Artigos

Conteúdo (article):

Autogestão da dor crônica no processo de retorno ao trabalho: revisão integrativa
Chronic pain self-management during the return to work process: an integrative review

AUTORES:
Rosilene de Oliveira Rosa João
Enfermeira. Mestre em Ciências da Saúde pelo Programa de Pós-graduação em Enfermagem da Universidade Federal de São Carlos; rosilenejoao@yahoo.com.br
ORCID: https://orcid.org/0009-0005-6754-9318
Bruna Vasconcelos dos Santos
Enfermeira graduada pela Universidade Federal de São Carlos; brunavasconcelos@estudante.ufscar.br
ORCID: https://orcid.org/0000-0002-3967-9327
Fernanda Maria de Miranda
Enfermeira. Doutora em Ciências da Saúde pelo Programa de Pós-graduação em Enfermagem da Universidade Federal de São Carlos; fermariademiranda@gmail.com
ORCID: https://orcid.org/0000-0003-2198-2827
Priscilla Hortense
Enfermeira. Professora Associada do Departamento de Enfermagem da Universidade Federal de São Carlos; prih@ufscar.br
ORCID: https://orcid.org/0000-0003-0554-451X
Vivian Aline Mininel
Enfermeira. Professora Adjunta do Departamento de Enfermagem da Universidade Federal de São Carlos; vivian.aline@ufscar.br
ORCID: https://orcid.org/0000-0001-9985-5575
 
Resumo
Introdução: As estratégias de autogestão da dor crônica são alternativas que possibilitam a manutenção ou recuperação da capacidade funcional em trabalhadores. Objetivo: sintetizar o conhecimento científico sobre as estratégias de autogestão da dor crônica no contexto de trabalho. Método: revisão integrativa da literatura guiada pelas recomendações do PRISMA, publicadas nas bases de dados MEDLINE, WoS e Scopus, em português e inglês, de 2017 a 2022, a partir dos descritores “chronic pain” e “return to work”. Resultados: dos 14 estudos incluídos, dez apontam estratégias para autogestão da dor crônica, predominantemente focadas no indivíduo por meio de programas multidisciplinares, dois apresentam participação do supervisor de trabalho neste processo e dois descrevem ações no ambiente de trabalho como facilitadores para o retorno ao trabalho. Conclusão: A atuação de múltiplos profissionais, o estabelecimento de plano terapêutico individualizado com participação ativa do trabalhador, o envolvimento do empregador e adaptações no local de trabalho foram apontadas como importantes estratégias para o retorno ao trabalho, mas ainda assim, com necessidade de maior envolvimento organizacional devido à característica biopsicossocial da dor e a alta influência do meio na eficácia da autogestão.
Palavras-chave: Saúde do Trabalhador; Dor Crônica; Autogestão; Retorno ao Trabalho.

Abstract
Introduction: Chronic pain self-management strategies are alternatives that enable the maintenance or recovery of worker functional capacity. Objective: To synthesize scientific knowledge about chronic pain self-management strategies in the work context. Method: we conducted an integrative literature review following the PRISMA recommendations. Searches were conducted of the MEDLINE, WoS, and Scopus databases for articles written in Portuguese and English published between 2017 and 2022 using the descriptors “chronic pain” and “return to work”. Results: Of the 14 included studies, 10 investigated multidisciplinary programs promoting chronic pain self-management strategies focused predominantly on the affected individual, two looked at interventions involving work supervisors in this process, and two described actions in the workplace as facilitators of return to work. Conclusion: The involvement of multiple disciplines and employers, the establishment of individualized therapy plans with active worker participation, and workplace adaptations were highlighted as important strategies for promoting return to work; however, there is a need for greater involvement of the organization given the biopsychosocial nature of pain and the significant influence of the work environment on the effectiveness of pain self-management.
Keywords: Occupational Health; Chronic Pain; Self-Management; Return to Work.

