A population-based, randomized clinical trial on back pain management

Cost-effectiveness of general practice care for low back pain: a systematic review

Care from a general practitioner (GP) is one of the most frequently utilised healthcare services for people with low back pain and only a small proportion of those with low back pain who seek care from a GP are referred to other services. The aim of this systematic review was to evaluate the evidence on cost-effectiveness of GP care in non-specific low back pain. We searched clinical and economic electronic databases, and the reference list of relevant systematic reviews and included studies to June 2010. Economic evaluations conducted alongside randomised controlled trials with at least one GP care arm were eligible for inclusion. Two reviewers independently screened search results and extracted data. Eleven studies were included; the majority of which conducted a cost-effectiveness or cost-utility analysis. Most studies investigated the cost-effectiveness of usual GP care. Adding advice, education and exercise, or exercise and behavioural counselling, to usual GP care was more cost-effective than usual GP care alone. Clinical rehabilitation and/or occupational intervention, and acupuncture were more cost-effective than usual GP care. One study investigated the cost-effectiveness of guideline-based GP care, and found that adding exercise and/or spinal manipulation was more cost-effective than guideline-based GP care alone. In conclusion, GP care alone did not appear to be the most cost-effective treatment option for low back pain. GPs can improve the cost-effectiveness of their treatment by referring their patients for additional services, such as advice and exercise, or by providing the services themselves.

Effect of integrated care for sick listed patients with chronic low back pain: economic evaluation alongside a randomised controlled trial

OBJECTIVE

To evaluate the cost effectiveness, cost utility, and cost-benefit of an integrated care programme compared with usual care for sick listed patients with chronic low back pain.

DESIGN

Economic evaluation alongside a randomised controlled trial with 12 months' follow-up.

SETTING

Primary care (10 physiotherapy practices, one occupational health service, one occupational therapy practice) and secondary care (five hospitals) in the Netherlands, 2005-9.

PARTICIPANTS

134 adults aged 18-65 sick listed because of chronic low back pain: 66 were randomised to integrated care and 68 to usual care.

INTERVENTIONS

Integrated care consisted of a workplace intervention based on participatory ergonomics, with involvement of a supervisor, and a graded activity programme based on cognitive behavioural principles. Usual care was provided by general practitioners and occupational physicians according to Dutch guidelines.

MAIN OUTCOME MEASURES

The primary outcome was duration until sustainable return to work. The secondary outcome was quality adjusted life years (QALYs), measured using EuroQol.

RESULTS

Total costs in the integrated care group (£13 165, SD £13 600) were significantly lower than in the usual care group (£18 475, SD £13 616). Cost effectiveness planes and acceptability curves showed that integrated care was cost effective compared with usual care for return to work and QALYs gained. The cost-benefit analyses showed that every £1 invested in integrated care would return an estimated £26. The net societal benefit of integrated care compared with usual care was £5744.

CONCLUSIONS

Implementation of an integrated care programme for patients sick listed with chronic low back pain has a large potential to significantly reduce societal costs, increase effectiveness of care, improve quality of life, and improve function on a broad scale. Integrated care therefore has large gains for patients and society as well as for employers.

Disparities by ethnicity, language, and immigrant status in occupational health experiences among Las Vegas hotel room cleaners

OBJECTIVE

We examined disparities in workers' occupational health experiences.

METHODS

We surveyed 941 unionized Las Vegas hotel room cleaners about their experiences with work-related pain and with employers, physicians, and workers' compensation. Data were analyzed for all workers and by ethnicity, language, and immigrant status.

RESULTS

Hispanic and English as second language (ESL) workers were more likely than their counterparts to report work-related pain and, along with immigrant workers, to miss work because of this pain. Hispanic, ESL, and immigrant workers were not consistently at a disadvantage with regard to their own responses to work-related pain but were so with respect to reported responses by workers' compensation, physicians, and employers.

CONCLUSIONS

There are indications of disparities in occupational health experiences within this job title. The use of different group classifications, while implying different mechanisms, produced similar results.

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.

Predictors of stable return-to-work in non-acute, non-specific spinal pain: low total prior sick-listing, high self prediction and young age. A two-year prospective cohort study

BACKGROUND

Non-specific spinal pain (NSP), comprising back and/or neck pain, is one of the leading disorders in long-term sick-listing. During 2000-2004, 125 Swedish primary-care patients with non-acute NSP, full-time sick-listed 6 weeks-2 years, were included in a randomized controlled trial to compare a cognitive-behavioural programme with traditional primary care. This prospective cohort study is a re-assessment of the data from the randomized trial with the 2 treatment groups considered as a single cohort. The aim was to investigate which baseline variables predict a stable return-to-work during a 2-year period after baseline: objective variables from function tests, socioeconomic, subjective and/or treatment variables. Stable return-to-work was a return-to-work lasting for at least 1 month from the start of follow-up.

METHODS

Stable return-to-work was the outcome variable, the above-mentioned factors were the predictive variables in multiple-logistic regression models, one per follow-up at 6, 12, 18 and 24 months after baseline. The factors from univariate analyzes with a p-value of at most .10 were included. The non-significant variables were excluded stepwise to yield models comprising only significant factors (p < .05). As the comparatively few cases made it risky to associate certain predictors with certain time-points, we finally considered the predictors which were represented in at least 3 follow-ups. They are presented with odds ratios (OR) and 95% confidence intervals.

RESULTS

Three variables qualified, all of them represented in 3 follow-ups: Low total prior sick-listing (including all diagnoses) was the strongest predictor in 2 follow-ups, 18 and 24 months, OR 4.8 [1.9-12.3] and 3.8 [1.6-8.7] respectively, High self prediction (the patients' own belief in return-to-work) was the strongest at 12 months, OR 5.2 [1.5-17.5] and Young age (max 44 years) the second strongest at 18 months, OR 3.5 [1.3-9.1].

CONCLUSIONS

In primary-care patients with non-acute NSP, the strong predictors of stable return-to-work were 2 socioeconomic variables, Low total prior sick-listing and Young age, and 1 subjective variable, High self-prediction. Objective variables from function tests and treatment variables were non-predictors. Except for Young age, the predictors have previously been insufficiently studied, and so our study should widen knowledge within clinical practice.

