The next sections present the sociodemographic characteristics of participants, along with the difficulties perceived by professionals from at least two disciplines, and all the identified solutions. The desired situations are not described, as most of them concerned only the absence or reduction of the difficulties identified.
Difficulties perceived
Characteristics of workers aged 55 and over
Certain personal factors associated with W55 + significantly impact rehabilitation and return-to-work strategies. According to the participants, these workers are often in poorer health, marked by increased fatigue and physical “wear and tear.” This was attributed in part to less healthy lifestyles and prolonged exposure to adverse working conditions. They also highlighted the frequent presence of comorbidities associated with aging, which can impede or delay recovery. The participants reported that when workers do not see themselves as having an active role in managing their symptoms and health, it tends to have a negative impact on their recovery.
In workers aged 55 and over, so what we see is (…) musculoskeletal fragility, especially if people aren’t active outside of work. This means people who are out of shape, who have more fragile structures, in their joints among other [places]. And particularly if it’s people who’ve done repetitive work, they also have more worn-out structures. (OCT-01)
According to the professionals, when W55 + perceive themselves as having particularly poor health it raises doubts about their ability to meet their work demands post-sick leave. This also appears to increase their fear of job loss. The difficulties associated with securing employment elsewhere could further increase this fear of job loss after successfully returning to work. Compounding this fear is the possibility of losing the cumulative social benefits acquired through their tenure with the company. Consequently, some individuals may feel compelled to rush back to work prematurely, even before attaining optimal health conditions.
I’d say [they feel] very insecure about the fit between their residual capacities and the demands of the workplace, of employers, depending on the type of job. A lot of them say to themselves, ‘Well, who’s going to want me with these kinds of limitations, if I’m not able to do my work?’ (PSY-04)
The participants noted that the involvement of W55 + in their rehabilitation and return-to-work process becomes more fragile and potentially diminishes if they perceive retirement as financially beneficial. In fact, many W55 + view retirement as a way of avoiding the difficulties inherent in rehabilitation and return-to-work process. Conversely, their engagement is heightened when financial stability (salary, fringe benefits, retirement plan) is at stake.
I can think of one woman who wanted to continue working because if she retired [due to her injury], she wouldn’t really be able to meet her needs (…). Given that her injury could take a long time to heal, she tended to perhaps skip some steps and then go a little too fast in order to return to work. In a way, this prolonged her sick leave. (OCT-03).
The preceding testimonial highlights the problem of the premature resumption of tasks and return to work. By trying to skip steps in their recovery process, W55 + may not only delay their return to work but worsen their condition in the process.
Other participants also mentioned that within the context of sick leave, some workers view retiring as their “right” to reap the rewards of their past contributions and/or as pre-retirement.
… sometimes, when it’s a question of first-time injuries, people say to themselves, ‘I want to take my time. I’ve never benefitted from these [income] indemnities. So if it takes a little more time (…), it’s not such a big deal (…). I’ve paid contributions my whole life, so… (PHY-04)
Sometimes people are on the verge [of retiring]. They weren’t necessarily ready for it financially, but rather than having to struggle, they consider taking their retirement… (PSY-02)
The wording “on the verge” illustrates the workers’ ambivalence about the decision to retire following an occupational injury. It also suggests a transitional period in which workers find themselves between two major phases of their life. This period reflects a tension between their desire or need to continue working and their recognition of their physical limitations or work constraints.
Work environment
The participants noted that workplaces offer little support to W55 + with work-related disabilities. They gave different explanations for this lack of support. According to them, some organizations fail to recognize the specific contribution made by workers in this age bracket. They also indicated that some organizations perceive these workers as less motivated at work and at greater risk of injury and relapse due to their health condition. Consequently, accommodations and the return to work for such workers are frequently viewed as imposing additional workload on both co-workers and supervisors, or as incurring additional costs for the organization. In certain situations, a worker’s return to work after an extended absence can be perceived as disrupting the newly established balance within the work group during the person’s absence. This type of situation can create inconvenience in workplaces. For example, if the return of a W55 + with high seniority leads reduced benefits for their co-workers, the latter may perceive little advantage in the worker returning to work successfully.