Introduction
Chronic pain has become a major public health problem, affecting around 20% of adults in the United States1, 45% in the United Kingdom2, and 46% in Brazil3, with prevalence tending to increase with age3. Pain is one of the leading causes of absenteeism in the workplace and causes physical and mental strain on workers, adversely affecting professional practice and performance4.
In 2022, 392,600 work-related health problems were reported to Brazil’s national notifiable diseases information system (SINAN)5. The most prevalent problems were repetitive strain injuries and work-related musculoskeletal disorders (RSIs/WMSDs), accounting for 7,259 cases. Notwithstanding the underreporting of work-related diseases and accidents, data from the National Social Security Institute (INSS)5 from the same year show the prevalence of WMSDs in illness-related work absences, with back pain and shoulder injuries accounting for 20.8% and 16.8% of cases, respectively.
Work-related injuries are directly related to workplace characteristics, work activities, productivity demands, and the type of furniture and equipment, and are caused by repetitive and unvarying movement, strenuous activities, poor or static posture, mechanical pressure, and vibration. Injuries therefore involve biomechanical, cognitive, sensory, and organizational aspects6. Ergonomically-sound adjustments to work activities and workplace adaptations should therefore be considered when workers in pain return to work, including the assessment of posture and movement, loads, tasks, relationships and environmental aspects7, as well as organizational factors such as work pace, demands, and productivity pressure.
People with chronic pain face a number of challenges in dealing with their limitations, which can make returning to work an ordeal. In addition to the persistence of pain, psychosocial aspects, long-term sick leave, job changes, psychological demands, organizational support from colleagues and management, and return-to-work programs can either facilitate or hinder this process8.
Attitudes towards self-management of pain based on self-knowledge, self-care and respecting limitations tend to facilitate adaptation9. People who are encouraged to engage in self-care and symptom management – sharing responsibility for pain control and improving function with health professionals and employers – can reduce absenteeism, find it easier to return to and remain at work, and obtain sustained motivation, social support and encouragement to overcome problems in the workplace10.
It is important to highlight that pain is a multifactorial and subjective phenomenon influenced by biopsychosocial factors, including work-related aspects6 and the general living environment11,12. It can be defined as an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage11, which interferes with people\'s lives and can lead to changes in lifestyle, personality, and functional ability9.
Given that pain is a complex, multidimensional phenomenon, any approach to address this problem needs to include the worker with pain, co-workers, managers or supervisors, occupational health services, and professionals from health services and the support network in a joint action that facilitates management in the process of returning to and remaining at work.
The adoption of a return-to-work model that considers biopsychosocial factors and involves different stakeholders13 is essential to ensure that the worker has the conditions necessary for returning to work. Dealing with workers with pain therefore entails co-responsibility between government bodies, employers, professionals, and other actors involved in the return to work process. Those who have decision-making power over cases of workers experiencing pain should develop strategies that guarantee sustainable return to work, adopting an integrated systemic approach.
Drawing on this broader perspective of the concept of pain and the return-to-work model, for the purposes of this study chronic pain self-management is a strategy developed in partnership between the person in pain (in this case, the worker), health professionals across all levels of care in the Unified Health System (SUS), and the employer (for example health and safety at work services) that uses educational actions and available resources for goal setting and therapeutic decision-making focused on solving identified problems to improve the self-management of chronic pain14. This process consists of helping people with pain shift their focus from cure to active participation, investing in improving levels of self-efficacy and the skills required to remain functional15, with support from health professionals. It also includes the use of strategies that address the complexity of pain based on the biopsychosocial model, whose social dimension encompasses the work context and other involved actors and processes15.
Pain self-management is therefore performed by the affected individual, who acquires knowledge from health professionals with the aim of controlling pain and maintaining or recovering functional ability while at the same time receiving support from their employer, who must seek knowledge and promote workplace adaptations and changes in work activities, preventing relapse15.
Despite the high prevalence of chronic pain in adults1,2,3 and the growing need for programs and strategies to help people cope with pain12, research into chronic pain self-management by workers is scarce14. Identifying return-to-work pain self-management strategies is important to motivate the creation of public policies and programs to address this issue and can contribute to scientific progress on an underexplored topic, thus enabling workers and employers to implement these measures.
The aim of this review was therefore to synthesize scientific knowledge about chronic pain self-management strategies in the workplace.