Back pain and work

Low back pain is a leading cause of work disability and constitutes a significant socioeconomic burden worldwide. In an attempt to stem the serious consequences of long-term disability, a new approach for back pain in primary care is being disseminated. It mainly focusses on identifying the relationship between pain/disability and work, recognising important workplace and psychosocial issues, providing patients reassuring messages about activity, facilitating the return to work process and engaging other resources as needed. This article examines current expert opinion and available evidence on work issues for effective back pain management. In general, return to work, if safe, is beneficial for recovery and well-being. Some cases might require physicians to actively communicate with employers, claims managers and others in order to achieve safe and sustained return to work, while in most instances, simple efforts to identify and discuss work issues directly with the patient can lead to better work outcomes.

Early intervention options for acute low back pain patients: a randomized clinical trial with one-year follow-up outcomes

INTRODUCTION

In an earlier study, Gatchel et al. (J Occup Rehabil 13:1-9, 2003) demonstrated that participants at high risk for developing chronic low back pain disability (CLBPD), who received a biopsychosocial early intervention treatment program, displayed significantly more symptom improvement, as well as cost savings, relative to participants receiving standard care. The purpose of the present study was to expand on these results by examining whether the addition of a work-transition component would further strengthen the effectiveness of this early intervention treatment.

METHODS

Using an existing algorithm, participants were identified as being high-risk (HR) or low-risk (LR) for developing CLBPD. HR participants were then randomly assigned to one of three groups: early intervention (EI); early intervention with work transition (EI/WT); or standard care (SC). Participants provided information regarding pain, disability, work status, and psychosocial functioning at baseline, periodically during treatment, and again 1 year following completion of treatment.

RESULTS

At 1-year follow-up, no significant differences were found between the EI and EI/WT groups in terms of occupational status, self-reports of pain and disability, coping ability or psychosocial functioning. However, significant differences in all these outcomes were found comparing these groups to standard care.

CONCLUSION

The addition of a work transition component to an early intervention program for the treatment of ALBP did not significantly contribute to improved work outcomes. However, results further support the effectiveness of early intervention for high-risk ALBP patients.

Workplace involvement improves return to work rates among employees with back pain on long-term sick leave: a systematic review of the effectiveness and cost-effectiveness of interventions

PURPOSE

Long-term sickness absence among workers is a major problem in industrialised countries. The aim of the review is to determine whether interventions involving the workplace are more effective and cost-effective at helping employees on sick leave return to work than those that do not involve the workplace at all.

METHODS

A systematic review of controlled intervention studies and economic evaluations. Sixteen electronic databases and grey literature sources were searched, and reference and citation tracking was performed on included publications. A narrative synthesis was performed.

RESULTS

Ten articles were found reporting nine trials from Europe and Canada, and four articles were found evaluating the cost-effectiveness of interventions. The population in eight trials suffered from back pain and related musculoskeletal conditions. Interventions involving employees, health practitioners and employers working together, to implement work modifications for the absentee, were more consistently effective than other interventions. Early intervention was also found to be effective. The majority of trials were of good or moderate quality. Economic evaluations indicated that interventions with a workplace component are likely to be more cost effective than those without.

CONCLUSION

Stakeholder participation and work modification are more effective and cost effective at returning to work adults with musculoskeletal conditions than other workplace-linked interventions, including exercise.

Cost-effectiveness of a participatory return-to-work intervention for temporary agency workers and unemployed workers sick-listed due to musculoskeletal disorders: design of a randomised controlled trial

Background

Within the working population there is a vulnerable group: workers without an employment contract and workers with a flexible labour market arrangement, e.g. temporary agency workers. In most cases, when sick-listed, these workers have no workplace/employer to return to. Also, for these workers access to occupational health care is limited or even absent in many countries. For this vulnerable working population there is a need for tailor-made occupational health care, including the presence of an actual return-to-work perspective. Therefore, a participatory return-to-work program has been developed based on a successful return-to-work intervention for workers, sick-listed due to low back pain.

The objective of this paper is to describe the design of a randomised controlled trial to study the (cost-)effectiveness of this newly developed participatory return-to-work program adapted for temporary agency workers and unemployed workers, sick-listed due to musculoskeletal disorders, compared to usual care.

Methods/Design

The design of this study is a randomised controlled trial with one year of follow-up. The study population consists of temporary agency workers and unemployed workers sick-listed between 2 and 8 weeks due to musculoskeletal disorders. The new return-to-work program is a stepwise program aimed at making a consensus-based return-to-work implementation plan with the possibility of a (therapeutic) workplace to return-to-work. Outcomes are measured at baseline, 3, 6, 9 and 12 months. The primary outcome measure is duration of the sickness benefit period after the first day of reporting sick. Secondary outcome measures are: time until first return-to-work, total number of days of sickness benefit during follow-up; functional status; intensity of musculoskeletal pain; pain coping; and attitude, social influence and self-efficacy determinants. Cost-benefit is evaluated from an insurer's perspective. A process evaluation is part of this study.

Discussion

For sick-listed workers without an employment contract there can be gained a lot by improving occupational health care, including return-to-work guidance, and by minimising the 'labour market handicap' by creating a return-to-work perspective. In addition, reduction of sickness absence and work disability, i.e. a reduction of disability claims, may result in substantial benefits for the Dutch Social Security System.

Trial registration

Trial registration number: NTR1047.

Randomised controlled trial of integrated care to reduce disability from chronic low back pain in working and private life

OBJECTIVE

To evaluate the effectiveness of an integrated care programme, combining a patient directed and a workplace directed intervention, for patients with chronic low back pain.

DESIGN

Population based randomised controlled trial.

SETTING

Primary care (10 physiotherapy practices, one occupational health service, one occupational therapy practice) and secondary care (five hospitals).

PARTICIPANTS

134 adults aged 18-65 sick listed for at least 12 weeks owing to low back pain.

INTERVENTION

Patients were randomly assigned to usual care (n=68) or integrated care (n=66). Integrated care consisted of a workplace intervention based on participatory ergonomics, involving a supervisor, and a graded activity programme based on cognitive behavioural principles.

MAIN OUTCOME MEASURES

The primary outcome was the duration of time off work (work disability) due to low back pain until full sustainable return to work. Secondary outcome measures were intensity of pain and functional status.

