shift to a critical lens to RTW process that addresses differences of knowledge, resources, and interests among different parties.