Method
This integrative literature review was conducted in five stages as proposed by Whittemore and Knafl16: 1) Problem identification and formulation of the guiding question; 2) Literature search to find studies that address the research question; 3) Data evaluation; 4) Data analysis; 5) Presentation.
The review findings are reported following the recommendations set out in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)17 statement, with the aim of providing a satisfactory and transparent account of the conduct of the study with the method employed. While designed for systematic reviews, the guideline is widely adopted for other types of review18-20 and its use is warranted by the lack of a specific instrument for reporting integrative reviews.
To achieve the proposed objective, the following research question was formulated (stage 1): What chronic pain self-management strategies do workers use during the return-to-work process? The question was formulated according to the PCC mnemonic for the literature search: (P) Population – workers; (C) Concept – chronic pain self-management strategies; and (C) Context – return to work21.
The articles were selected (stage 2 - literature review) by three reviewers (RORJ, BVS, FMM). A search of the virtual research databases Medical Literature Analysis and Retrieval System Online (MEDLINE), Web of Science (WoS) and Scopus was performed by RORJ.
These databases were selected as they include a large number of health journals included, resulting in a potentially large number of indexed articles related to the topic. The inclusion criteria were full-text versions of studies that addressed the guiding question published in English and Portuguese between 2017 and 2022 (a time frame that encompasses both recent publications and current pain self-management strategies that are being used due to recent advances in knowledge in this area). Duplicate studies, review articles and gray literature were excluded.
The search strategy (string) was based on the Medical Subject Headings (MeSH) descriptors “chronic pain” and “return to work”, as well as suggested terms with the Boolean Operators AND and OR, as shown in Box 1.
Box 1: Medline, Web of Science and Scopus database search strategies.
We chose not to use the descriptor “self-management” in the search strategy after finding that it greatly reduced the number of articles retrieved. It was therefore decided to broaden the scope of the search by reading the full-text version of the articles to identify chronic pain self-management strategies.
The retrieved articles were exported in BIBTXT or RIS format to separate folders with the name of each database and the search date. They were then exported to Rayyan22, a review manager that conducts initial screening of abstracts and titles using a process of semi-automation with a high level of usability22. The selection process was double-blinded (R1-RORJ and R2-BVS) and any disagreements between the two reviewers were resolved by a third reviewer (R3-FMM).
In stage 3, the included articles were classified according to level of evidence and critically appraised using the Johns Hopkins Nursing Evidence-Based Practice Research Evidence Appraisal Tool23, which is suitable for quantitative, qualitative or mixed studies. The tool presents three levels of evidence: 1. - randomized controlled trial; 2. - quasi-experimental; and 3. - nonexperimental. The critical appraisal is based on the responses “yes”, “no” or “not applicable”, resulting in three categories: high quality (A); good quality (B); low quality (C). This stage was also conducted by two double-blinded reviewers. The results for each study are presented in Box 2.
Box 2: Level of evidence and critical appraisal of the articles23.
The intention of the critical appraisal of evidence of studies in an integrative review is not to exclude low-quality studies (it is not a selection criterion) but rather demonstrate the level of evidence for the reader to understand the studies included. Only one study in the present review was classified as low quality (C). The study was retained in the sample, and the most common considerations in the corpus of evidence were as follows: lack of currency of the references used (most sources within the past five years or seminal study); low reliability of the data collection instruments; and imprecise conclusions not fully reflecting the study findings.
Two instruments were used for data analysis (stage 4): an analysis matrix of the characteristics of the articles, including title, year, country, objective, study design, sample, and description of pain; and a spreadsheet containing the outcomes of interest, including strategies used, results, and factors influencing return to work. The data were interpreted using a conceptual framework of chronic pain self-management14-15 and the results were presented descriptively and organized into tables (stage 5).