RESULTS

The median duration until sustainable return to work was 88 days in the integrated care group compared with 208 days in the usual care group (P=0.003). Integrated care was effective on return to work (hazard ratio 1.9, 95% confidence interval 1.2 to 2.8, P=0.004). After 12 months, patients in the integrated care group improved significantly more on functional status compared with patients in the usual care group (P=0.01). Improvement of pain between the groups did not differ significantly.

CONCLUSION

The integrated care programme substantially reduced disability due to chronic low back pain in private and working life. Trial registration Current Controlled Trials ISRCTN28478651.

Long-term return to work after a functional restoration program for chronic low-back pain patients: a prospective study

Low-back pain is a major health and socio economic problem. Functional restoration programs (FRP) have been developed to promote the socio-professional reintegration of patients with important work absenteeism. The aim of this study was to determine the long-term effectiveness of FRP in a group of 105 chronic low-back pain patients and to determine the predictive factors of return to work. One hundred-and-five chronic LBP patients with over 1 month of work absenteeism were included in a FRP. Pain, professional status, quality of life, functional disability, psychological impact, and fear and avoidance beliefs were evaluated at baseline, after 1 year and at the end of follow-up. Main effectiveness criterion was return to work. Fifty-five percent of the patients returned to work after mean follow-up time of 3.5 years, compared with 9% of the patients at work at baseline. Quality of life, functional disability, psychological factors, and fear and avoidance beliefs were all significantly improved. Three predictive factors were found: younger age at the onset of low-back pain, practice of sports, and shorter duration of sick leave at baseline. FRP show positive results in terms of return to work for chronic LBP patients with prolonged work absenteeism. Efforts should be made to propose such programs at an earlier stage of the disease.

Physical conditioning programs for improving work outcomes in workers with back pain

BACKGROUND

Physical conditioning programs aim to improve work status for workers on sick leave. This is an update of a Cochrane Review (Work conditioning, work hardening and functional restoration for workers with back and neck pain) first published in 2003.

OBJECTIVES

To compare the effectiveness of physical conditioning programs in reducing time lost from work for workers with back pain.

SEARCH STRATEGY

We searched the following databases to June/July 2008: CENTRAL (The Cochrane Library 2008, issue 3), MEDLINE from 1966, EMBASE from 1980, CINAHL from 1982, PsycINFO from 1967, and PEDro.

SELECTION CRITERIA

Randomized controlled trials (RCTs) and cluster RCTs that studied workers with work disability related to back pain and who were included in physical conditioning programs.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias.

MAIN RESULTS

Thirty-seven references, reporting on 23 RCTs (3676 workers) were included, 13 of which had a low risk of bias. In 14 studies, physical conditioning programs were compared to usual care. In workers with acute back pain, there was no effect on sickness absence. For workers with subacute back pain, we found conflicting results, but subgroup analysis showed a positive effect of interventions with workplace involvement. In workers with chronic back pain, pooled results of five studies showed a small effect on sickness absence at long-term follow-up (SMD: -0.18 (95% CI: -0.37 to 0.00)). In workers with chronic back pain, physical conditioning programs were compared to other exercise therapy in six studies, with conflicting results. The addition of cognitive behavioural therapy to physical conditioning programs was not more effective than the physical conditioning alone.

AUTHORS' CONCLUSIONS

The effectiveness of physical conditioning programs in reducing sick leave when compared to usual care or than other exercises in workers with back pain remains uncertain. In workers with acute back pain, these programs probably have no effect on sick leave, but there may be a positive effect on sick leave for workers with subacute and chronic back pain. Workplace involvement might improve the outcome. Better understanding of the mechanism behind physical conditioning programs and return-to-work is needed to be able to develop more effective interventions.

Does graded return-to-work improve sick-listed workers' chance of returning to regular working hours?

Using Danish register and survey data, we examine the effect of a national graded return-to-work program on the probability of sick-listed workers returning to regular working hours. During program participation, the sick-listed worker works fewer hours and receives the normal hourly wage for the hours worked and sickness benefit for the hours off work. When the worker's health improves, working hours are increased until the sick-listed worker is able to work regular hours. Taking account of unobserved differences between program participants and non-participants, we find that participation in the program significantly increases the probability of returning to regular working hours.

Can cross country differences in return-to-work after chronic occupational back pain be explained? An exploratory analysis on disability policies in a six country cohort study

INTRODUCTION

There are substantial differences in the number of disability benefits for occupational low back pain (LBP) among countries. There are also large cross country differences in disability policies. According to the Organization for Economic Cooperation and Development (OECD) there are two principal policy approaches: countries which have an emphasis on a compensation policy approach or countries with an emphasis on an reintegration policy approach. The International Social Security Association initiated this study to explain differences in return-to-work (RTW) among claimants with long term sick leave due to LBP between countries with a special focus on the effect of different disability policies.

METHODS

A multinational cohort of 2,825 compensation claimants off work for 3-4 months due to LBP was recruited in Denmark, Germany, Israel, the Netherlands, Sweden, and the United States. Relevant predictors and interventions were measured at 3 months, one and 2 years after the start of sick leave. The main outcome measure was duration until sustainable RTW (i.e. working after 2 years). Multivariate analyses were conducted to explain differences in sustainable RTW between countries and to explore the effect of different disability policies.

RESULTS

Medical and work interventions varied considerably between countries. Sustainable RTW ranged from 22% in the German cohort up to 62% in the Dutch cohort after 2 years of follow-up. Work interventions and job characteristics contributed most to these differences. Patient health, medical interventions and patient characteristics were less important. In addition, cross-country differences in eligibility criteria for entitlement to long-term and/or partial disability benefits contributed to the observed differences in sustainable RTW rates: less strict criteria are more effective. The model including various compensation policy variables explained 48% of the variance.

CONCLUSIONS

Large cross-country differences in sustainable RTW after chronic LBP are mainly explained by cross-country differences in applied work interventions. Differences in eligibility criteria for long term disability benefits contributed also to the differences in RTW. This study supports OECD policy recommendations: Individual packages of work interventions and flexible (partial) disability benefits adapted to the individual needs and capacities are important for preventing work disability due to LBP.

Does participation in interdisciplinary work rehabilitation programme influence return to work obstacles and predictive factors?

PURPOSE

Musculoskeletal disorders evolve into long-term work disabilities in--10% of work-injury cases. From a prevention perspective, screening for predictive factors and obstacles associated with long-term work disability appear to offer a promising avenue for work rehabilitation. However, knowledge of the factors at play during the chronic phase remains limited. This study aims to explore the presence of a relationship between the predictive factors and obstacles identified at the time of admission to an interdisciplinary work rehabilitation programme and return to work upon completion of the programme, in individuals with a long-term work disability.