So am I going to have someone who’s productive? Am I going to have someone who’s able to keep on working? Like I said, the work has been reorganized, sometimes that works well, [so] do you take the risk of turning everything upside down again to reintegrate the person? (…) you have to assess the risks against the likelihood of them staying on the job. That’s pretty much how it always is with an older employee (…). But there’s also the question of how this upsets the order established during the person’s absence (…) And you know, that involves co-workers too. In the choice of vacation days, in all that. Some people are going to lose privileges! (PSY-01)
According to the participants, the tendency to offer less support is likely to be particularly detrimental to the rehabilitation and return to work of W55+. It could exacerbate their sense of being undervalued or rejected at a time when they most need recognition and support. This lack of support could also fuel their existing fears and worries, significantly impacting their motivation and their engagement in the return-to-work process.
I think it’s often people who’ve had careers somewhere, [and] then suddenly, when they get injured or when the employer has to fork out money for their employee, to take care of them, generally the employer kind of disappears (…) I think this notion of [lack of] recognition is all the more hurtful (…) for people aged 55 and over [because] they’re more likely to have invested their time in a company, in their workplace. (PSY-02)
Financial compensation system
The participants identified the application of certain compensation regulations as impeding the adaptation of rehabilitation interventions to meet the specific needs of W55+. Specifically, they mentioned the impossibility of adapting treatment duration and frequency to align with some workers’ slower pace of recovery. They also reported that the treatments offered focus solely on the injury, whereas some other treatments, such as general reconditioning, may be required to prevent relapses in W55+.
If we’re talking about the insurance system – a system where you’re generally limited in terms of length or number of sessions. But it’s as if [the insurer] doesn’t take into account the fact that it takes longer for workers who are a little older. (OCT-03)
When we see that there’s a bit of a biospsychosocial [element] and that their job is very physically demanding, we refer them quickly for occupational therapy (…). [As for] kinesiology, well it’s not very popular with insurance companies. It’s hard to obtain that kind of service (…) And yet, sometimes all it would take is a few sessions of reinforcement [exercises] and we’d send them back to work, and they’d probably be at lower risk of re-injury. (PHY-04)
The participants also reported that W55 + lack awareness of the mechanisms and administrative procedures of the compensation system, which can contribute to their fears about returning to work. They also stated that these W55 + often feel that the systems are looking for ways to ‘get rid of them,’ indicating a sense of marginalization and aged-based discrimination.
These systems [the insurance and compensation systems] generate mistrust. People have the impression that they [the systems] are looking for ways to get rid of them, that they’re not respecting their rights. (PSY-01)
Moreover, according to the participants, insurers tend to question more frequently whether to offer rehabilitation to W55 + compared to when younger workers are involved. This questioning process is influenced by their perceptions of injured older workers’ limited capacities and motivations and the proximity of their retirement. According to participants, this results in fewer rehabilitation and reorientation services being offered, and instead, in implementing more medico-administrative measures (functional limitations).
Sometimes, [looking at] the health condition versus age, the agent can see it as something major, and I have the impression at times that they might be a little less optimistic about the possibility of a return to regular full-time work (…). For example, they may therefore tend to rush things a bit (…). Taking into account that [the work] is demanding, we [the insurer] might be better to speed things up right away and issue functional limitations. (OCT-04)
Quality of communication among stakeholders and its consequences.
The participants unequivocally identified major communication difficulties between the stakeholders involved in the rehabilitation and return to work of this worker population. While these difficulties are generally recognized as affecting the rehabilitation process of all people on sick leave for an MSD, the participants emphasized that the impacts of this situation are more harmful to the health of W55+, due partly to comorbidities.
In fact, the first thing we look at is comorbidities. Are we looking at conditions that are stabilized? So for sure we ask the client this question, but also the doctor. This means we need pretty close collaboration with the doctor (…). And we can’t always reach doctors quickly or they don’t always get back to us quickly about these conditions (…) If we could have something that was more efficient, in my opinion, we’d be able to optimize at least the overall management of those conditions. (OCT-02)
These problems appear first in the communications between the rehabilitation professionals and attending physicians.
It’s hard to work in collaboration with the doctor, to find out what we can do, I mean, what are the limitations? Are there other conditions [involved] that mean this person has a guarded prognosis, [that are] unfavourable to being able to stay on the job? (…) It’s not always easy to communicate with the doctors. (PSY-05)
According to the participants, this communication gap undermines the consistency of the clinicians’ messages to workers and could fuel workers’ perception that they have a serious condition.