Results
A total of 562 articles were retrieved. Double-blinded screening resulted in a final sample of 14 articles24-37, as shown in Figure 1.
Figure 1. Flow diagram of the article selection process.
The study characteristics (author information, year of publication, country, objective, design and sample) are presented in Box 3.
Box 3. Study characteristics.
Most of the studies (42,8%) were published in 2017. Most of the publications were from Sweden (35.7%), followed by Switzerland (14.3%) and Norway (14.3%). While a variety of methodologies were used, the studies were predominantly randomized controlled trials (35.7%) and cohort studies (35.7%). The scope of the studies also varied, with the following focuses being identified: increasing employability; decreasing disability due to pain; reducing time off work; increasing work participation through functional recovery; identifying fear-avoidance behaviors; investigating predictors of recovery of work capability; and analyzing the effects of chronic pain management programs.
The mean age of study participants was 44 (SD=2.7), and duration of sick leave ranged from 147 days31,37 to more than 7 years30,35. Only two studies24,28 described the professions, namely: administrator, health professional, social worker24, factory supervisor and cashier28. In other studies participants are described as having medium to heavy job demands26, professions requiring physical effort29 or performing physically demanding work31.
Some articles25,28-30 mixed employed and unemployed participants in functional recovery to return to employment, while another study34 included retired participants, considering that return to function is a return to daily activities. Only the results for employed participants from these articles were included, since the focus of this study was strategies used by workers returning to work.
Five of the 14 articles included in this review did not provide data on the education level of the study sample24-26,28,34. Participants had a low to medium level of education in all of the remaining studies27,29-32,35-37, except one33, in which 67% of the participants had completed higher education. However, this study did not describe the professions or field of work.
Box 4 presents the descriptions of pain, the return-to-work chronic pain self-management strategies used, and respective results.
Box 4: Description of pain, return-to-work chronic pain self-management strategies, and results.
Low back pain26,28-29,31-33,35-36 was the leading cause of disability and time off work, followed by neck pain24,30-31,33,36, musculoskeletal pain27,34,37, and fibromyalgia30-31, which are potentially related to physically demanding activities29 and posture, as described in studies with workers with medium to heavy job demands26 and performing physically demanding work31.
With regard to return-to-work pain self-management strategies, ten studies focused on the individual or worker and addressed rehabilitation, readaptation and coping25-26,28,30-32,34-37. The remaining studies focused on organizational aspects, including supervisor involvement24,27, workplace assessment29, and workplace interventions33. Only one of the studies mentioned that the company physician referred workers to a return-to-work program27.
In general, strategy development involved the simultaneous use of therapies and the participation of multiple professionals, with the establishment of individual therapy plans focusing on disability and rehabilitation, reducing kinesiophobia, improving quality of life, and increasing the possibility of returning to work. Eleven studies25-27,29,31-37 described the development of multidisciplinary pain management programs, one focused solely on physiotherapy24, one investigated cognitive behavioral therapy with physical therapy28, and one looked at a multidisciplinary intervention with acceptance and commitment therapy30.
While some studies used multidisciplinary pain self-management strategies27, 29, 33 with organizational support, others centralized the responsibility for pain control and improvements in relation to disability on the worker, which is inconsistent with the biopsychosocial model, in which responsibility is shared among different stakeholders.
The duration of rehabilitation and pain management programs varied between 5.5 hours31 and 15 weeks27, while post-intervention follow-up duration ranged from 1.5 hours25 to 24 months33,37.
The strategies that showed positive return-to-work outcomes included multidisciplinary programs and interventions with different combined actions. The former29 consisted of a four-week program (100 hours) including workplace assessment (emphasis on workplace activities and adaptations), physical and occupational therapy, education, self-management exercises, and support groups. The results of the program included improvements in pain (from 6.7 to 4.8 points), disability (from 41 to 30.7 points), and kinesiophobia (from 43.5 to 39.5 points), with 78.5% of participants returning to work at 18-month follow-up.
The second strategy33 lasted 12 weeks and included active worker participation, workplace interventions, individual and group activities, goal setting, exercises, coping strategies, recommendations for workplace adaptations, and a gradual start to work training, resulting in a return to work rate of 65% at 2-year follow-up. The strategy did not result in a significant reduction in pain intensity, as the focus was on coping strategies, with workers being encouraged to focus on their individual goals and on increasing activity and participation, combined with recommendations and work and workplace adaptations.
The third strategy34 that showed a significant positive return-to-work outcome was an educational intervention including medication management, physical and occupational therapy, individual, group and family counseling, yoga, and Pilates. As a result of the 4-week program, 64.5% of the participants returned to work within 3 months.
Another strategy31 that achieved significant results focused on health, psychosocial factors, quality of life, communication, and the assessment of working conditions and situation. Based on the biopsychosocial model and involving a physician, physiotherapist, and social worker, the intervention emphasized education and skills development to deal with fear-avoidance beliefs and negative expectations. The latter are significant risk factors and, when managed, can contribute to improvements in relation to chronic pain and result in faster return to work. Health professionals designed the rehabilitation plan together with patient with the aid of the Interdisciplinary Structured Interview with a Visual Educational Tool (ISIVET). The 3-month (five-and-a-half hours) intervention resulted in a 63.8% return to work rate. The authors demonstrated the validity of the results using statistical tests and concluded that multi-professional interventions are beneficial even for workers with low support at work, since they combine psychosocial, health, and work aspects with a focus on coping skills and include initiatives aimed at improving the work situation.
Eight studies24,26,28-29,31-34 assessed pain intensity before and after interventions, three of which28-29,34 reported a reduction in pain post-intervention. The remaining studies described strategies that did not bring about significant improvements in relation to pain intensity but led to improvements in functional capacity and decreased pain interference in work activities, resulting in a greater likelihood of return to work24,26,31,33. Only one study32 failed to provide a definitive conclusion on the effect of the strategy, due to limited sample size.
The other studies investigating multidisciplinary approaches where the outcome was return to work reported the following results: 56.3%32 of participants returned to work within 12 months after a five-day intervention; 42.6%37 returned to work within 24 months after a five-and-a-half-hour intervention; 38%27 returned to work within six months after a 15-week strategy involving the employer and workplace inspection with a view carrying out ergonomic adjustments; 31.3%30 returned to work within 12 months after participating in nine sessions of a multidisciplinary program.
A study28 using cognitive behavioral therapy with physical therapy reported that 100% of the participants returned to work after participating in a strategy consisting of at least six 60-minute sessions involving education, progressive exercise, and identification of negative beliefs and fear-avoidance behaviors.
Nine studies24, 27-29, 31-32, 34, 36-37 described educational strategies, underlining the importance of knowledge about pain, both for the affected individual and the employer, supervisors, and coworkers. Self-awareness and awareness of the other increases the chances of acceptance for what is possible when it comes to understanding capacity and drives the development of new skills, with greater security, confidence and support.