METHOD

A descriptive correlational study involving 222 individuals assessed using the Work Disability Diagnostic Interview and who participated in the PREVICAP work rehabilitation programme.

RESULTS

The general model accurately predicts the work status of 77% of the participants. Seven to nine factors were found to be associated with return to work in each model produced (3). Those factors were mainly psychosocial and work-related in nature and differ according to gender. Unexpectedly, certain obstacles observed at the time of admission to the programme appear to have a protective effect and thus promote participants' return to work.

CONCLUSION

The results obtained support the hypothesis that screening for predictive factors and obstacles at the time of admission of a work rehabilitation programme for individuals with a long-term work disability allows for more effective intervention regarding these factors, and in all likelihood, promotes return to work.

Administrative delays and chronic disability in patients with acute occupational low back injury

OBJECTIVES

This study assessed whether an organizational factor, delays to claim acceptance or administrative delays, had an influence on outcomes for individuals with acute back injuries in the workers' compensation system.

METHODS

Multivariate logistic regression was used to test whether individuals who experienced administrative delays were more likely to develop chronic disability than those who did not experience delays.

RESULTS

Beyond the first 2 weeks, each interval of administrative delay was associated with increased odds of developing chronic disability. Injury severity, physician experience and weeks to medical treatment were additionally very strong predictors for the development of chronic disability.

CONCLUSIONS

Insurers, employers, and policy makers can significantly reduce chronic disability if controls are adopted to reduce administrative and treatment delays and to direct workers to experienced clinicians.

Disability management practices in Ontario workplaces: Employees' perceptions

PURPOSE

The purpose of this study was to obtain employees' perceptions about disability management (DM) at their workplaces.

METHODS

Data were obtained from focus group interviews and individual telephone interviews with 58 employees who had sustained a work-related injury or disability in Ontario, Canada. Participants also completed a 22-item Organizational Policies and Practices (OPP) Questionnaire that asked questions about workplace DM practices.

RESULTS

Respondents emphasized the need for job accommodation, the importance of open and clear communication and the necessity of job retraining. The provision of ergonomic modifications to their worksites and the development of meaningful and specific DM policies and procedures were seen as key to a comprehensive workplace DM program. Education about health and safety also was identified as an important component of creating a supportive workplace environment. The OPP questionnaire showed good internal consistency (Cronbach's alpha=0.95) and discriminant validity.

CONCLUSION

This study demonstrates the importance of workplaces communicating with their employees and respecting their opinions when establishing and carrying out DM policies and practices. The OPP Questionnaire is useful in determining how DM is managed in the workplace.

An analysis of the communication during an enhanced and structured information exchange between social insurance physicians and occupational physicians in disability management in Belgium

PURPOSE

The overall objective of this study was to analyse the inter-physician communication during an intervention that aimed at enhancing and structuring the information exchange practices among Belgian social insurance physicians and occupational physicians. We aimed at determining: (i) the communication frequency; (ii) the communication content; and (iii) the type of patients for whom social insurance physicians want communication with occupational physicians.

METHOD

We analysed inter-physician information exchange data derived from communication forms. The communication forms were, during a two-year prospective intervention trial, exchanged between 15 social insurance and 40 occupational physicians for 505 sick-listed patients.

RESULTS

Inter-physician communication was initiated for 52% of patients, mainly to execute work modifications. Communication was implemented particularly for patients that had mental disorders, poor decision latitude, high physical work demands at their workplace, pronounced pain perceptions, bad work resumption prognosis, or work-related health disorders.

CONCLUSION

A simple information exchange system already has the benefit to enhance inter-physician communication in disability management.

Effects of patient – clinician disagreement in occupational low back pain: A pilot study

PURPOSE

To determine (1) patient--physical therapist and patient--physician agreement on clinical management of LBP, (2) patient perception of agreement between physical therapist and physician, (3) association between agreement and outcome (return to work, self-perceived disability).

METHOD

Thirty-five workers compensated for LBP responded to a telephone interview within 1 week of referral to physical therapy. They were asked about agreement with the physical therapist and the physician regarding the clinical management of their LBP and whether they thought the physical therapist was providing the treatment the physician would have thought appropriate. They completed a second interview upon returning to work or after 3 months. They answered questionnaires on self-perceived disability, psychological distress, coping strategies, and job satisfaction at both baseline and follow-up.

RESULTS

Nearly all patients (97.1%) agreed with the physical therapist and all believed the physical therapist was providing the treatment the physician would have thought appropriate. The 10 (28.6%) patients who disagreed with their physician on medical management of their LBP were less satisfied with the medical care (P=0.05), technical quality of the visit (P=0.01), and catastrophized more about their pain (P=0.03) than those who agreed. Disagreement was not associated with greater time off-work or greater self-perceived disability.

CONCLUSION

Patients who disagreed with their physician were less satisfied with their medical management, and catastrophized more about their pain than those who agreed, but disagreement was not associated with chronicity or disability. Studies with larger sample sizes should investigate the role of other factors, such as patient expectations, in the transition to chronicity.

Effectiveness of workplace rehabilitation interventions in the treatment of work-related low back pain: A systematic review

PURPOSE

A systematic review was conducted to evaluate the effectiveness of workplace rehabilitation interventions for injured workers with low back pain (LBP).

METHOD

MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), EMBASE, and AMED (Allied and Complementary Medicine) were searched from 1982 to 2005 for peer-reviewed studies of rehabilitation interventions that were provided at the workplace to workers with musculoskeletal work-related LBP. Methodological quality appraisal and data extraction were conducted by five reviewers.

RESULTS

Of a total of 1,224 articles that were identified by the search, 15 articles, consisting of 10 studies, were of sufficient quality to be included in the review. The best evidence was that clinical interventions with occupational interventions as well as early return to work/modified work interventions were effective in returning workers to work faster, reducing pain and disability, and decreasing the rate of back injuries. Ergonomic interventions also were found to be effective workplace interventions.

CONCLUSION

The need for further research in this area is necessary to reduce the burden of back pain on employees and their families, employers, and the health care system.