[We see] an overmedicalization of musculoskeletal conditions, (…) then there are the iatrogenic effects that occur when there are lots of interventions, examinations. This feeds catastrophic representations of the condition. (…) People arrive here [for rehabilitation] with the impression that they’re finished, at the end of the road, that their body’s worn out. (PSY-01)
Communication difficulties also appear to be reinforced by barriers to accessing care from general practitioners and specialists. However, the latter could offer interventions that are better adapted to the health condition of these workers.
I try exercises, but the person is in too much pain. They need medication to manage their pain because otherwise I achieve nothing with (…) if there’s no family doctor, when they’ve tried Advil and Tylenol, it’s hard to get a medication that’s more effective (…) Essentially this slows down our work. And sometimes, we’re also waiting for surgery. Which means that we work on maintenance (…). But then, the person also declines because things heal, but a little crooked because what’s really needed is surgery. (PHY-03).
Another difficulty reported was communication between rehabilitation professionals and insurers. Insurers are often the only intermediaries providing clinicians access to information about the workplace. When this communication channel is not effectively utilized, it hinders adjustments to the intervention and the workers’ return to work.
But with [some insurers], the agents are often harder to reach (…). We have less chance to talk to them, and to explain a little our point of view in the case (…) Sometimes I have to call the general number, I wait until somebody answers, and then they tell me, ‘Oh, that’s such-and-such an agent. He’ll call you back in two or three days.’ Sometimes you have to wait a long time (…). (OCT-04).
One of the explanations provided for the communication difficulties is the inadequacy of available means of communication (e.g., fax, telephone), which may not meet the demands of current practice.
We’re in contact with the doctors in the [healthcare establishment], [and] it’s still by fax, and that, it’s (…) we’re no longer in 1920! (…) It’s not efficient. Same thing with the [insurers]. (…). So… sometimes you let it go for a while (…) and you say, ‘ok, forget it, we’ll manage some other way.’ (PHY-06)
Solutions
Be better equipped to support workers aged 55 and over.
Participants expressed a desire for training aimed at optimizing worker education and mobilizing this population in their recovery process. They suggested that having access to a bank of clinical tools specifically for rehabilitation professionals, addressing common issues encountered with individuals aged 55 and above (such as motivation and fatigue), would be valuable for improving clinical interventions. In addition, training for front-line clinicians on the biopsychosocial approach could foster less biomedical and better-adapted interventions focussed on rehabilitation.
But often it’s tools we’re trained to use with other types of clients, [tools] like motivational interviewing or negotiating (…) I think it’s tools that pretty much exist already, that we could use with this clientele, knowing that the issues are more specific with them. (…) We need to have access to this information [these tools], which is [are] extremely valuable and pertinent, but [it’s got to be] fast, efficient access. (OCT-01).
I think that some physiotherapists can have a very, very biomedical approach to treating musculoskeletal problems, [and] would probably benefit from having a slightly more biopsychosocial view from the outset, and [they could] then go seek out other types of resources when relevant (…) And I think that some physiotherapy interventions can unfortunately reinforce certain movement phobias and catastrophic thinking about the situation. (PSY-01)
Create mechanisms for communication between physicians, rehabilitation professionals, and insurers.
Several participants reported that the presence of comorbidities in W55 + requires more frequent and timely communication between rehabilitation professionals, attending physicians, and insurers. This solution would facilitate access to and sharing of information about the worker’s medical conditions and progress. They proposed several mechanisms, including a centralized computerized platform, the use of a shared form, communication through new technologies (e.g., TEAMS or ZOOM), and regular telephone contact.
(…) I think that having a doctor who gives us indications very quickly about what they’ve done with the client (…) It could be saying [something like], ‘Well, there’s a checklist indicating that I’ve reviewed the MRI report, I’ve prescribed such and such, or I recommend such and such’ (….). I mean, if we were able to reach [them] more easily, to have a fax number or a portal at the very least, which would make doctor-therapist exchanges possible (…) To have a sort of shared file or a platform where we could communicate, so that if we have any questions, well, then we can ask them directly rather than waiting three months for the client to see the doctor again. (OCT-02)
Integrate a return-to-work coordinator (RTWCO).