Discussion
According to Mann et al.15, self-management strategies should view pain as an objective outcome measured in terms of intensity, disability, or interference. Our results reveal that while improvements in relation to pain intensity were not always found, participants showed improvements in the ability to perform activities and a greater likelihood of return to work. Lima et al38 point out that it is possible to prevent disability through return-to-work programs that adopt a proactive approach, recognize the determinants of pain, and develop rehabilitation plans that include workplace interventions and institutional awareness of the need for support and adjustments.
In general, the studies demonstrated multidisciplinary pain self-management strategies in which workers play a central role in pain control assisted by health professionals to achieve improvements in relation to disability and successful return to work8,14,39. While this illustrates the importance of partnering with health professionals to build knowledge and develop coping skills14, it also shows the fragility of strategies that make the individual responsible for improving their health without considering other factors that influence pain, including work-related aspects such as the need for adjustments to work activities and the workplace.
Pain self-management is only possible if workers are provided with conditions that enable them to recover from severe situations, including sick leave and adequate rest (without affecting pay), flexibility to gradually return to work activities, and work adaptations or job changes within their field of expertise40. Work and workplace adaptations and institutional support for workers with pain increase the chances of a faster40 sustainable return to work.
The findings of this review are similar to those of Cullen et al.41, who reported an increase in return to work and improved management of chronic pain after a targeted strategy focusing on quality of life and maintaining functional capacity42 where individuals are assisted by multiple disciplines.
Despite the importance of institutional support in the return to work process, less than half of the articles included in this review describe the participation of supervisors or employers and strategies focusing on the workplace, indicating a weakness in approaches. In this sense, the literature41-43 highlights the need for investment in approaches that promote the dissemination of knowledge and awareness about pain in the workplace so that the return to work is seen as a positive process.
It is worth highlighting that the articles29,33 that reported the highest rate of return to work (78.5% and 65%, respectively) were the two studies that investigated strategies in the workplace, underlining the importance of work adaptations for workers with pain and the involvement of managers and colleagues41. This finding also reinforces the importance of adopting return-to-work models that do not make the worker solely responsible but rather meet their needs through actions developed by other stakeholders across multiple levels. In other words, self-management is only possible when the worker has sufficient knowledge, autonomy, and control to make the best decisions and this in turn is only possible when there is sharing of power and responsibilities (the employer being the party with the greatest decision-making power in this context) and when the above conditions are secured for the worker.
Challenges and factors that limit return to work described by the studies include long-term medical leave, labor market demands31, lack of collaboration between stakeholders, and the need for workplace adaptations25; however, these factors are not explored by all the selected articles, which generally focus on the worker rather than the workplace.
Blake, Somerset, and Greaves43 highlight that there is a lack of strategies that address barriers to and facilitators of chronic pain self-management in the work context, suggesting that interventions generally concentrate on the neurophysiological aspects of pain and function, which was also found by the present review. According to Brendbekken et al., this means that even workers with high expectations of returning to work after prolonged medical leave experience have difficulty reintegrating into the job market when they encounter an unfavorable environment and lack of institutional support.
In contrast, Cullen et al.41 found strong evidence that time away from work is reduced by work accommodation offers and contact between health care providers and the workplace, demonstrating once again the importance of support during the return to work process.
Thus, while most strategies did not include institutional support or result in improvements related to pain intensity (a negative predictor of functional capacity, along with anxiety and depression26, 31), they positively influenced return to work, knowledge, and acceptance of the ability to perform tasks and develop skills as far as possible.
The findings show that even strategies with a shorter duration (12 months31 and 24 months37) promoted return to work during the follow-up period. These strategies focused on education, negative beliefs, and coping skills, which are significant risk factors for workers with chronic pain31,37. However, a review by Devan et al.42 shows that difficulty with sustaining motivation for pain self-management over time can be a barrier to self-management due to the persistence of pain, requiring the provision of intermittent support. However, this support was not identified in the selected studies, and it was not possible to evaluate indicators that would allow us to understand how specific and short-term interventions achieved significant results capable of ensuring sustained return to work.
Although several strategies combined different activities and types of professionals, further efforts are needed to promote integrated approaches based on the biopsychosocial model and the broader concept of health and focusing on the prevention of worsening of pain and health promotion in the workplace. To this end, the participation of managers, directors, and decision-makers, as well as making changes to work and the workplace in pursuit of a common objective is essential to promote sustainable return to work. In this sense, Foster et al.8 make a number of recommendations to guide the management of persistent pain, including self-management, resumption of normal activities, exercises, and psychological and educational programs.
Another aspect not addressed by the studies was the phenomenon of working with pain, which could be explored in future investigations. People living with chronic pain need to adapt to new conditions and develop self-management strategies to maintain their social and work activities. Understanding how workers experience this process is another element that can contribute to strategies for promoting safe and sustainable return to work.
It is worth highlighting that the lack of studies in Brazil meant it was not possible to identify intra- and inter-sectoral strategies involving different disciplines and services provided by the SUS and other bodies involved in the process of leaving and returning to work, such as the INSS, unions, and Ministry of Labor. This suggests that this topic warrants investigation at the national level in the light of public policies aimed at promoting health and safety at work.
The strategies addressed in the selected articles are not necessarily described using the term “self-management” but were identified as such based on the frame of reference used in this review. This is therefore considered a limitation, as it may compromise replicability when this specific term is used. With regard to evidence-based decision-making, one of the limitations of integrative reviews is the fact that it is not possible to measure the real impact of strategies on return to work using more robust tests such as meta-analyses.