Intervention mapping for development of a participatory return-to-work intervention for temporary agency workers and unemployed workers sick-listed due to musculoskeletal disorders

Background

In the past decade in activities aiming at return-to-work (RTW), there has been a growing awareness to change the focus from sickness and work disability to recovery and work ability. To date, this process in occupational health care (OHC) has mainly been directed towards employees. However, within the working population there are two vulnerable groups: temporary agency workers and unemployed workers, since they have no workplace/employer to return to, when sick-listed. For this group there is a need for tailored RTW strategies and interventions. Therefore, this paper aims to describe the structured and stepwise process of development, implementation and evaluation of a theory- and practise-based participatory RTW program for temporary agency workers and unemployed workers, sick-listed due to musculoskeletal disorders (MSD). This program is based on the already developed and cost-effective RTW program for employees, sick-listed due to low back pain.

Methods

The Intervention Mapping (IM) protocol was used to develop a tailor-made RTW program for temporary agency workers and unemployed workers, sick-listed due to MSD. The Attitude-Social influence-self-Efficacy (ASE) model was used as a theoretical framework for determinants of behaviour regarding RTW of the sick-listed worker and development of the intervention. To ensure participation and facilitate successful adoption and implementation, important stakeholders were involved in all steps of program development and implementation. Results of semi-structured interviews and 'fine-tuning' meetings were used to design the final participatory RTW program.

Results

A structured stepwise RTW program was developed, aimed at making a consensus-based RTW implementation plan. The new program starts with identifying obstacles for RTW, followed by a brainstorm session in which the sick-listed worker and the labour expert of the Social Security Agency (SSA) formulate solutions/possibilities for suitable (therapeutic) work. This process is guided by an independent RTW coordinator to achieve consensus. Based on the resulting RTW implementation plan, to create an actual RTW perspective, a vocational rehabilitation agency is assigned to find a matching (therapeutic) workplace. The cost-effectiveness of this participatory RTW program will be evaluated in a randomised controlled trial.

Conclusion

IM is a promising tool for the development of tailor-made OHC interventions for the vulnerable working population.

Designing a workplace return-to-work program for occupational low back pain: an intervention mapping approach

Background

Despite over 2 decades of research, the ability to prevent work-related low back pain (LBP) and disability remains elusive. Recent research suggests that interventions that are focused at the workplace and incorporate the principals of participatory ergonomics and return-to-work (RTW) coordination can improve RTW and reduce disability following a work-related back injury. Workplace interventions or programs to improve RTW are difficult to design and implement given the various individuals and environments involved, each with their own unique circumstances. Intervention mapping provides a framework for designing and implementing complex interventions or programs. The objective of this study is to design a best evidence RTW program for occupational LBP tailored to the Ontario setting using an intervention mapping approach.

Methods

We used a qualitative synthesis based on the intervention mapping methodology. Best evidence from systematic reviews, practice guidelines and key articles on the prognosis and management of LBP and improving RTW was combined with theoretical models for managing LBP and changing behaviour. This was then systematically operationalized into a RTW program using consensus among experts and stakeholders. The RTW Program was further refined following feedback from nine focus groups with various stakeholders.

Results

A detailed five step RTW program was developed. The key features of the program include; having trained personnel coordinate the RTW process, identifying and ranking barriers and solutions to RTW from the perspective of all important stakeholders, mediating practical solutions at the workplace and, empowering the injured worker in RTW decision-making.

Conclusion

Intervention mapping provided a useful framework to develop a comprehensive RTW program tailored to the Ontario setting.

Margin of manoeuvre indicators in the workplace during the rehabilitation process: a qualitative analysis

INTRODUCTION

The task of evaluating workers' capacity to return to their pre-injury employment or other jobs continues to pose a daily challenge for clinicians. In this study, a concept frequently used in the field of ergonomics, the margin of manoeuvre (MM), was applied during the rehabilitation process. The study identified the indicators of the MM taken into account during the return to work of workers with musculoskeletal disorders.

METHODS

This study used a multiple-case design. A case was defined as a dyad comprising a worker admitted to a work rehabilitation program and the clinician who was managing the return-to-work process. The results were then validated with investigators and expert ergonomists, through group interviews. Content analyses were performed using the conceptual framework for the work activity model adapted from Vézina and the procedures recommended by Miles and Huberman.

RESULTS

A total of 11 workers, five clinicians, two experts and two investigators participated in this study. The interview analysis process resulted in a more detailed definition of the MM and the identification of 50 indicators. The indicators were classified according to six dimensions: (1) work context; (2) employer's requirements and expectations; (3) means and tools; (4) worker's personal parameters; (5) work activity; and (6) impacts of the work situation.

CONCLUSIONS

The more specific indicators identified in this study will allow for more systematic observation of the MM. Subsequent studies will seek to link each indicator described in the model with a specific method of observation.

Workplace interventions for preventing work disability

BACKGROUND

Work disability has serious consequences for all stakeholders and society. Workplace interventions are considered appropriate to facilitate return to work by reducing barriers to return to work, involving the collaboration of key stakeholders.

OBJECTIVES

To determine the effectiveness of workplace interventions compared to usual care or clinical interventions on work-related outcomes and health outcomes; and to evaluate whether the effects differ when applied to musculoskeletal disorders, mental health problems, or other health conditions.

SEARCH STRATEGY

We searched the Cochrane Occupational Health Field Trials Register, CENTRAL, MEDLINE and EMBASE (EMBASE.com), and PsycINFO databases (to November 2007).

SELECTION CRITERIA

We included randomized controlled trials of workplace interventions aimed at return to work for workers where absence from work because of sickness was reported as a continuous outcome.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed risk of bias of the studies. Meta-analysis and qualitative analysis (using GRADE levels of evidence) were performed.

MAIN RESULTS

We included six randomized controlled trials (749 workers): three on low back pain, one on upper-extremity disorders, one on musculoskeletal disorders, and one on adjustment disorders. Five studies were rated as having low risk of bias for the sickness absence outcome. The results of this review show that there is moderate-quality evidence to support the use of workplace interventions to reduce sickness absence among workers with musculoskeletal disorders when compared to usual care. However, workplace interventions were not effective to improve health outcomes among workers with musculoskeletal disorders. The lack of studies made it impossible to investigate the effectiveness of workplace interventions among workers with mental health problems and other health conditions. A comparison of a workplace intervention with a clinical intervention, in one study only, yielded similar results for sickness absence and symptoms for workers with mental health problems.