Participants proposed the implementation of a return-to-work coordinator (RTWCO) who is involved on a continuous basis and who supports the worker throughout the return-to-work process. This person would actively engage with the worker, serving as a liaison among various stakeholders to facilitate better communication. The RTWCO would ensure the worker’s perspective is considered and provide support throughout the rehabilitation and compensation process.
In an ideal world, there would be (…) a pivot person who’d serve as the transmission belt between all the people involved in the person’s return to work. In other words, the employer, payer, medical specialist (…) A sort of return-to-work coordinator. (PSY-02)
Develop a joint action plan for managing workers aged 55 and over.
The participants agreed on the need to raise awareness among stakeholders (health professionals, employers, insurers) regarding the issues involved in the return-to-work process and the specific needs of W55+. They reported that stakeholders often seem unaware or have misconceptions about these issues. Key concerns include companies’ failure to recognize of the added value of W55+, particularly of their experience, which could in fact be an asset.
Well, for sure, I think that the key is to provide them with information about what clients of a certain age can bring to the company [experienced workers], (…) what can be gained from having an employee… who is aged 55 and over, and that, above all, [since] they’ve been with the company for years, how good it can be to have them on the team. They would then see them more as a form of investment, and I think that would foster a degree of openness toward seeing these clients back at work. (OCT-04)
The participants consider it essential to compel stakeholders to recognize that aging influences work disability and the process of mitigating it.
… understanding that a person aged 55 and over is going to take longer to progress, (…) that doesn’t mean not getting the person to be active. It just means going a little more at their pace. (OCT-03)
Several participants suggested promoting the relaxation of laws and regulations to permit easier adjustment of the duration and nature of treatments, as well as provide more adequate access to treatments.
… having some kind of set treatment, [that’s] paid for, but that we actually have some sort of control over. (…) I think the patient would really be seen (…) in terms of their needs (…) Because when I think of that, a set treatment of 20 sessions, but three times a week, that’s not very long. But if we go with an approach that’s a little more proactive and all that, I mean, it could be for several, several weeks at least. (PHY-02)
When considering treatment approach, it could, for example, be a matter of providing faster access to occupational therapy services aimed specifically at developing functional capacities or overall physical conditioning.
In an ideal world, all these processes of sending a patient to develop their functional capacities, [or] of sending a patient for occupational therapy because they struggle with activities of daily living or domestic chores, we have difficulties with this [getting their need for services recognized]… we see that there’s a bigger biospsychosocial component; well, in an ideal world, this [the referral for occupational therapy] would all go very fast, you know. (PHY-06)
The participants mentioned that insurers are unfamiliar with the benefits of long-term physical conditioning programs, yet the benefits for these workers warrant being explored.
They [the insurers] see that [physical reconditioning] as more of an expense. They don’t see it as a long-term investment. It’s not costly to get [someone] to do a month of exercises (…). But it’ll pay off in the long run because the person will have learned to work out, to move, they will have learned to see the benefits, and then recover. But this rarely happens. (PHY-01)
Implement an integrative prevention approach in companies.
According to the participants, the rehabilitation of W55 + should be part of a broader integrative prevention approach. Companies should therefore target all three levels of prevention simultaneously: 1) reduce the incidence of disease (primary prevention), 2) reduce the prevalence of disease (secondary prevention), and 3) reduce the prevalence of work disability and support return to work (tertiary prevention). Examples provided for each level of prevention included implementing safe work environments, promoting personal health maintenance, offering support when a health problem arises, or adapting work demands and conditions based on workers’ capacities.
Perhaps this brings us back mainly to prevention. (…) Personally, I’d like to see if there might already be something written down [about this] in the company. Something like, ‘Here. First, we practice prevention, we prevent injuries as much as possible. [Then] if they happen, here are the basic guidelines. Here’s the process.’ (OCT-03)
Acknowledging the potential reluctance of workplaces discussed earlier, some participants emphasized the necessity of incentivizing measures to encourage workplaces to undertake these actions. This support could come form insurers or be integrated within the legislative framework:
Yes, maybe specific incentivizing measures to help … to help reassure … I can think of one woman, among other people, who went back to work. There were several things involved, but there was a whole concept of cost sharing between the insurer, (…) [measures] that somewhat reassured the employer that it would not be saddled with a bill or a bunch of problems. So, I would see measures like that. (PSY-01)