Conclusion
Multidisciplinary approaches to chronic pain self-management combining different therapies, actions, and disciplines were the strategies most used by workers. These strategies had a positive impact on sustainable return to work in the medium term, functional capacity, and work capability; however, they did not always result in significant improvements in relation to pain intensity.
Strategy duration varied, with even shorter interventions lasting less than six hours achieving positive return to work outcomes and improvements in functional capacity.
Most of the strategies focused on actions targeting the affected person and the development of individual pain self-management skills, with few involving employers, job changes, and workplace adaptations to accommodate worker needs. The latter is a critical aspect of the return to work process, since effective self-management is only possible when workers are provided opportunities, support, and autonomy. The few strategies that involved employers and institutional support obtained better results than those that failed to consider these aspects, underlining the importance of engaging managers, directors, and decision-makers in this process.
The involvement of multiple disciplines and employers, establishment of individual therapy plans tailored to personal needs and limitations, and workplace adaptations were highlighted as important strategies for promoting return to work; however, greater involvement of the organization is required due to the biopsychosocial nature of pain and significant influence of the working environment on the effectiveness of self-management.
The findings of this review underline the importance of strategies involving different types of professionals and actions tailored to individual needs and the specific work context. The interpretation of the findings in the light of the theoretical framework is an important advance in that it addresses an underexplored facet of chronic pain self-management, where the work context is an inseparable part of pain self-management, since it is the workplace that must accommodate the needs of workers, facilitating and supporting them in their efforts to return to and remain at work despite the pain.
Strategies aimed at helping workers with chronic pain return to work and future research in this field should explore this dimension of pain self-management, advancing a model that considers individual aspects but gives priority work-related factors and ergonomic adjustments. Furthermore, it is important to advance studies that investigate the role of the SUS, INSS, occupational health and safety services (inside and outside companies), and employers in this process, and whether they facilitate or hinder (and perhaps even prevent) return to work.

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