AUTHORS' CONCLUSIONS

As a result of the few available studies, no convincing conclusions can be formulated about the effectiveness of workplace interventions on work-related outcomes and health outcomes regardless of the type of work disability. The pooled data for the musculoskeletal disorders subgroup indicated that workplace interventions are effective in the reduction of sickness absence, but they are not effective in improving health outcomes. The evidence from the subgroup analysis on musculoskeletal disorders was rated as moderate-quality evidence. Unfortunately, conclusions cannot be drawn on the effectiveness of these interventions for mental health problems and other health conditions due to a lack of studies.

Coordinated and tailored work rehabilitation: a randomized controlled trial with economic evaluation undertaken with workers on sick leave due to musculoskeletal disorders

INTRODUCTION

In Denmark, the magnitude and impact of work disability on the individual worker and society has prompted the development of a new "coordinated and tailored work rehabilitation" (CTWR) approach. The aim of this study was to compare the effects of CTWR with conventional case management (CCM) on return-to-work of workers on sick leave due to musculoskeletal disorders (MSDs).

METHODS

The study was a randomized controlled trial with economic evaluation undertaken with workers on sick leave for 4-12 weeks due to MSDs. CTWR consists of a work disability screening by an interdisciplinary team followed by the collaborative development of a RTW plan. The primary outcome variable was registered cumulative sickness absence hours during 12 months follow-up. Secondary outcomes were work status as well as pain intensity and functional disability, measured at baseline, 3 and 12 months follow-up. The economic evaluation (intervention costs, productivity loss, and health care utilization costs) was based on administrative data derived from national registries.

RESULTS

For the time intervals 0-6 months, 6-12 months, and the entire follow-up period, the number of sickness absence hours was significantly lower in the CTWR group as compared to the control group. The total costs saved in CTWR participants compared to controls were estimated at US $ 1,366 per person at 6 months follow-up and US $ 10,666 per person at 12 months follow-up.

CONCLUSIONS

Workers on sick leave for 4-12 weeks due to MSD who underwent "CTWR" by an interdisciplinary team had fewer sickness absence hours than controls. The economic evaluation showed that-in terms of productivity loss-CTWR seems to be cost saving for the society.

Self-management education en masse: effectiveness of the Back Pain: Don't Take It Lying Down mass media campaign

Despite the availability of a range of Australian self-management support programs targeting the individual patient and/or health professional, three-quarters of Australians have at least one long-term medical condition, suggesting that a more comprehensive public health approach is needed. Use of mass media to deliver community health messages is a well established public health strategy. It may enhance more targeted approaches with its ability to reach large numbers of people simultaneously, including those difficult to identify, high-risk groups and those difficult to reach through traditional medical delivery. By simultaneously influencing large numbers of people, well designed health messages have the potential to promote and maintain behavioural change over time. Back Pain: Don't Take It Lying Down (1997-1999), a mass media campaign of the Victorian WorkCover Authority, can be seen as a prototype of a successful public health strategy designed to enhance people's self-management abilities. One of the main messages of the campaign was that there is a lot you can do to help yourself, which emphasises shifting the responsibility of control onto the individual. The success of the campaign makes a compelling evidence-based case for using a similar strategy to enhance the self-management abilities of the population.

Organizing health services for patients with chronic pain: when there is a will there is a way

SETTING

Due to its magnitude as a health problem, its associated burden, and the viability of modes of intervention, chronic pain (CP) should be considered a priority within health care systems. The lives of many patients with CP are devastated by this problem and health care professionals have a responsibility to assist them in reducing their suffering. Countries, regions, and systems differ considerably with regard to how they organize, administer, and finance services for CP patients.

OBJECTIVE

In this review, we highlight initiatives in three jurisdictions--France, Australia, and the Veterans' Health Administration in the United States--which demonstrate that when there is a will there is a way to change health care services for patients with CP. This work is a synopsis of a health technology assessment report we completed on behalf of the Quebec Health Services and Technology Assessment Agency (http://www.aetmis.gouv.qc.ca) at the request of the Ministry of Health and Social Services in Quebec, Canada, to inform policymakers at various levels of the health care system.

DESIGN

A literature search of published and unpublished "gray" literature was used to identify organizational themes according to structure, process, and outcome elements of health care services. For each theme, literature was reviewed in a qualitative manner; in addition, "real world" information was sought from example jurisdictions that have prioritized management of CP. Our conclusions point to key issues to consider when organizing health services for CP patients.

Stay@Work: Participatory Ergonomics to prevent low back and neck pain among workers: design of a randomised controlled trial to evaluate the (cost-)effectiveness

Background

Low back pain (LBP) and neck pain (NP) are a major public health problem with considerable costs for individuals, companies and society. Therefore, prevention is imperative. The Stay@Work study investigates the (cost-)effectiveness of Participatory Ergonomics (PE) to prevent LBP and NP among workers.

Methods

In a randomised controlled trial (RCT), a total of 5,759 workers working at 36 departments of four companies is expected to participate in the study at baseline. The departments consisting of about 150 workers are pre-stratified and randomised. The control departments receive usual practice and the intervention departments receive PE. Within each intervention department a working group is formed including eight workers, a representative of the management, and an occupational health and safety coordinator. During a one day meeting, the working group follows the steps of PE in which the most important risk factors for LBP and NP, and the most adequate ergonomic measures are identified on the basis of group consensus. The implementation of ergonomic measures at the department is performed by the working group. To improve the implementation process, so-called 'ergocoaches' are trained.

The primary outcome measure is an episode of LBP and NP. Secondary outcome measures are actual use of ergonomic measures, physical workload, psychosocial workload, intensity of pain, general health status, sick leave, and work productivity. The cost-effectiveness analysis is performed from the societal and company perspective. Outcome measures are assessed using questionnaires at baseline and after 6 and 12 months. Data on the primary outcome as well as on intensity of pain, sick leave, work productivity, and health care costs are collected every 3 months.

Discussion

Prevention of LBP and NP is beneficial for workers, employers, and society. If the intervention is proven (cost-)effective, the intervention can have a major impact on LBP and NP prevention and, thereby, on work disability prevention. Results are expected in 2010.

Trial registration

ISRCTN27472278

Can a transitional work grant program in a workers' compensation system reduce cost and facilitate return to work?

Although previous research has shown returning the injured worker to work as soon as possible is important to the long-term prospects of the worker remaining in the work force, there is limited economic support for implementing such programs. Thus, the purpose of this case control study was to determine the cost savings of the implementation of a Transitional Work Grant (TWG) program, which consisted of several components including job analyses, education, communication and transitional work (TW). Companies that enrolled in the TWG program were matched to nonparticipating companies (NTW) based on employer size, type of industry, number of overall claims, and number of claims with > 7 days lost time (LT claims) submitted the year prior to enrollment. The study analyzed economic data: number of claims, number of LT claims, indemnity costs, medical costs, and days lost (days away from the workplace). An additional outcome was the ratio of LT claims (> 7 days lost work) to medical only (MO) claims (LT/MO ratio). Overall, participation in the TWG program was associated with decreased indemnity cost and decreased LT/MO ratio. However, effectiveness of the program varied by employer size and industry. In terms of the state of Ohio, these costs translate into substantial savings: more than $2.3 million per year. Although the cost savings and reduction in lost time claims is encouraging, the true benefit of TW has yet to be completely quantified. Future work must account for other potential co-factors and programs that could also contribute to the savings as well as document further the indirect benefits associated with a TWG program, such as improved employee morale and increased productivity and product quality that could be four times greater than the direct savings. In summary, programs such as this one adopted by several companies in Ohio can reduce the cost burden of injuries.

[Prevention of low back pain at work]

The aetiology of low back pain is complex and multidimensional. Physical and (partially) psychosocial occupational factors seem to play an important aetiological role. In this article, the evidence for specific primary and secondary prevention and intervention strategies -- which are derived from the analysis of risk factors for low back pain -- is summarized. Multidimensional interventions focussing on the workplace as well as on the affected individual have proven to effectively influence the occurrence and the course of low back pain. There is a need for additional high-quality randomized controlled studies -- particularly focussing on workplace interventions -- and for a continuous evaluation of existing prevention and intervention strategies.

A prospective study of the effectiveness of early intervention with high-risk back-injured workers--a pilot study

INTRODUCTION

It was postulated that workers, at the sub-acute stage after injury, respond differently to clinical and occupational interventions offered in a workers' compensation environment. Individual worker risk of disability, it was further believed, would influence the effectiveness of early intervention. The objective of the current pilot study was to evaluate return to work (RTW) outcomes following proactive, combined clinical, occupational and case management-based interdisciplinary early intervention, provided in a workers' compensation environment 4-10 weeks of onset of back pain, to workers with medium and high risk for disability.

METHODS

The project was a controlled study comparing conventional workers' compensation case management with integrated, interdisciplinary and multimodal early intervention (hereinafter referred to as "EI"). At baseline, risk status was determined by a validated Risk for Disability Questionnaire by Carragee et al. (Spine 5(1):24-35, 2005). Seventeen workers at high risk of protracted disability and 20 workers at moderate risk of disability received conventional case management, and 17 workers assessed at high risk of protracted disability and 18 workers at moderate risk of disability received the Early Intervention.

RESULTS

At 3 months post back pain onset, no statistically significant differences were identified in RTW outcomes between conventional case management and the Early Intervention. However, by 6 months post back pain onset, workers at high risk of work disability who received the Early Intervention were significantly more likely to RTW than high risk workers who received conventional case management. In contrast, moderate risk workers continued to exhibit no statistically significant differences in RTW outcomes.

CONCLUSION

Multimodal Early Intervention in the workers' compensation case management context is likely effective for workers with sub-acute back pain who are at high risk of occupational disability. The comprehensive Early Intervention is, however, likely redundant for workers who are not at high risk for disability and should not be applied indiscriminately. Further studies are required to determine longer-term Early Intervention outcomes, and to replicate the findings using a randomized control design. Also, with a larger sample size, it will be possible to determine predictors of occupational outcomes.

How well do return-to-work interventions for musculoskeletal conditions address the multicausality of work disability?

INTRODUCTION

The best-documented return-to-work rehabilitation programs concern workers with musculoskeletal disorders (MSKD). For this clientele, a global perspective has been adopted which explains the multicausality of work disability. This perspective of work disability proposes that return-to-work interventions should address three central elements: individual psychological factors, work environmental factors and factors related to the involvement of the various stakeholders. Long-term work disability is no longer seen simply as the consequence of impairment, but rather as the result of interactions between the worker and main systems: the health care, work environment and financial compensation systems.

METHODS

This paper presents a descriptive content analysis of return-to-work interventions delivered to workers with MSKD which consider this global perspective and which are found to be effective in systematic reviews of the literature.

RESULTS

The review of programs designed for workers with MSKD showed that eleven programs address the individual clinical and psychological factors, work environmental factors and factors related to the involvement of the various stakeholders, but in different ways. Only two programs met the essential components identified by the literature. These essential components are: centralized coordination of the worker's return to work, formal individual psychological and occupational interventions, workplace-based interventions, work accommodations, contact between the various stakeholders and interventions to foster concerted action.

CONCLUSIONS

Interventions which involve the work environment and concerted action by the various partners seem to require the most investment in terms of energy. The establishment of common principles and shared values regarding work rehabilitation as well as less divided mechanisms for action among the various partners should be considered.

Meeting the challenges of an aging workforce

BACKGROUND

Demographic, labor market and economic forces are combining to produce increases in the number and percentage of U.S. workers 55 and older. In some ways these workers will be our most skilled and productive employees but in others the most vulnerable.

METHODS

The literature on aging and work was reviewed, including demographic trends, physical and cognitive changes, safety and performance, work ability, and retirement patterns.

RESULTS AND CONCLUSIONS

Older workers have more serious, but less frequent, workplace injuries and illnesses than younger ones. There is evidence that many of these problems can be prevented and their consequences reduced by anticipating the physical and cognitive changes of age. Many employers are aware that such efforts are necessary, but most have not yet addressed them. There is a need for implementation and evaluative research of programs and policies with four dimensions: the work environment, work arrangements and work-life balance, health promotion and disease prevention, and social support. Employers who establish age-friendly workplaces that promote and support the work ability of employees as they age may gain in safety, productivity, competitiveness, and sustainable business practices.

Epidemiologic perspective on chronic pain treatment

OBJECTIVE

To review the epidemiologic literature concerning psychosocial mediators of outcome in chronic pain. These factors deserve attention in the assessment and treatment of chronic pain by mental health professionals.

METHOD

We reviewed literature dealing with epidemiologic perspectives on abuse, depression, addiction, employment, coping skills, and psychosocial problems. Treatments considered include analgesics, psychological rehabilitation, and prevention of disability.

RESULTS

Psychosocial factors such as abuse, mood disorder, employment handicap, poor coping skills, and other psychosocial problems are commonly found in chronic pain patients referred to clinics.

CONCLUSION

Many psychosocial factors that can be identified in chronic pain sufferers are relevant to the professional skills of mental health professionals. These factors are determinants of prognosis, course, and outcome of chronic pain.

Responsiveness of the physical work performance evaluation, a functional capacity evaluation, in patients with low back pain

BACKGROUND AND PURPOSE

The Physical Work Performance Evaluation (PWPE) is a functional capacity evaluation. This study investigated the responsiveness of the PWPE.

METHODS

The internal and external responsiveness was tested. For the internal responsiveness, the change in the pre-/post-test PWPE scores of a group participating in a work rehabilitation program (n = 27) was compared to that of a comparison group of healthy subjects (n = 30). The external responsiveness was tested with the rehabilitation group, and the change in their PWPE scores was compared to concurrent and empirical criteria.

RESULTS

The comparison of the change in pre-/post-test PWPE scores showed that the change for the rehabilitation group was significantly different from that for the comparison group, but only for one section of the PWPE. Changes in six criteria were seen after completion of the program, but there was no significant correlation between these changes and the change in the overall PWPE score.

DISCUSSION AND CONCLUSION

The overall PWPE level of work score does not appear to have the ability to measure clinically significant changes achieved through a work rehabilitation program.

A literature review describing the role of return-to-work coordinators in trial programs and interventions designed to prevent workplace disability

OBJECTIVE

Return-to-work (RTW) coordination has been suggested as an effective strategy for preventing workplace disability, but the scope of these services is not well described. The objective of this study was to describe the activities of RTW coordinators in published trials to provide a basis for establishing necessary competencies.

METHODS

A keyword search of MEDLINE and CINAHL databases was conducted to identify intervention studies with a RTW coordinator providing direct, on-site workplace liaison to reduce work absences associated with physical health ailments. This search yielded 2,383 titles that were inspected by two examiners. Using a stepwise process that allowed for assessment of inter-observer agreement, 90 full articles were selected and reviewed, and 40 articles (22 studies) met criteria for inclusion.

RESULTS

All but two studies (of traumatic brain injury) focused on musculoskeletal conditions or work injuries. Twenty-nine RTW coordinator activities were identified, but there was variation in the training background, workplace activities, and contextual setting of RTW coordinators. Based on reported RTW coordinator activities, six preliminary competency domains were identified: (1) ergonomic and workplace assessment; (2) clinical interviewing; (3) social problem solving; (4) workplace mediation; (5) knowledge of business and legal aspects; and (6) knowledge of medical conditions.

DISCUSSION

Principal activities of RTW coordination involve workplace assessment, planning for transitional duty, and facilitating communication and agreement among stakeholders. Successful RTW coordination may depend more on competencies in ergonomic job accommodation, communication, and conflict resolution than on medical training.

Timing makes a difference: early nurse case management intervention and low back pain

PURPOSE OF STUDY

* To examine whether early nurse contacts influenced workers' satisfaction with their nurse case management, their healthcare, and the way the firm was treating their injury.* To examine whether early nurse contacts influenced self-reported measures of back pain and returns to work.

PRIMARY PRACTICE SETTING(S)

Workers with low back pain resulting in workers' compensation claims.

METHODOLOGY AND SAMPLE

To quantify the influence of nurse case management on workers' satisfaction with their treatment by the firm and their healthcare provider, as well return to work, we follow 747 Marriott workers with incident episodes of low back pain in a prospective analysis. Predictors of outcomes include demographics, injury severity, and the timing of nurse case manager and work supervisor contacts.

RESULTS

While early contacts do not have much impact on satisfaction with the treatment by the healthcare provider, early nurse case management contacts improve worker satisfaction with the firm's treatment of their claim, increasing satisfaction by 0.5 standard deviations (on a 4-point scale). The change in odds ratio with respect to a contact during the first week after injury is 8, indicating a 50-percentage point increase in the likelihood of continual employment.

IMPLICATIONS FOR CM PRACTICE

*Among workers with low back pain, early nurse case management contacts improved workers' satisfaction with their healthcare provider and their treatment by the firm.* Contacts made during the first week after the injury were most valuable, but in our sample it did not matter when during that first week the contact was made (as long as it was within the first week).* Early nurse case management contacts substantially improved the odds of continual employment, dominating the influence of age, job satisfaction, and the expectation of a good recovery.

Cost-effectiveness of a workplace intervention for sick-listed employees with common mental disorders: design of a randomized controlled trial

Background

Considering the high costs of sick leave and the consequences of sick leave for employees, an early return-to-work of employees with mental disorders is very important. Therefore, a workplace intervention is developed based on a successful return-to-work intervention for employees with low back pain. The objective of this paper is to present the design of a randomized controlled trial evaluating the cost-effectiveness of the workplace intervention compared with usual care for sick-listed employees with common mental disorders.

Methods

The study is designed as a randomized controlled trial with a follow-up of one year. Employees eligible for this study are on sick leave for 2 to 8 weeks with common mental disorders. The workplace intervention will be compared with usual care. The workplace intervention is a stepwise approach that aims to reach consensus about a return-to-work plan by active participation and strong commitment of both the sick-listed employee and the supervisor. Outcomes will be assessed at baseline, 3, 6, 9 and 12 months. The primary outcome of this study is lasting return-to-work, which will be acquired from continuous registration systems of the companies after the follow-up. Secondary outcomes are total number of days of sick leave during the follow-up, severity of common mental disorders, coping style, job content, and attitude, social influence, and self-efficacy determinants. Cost-effectiveness will be evaluated from the societal perspective. A process evaluation will also be conducted.

Discussion

Return-to-work is difficult to discuss in the workplace for sick-listed employees with mental disorders and their supervisors. Therefore, this intervention offers a unique opportunity for the sick-listed employee and the supervisor to discuss barriers for return-to-work. Results of this study will possibly contribute to improvement of disability management for sick-listed employees with common mental disorders. Results will become available in 2009.

Trial registration

ISRCTN92307123