Physical conditioning as part of a return to work strategy to reduce sickness absence for workers with back pain.

BACKGROUND: Physical conditioning as part of a return to work strategy aims to improve work status for workers on sick leave due to back pain. This is the second update of a Cochrane Review (originally titled 'Work conditioning, work hardening and functional restoration for workers with back and neck pain') first published in 2003, updated in 2010, and updated again in 2013. OBJECTIVES: To assess the effectiveness of physical conditioning as part of a return to work strategy in reducing time lost from work and improving work status for workers with back pain. Further, to assess which aspects of physical conditioning are related to a faster return to work for workers with back pain. SEARCH METHODS: We searched the following databases to March 2012: CENTRAL, 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 programmes. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed risk of bias. We used standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS: We included 41 articles reporting on 25 RCTs with 4404 participants. Risk of bias was low in 16 studies.Three studies involved workers with acute back pain, eight studies workers with subacute back pain, and 14 studies workers with chronic back pain.In 14 studies, physical conditioning as part of a return to work strategy was compared to usual care. The physical conditioning mostly consisted of graded activity with work-related exercises aimed at increasing back strength and flexibility, together with a set date for return to work. The programmes were divided into a light version with a maximum of five sessions, or an intense version with more than five sessions up to full time or as inpatient treatment.For acute back pain, there was low quality evidence that both light and intense physical conditioning programmes made little or no difference in sickness absence duration compared with care as usual at three to 12 months follow-up (3 studies with 340 workers).For subacute back pain, the evidence on the effectiveness of intense physical conditioning combined with care as usual compared to usual care alone was conflicting (four studies with 395 workers). However, subgroup analysis showed low quality evidence that if the intervention was executed at the workplace, or included a workplace visit, it may have reduced sickness absence duration at 12 months follow-up (3 studies with 283 workers; SMD -0.42, 95% CI -0.65 to -0.18).For chronic back pain, there was low quality evidence that physical conditioning as part of integrated care management in addition to usual care may have reduced sickness absence days compared to usual care at 12 months follow-up (1 study, 134 workers; SMD -4.42, 95% CI -5.06 to -3.79). What part of the integrated care management was most effective remained unclear. There was moderate quality evidence that intense physical conditioning probably reduced sickness absence duration only slightly compared with usual care at 12 months follow-up (5 studies, 1093 workers; SMD -0.23, 95% CI -0.42 to -0.03).Physical conditioning compared to exercise therapy showed conflicting results for workers with subacute and chronic back pain. Cognitive behavioural therapy was probably not superior to physical conditioning as an alternative or in addition to physical conditioning. AUTHORS' CONCLUSIONS: The effectiveness of physical conditioning as part of a return to work strategy in reducing sick leave for workers with back pain, compared to usual care or exercise therapy, remains uncertain. For workers with acute back pain, physical conditioning may have no effect on sickness absence duration. There is conflicting evidence regarding the reduction of sickness absence duration with intense physical conditioning versus usual care for workers with subacute back pain. It may be that including workplace visits or execution of the intervention at the workplace is the component that renders a physical conditioning programme effective. For workers with chronic back pain physical conditioning has a small effect on reducing sick leave compared to care as usual after 12 months follow-up. To what extent physical conditioning as part of integrated care management may alter the effect on sick leave for workers with chronic back pain needs further research.

The trend in total cost of back pain in The Netherlands in the period 2002 to 2007.

STUDY DESIGN: Cost of illness study. OBJECTIVE: To investigate the total costs of back pain in The Netherlands over the years 2002 to 2007. SUMMARY OF BACKGROUND DATA: In 1991, the cost of back pain to the Dutch society was estimated at € 4.2 billion. In the last two decades, new laws regarding health insurance and sickness benefits and new guidelines for health care professionals have been introduced and may have affected the societal costs of back pain in The Netherlands. METHODS: We conducted a cost-of-illness study in which we gathered relevant available data from national registries, reports of research institutes, descriptive studies, and occupational health care authorities to estimate the total cost of back pain to the Dutch society for the years 2002 to 2007. RESULTS.: The total costs of back pain decreased from € 4.3 billion in 2002 to € 3.5 billion in 2007. The share of these costs was about 0.9% of the gross national product (GNP) in 2002 and 0.6% of GNP in 2007. The ratio between direct and indirect costs did not change noticeably over the years, that is, 12% for direct and 88% for indirect costs. CONCLUSIONS: The total societal costs of back pain have decreased since 1991 and also between 2002 and 2007. Although Dutch policy interventions to lower the indirect costs seem to be successful in the last decades, costs of back pain are still substantial, and indirect costs represent the majority of these costs. Policy interventions and implementation of cost-effective interventions focusing on return-to-work management for back pain in health care is important to further decrease the economic burden of back pain on society.

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.

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.

Can workers with chronic back pain shift from pain elimination to function restore at work? Qualitative evaluation of an innovative work related multidisciplinary programme.

INTRODUCTION: Workers with chronic low back pain (LBP) mean a heavy human and social-economic burden. Their medical histories often include different treatments without attention to work-relatedness or communication with occupational health providers, leaving them passive and medicalized in (outpatient) health care. So we developed and implemented an innovative, patient-activating alternative: the multidisciplinary outpatient care (MOC) programme, including work(place) intervention and graded activity. It aims at function restore (instead of pain elimination), return to work (RTW) and coordinated communication. OBJECTIVES: To qualitatively explore how patients and health care providers perceive the programme effectiveness and which factors influence its implementation. METHODS: In-depth, semi structured interview with patients and focus groups of health care providers are used, all recorded, transformed into verbatim transcript and analysed. RESULTS: This qualitative study shows that although patients' expectations were low at the start of the program, and despite long LBP histories, including many different therapies, (primarily) directed at pain reduction, the MOC programme was successful in changing patients' goal setting from pain oriented towards function restore and RTW. The programme was therefore perceived as applicable and effective. Patient compliance was influenced by barriers - despair, supervisory and subordinate resistance at work, waiting period, medicalisation in health care - and facilitators: disciplinary motivation, protocolled communication, information supply, tailor-made exercises. For some patients the barriers were too high. Several improvement suggestions were given. CONCLUSIONS: This qualitative study shows that generally, patients and professionals perceived the multidisciplinary outpatient care programme as applicable and effective. After incorporating improvement suggestions this program seems promising for further, broader application and hypothesis testing. For those, negatively evaluating the programme, alternatives should be explored.

An integrated care program to prevent work disability due to chronic low back pain: a process evaluation within a randomized controlled trial.

BACKGROUND: In the past decade, a considerable amount of research has been carried out to evaluate the effectiveness of innovative low back pain (LBP) interventions. Although some interventions proved to be effective, they are not always applied in daily practice. To successfully implement an innovative program it is important to identify barriers and facilitators in order to change practice routine. Because usual care is not directly aimed at return to work (RTW), we evaluated an integrated care program, combining a patient-directed and a workplace-directed intervention provided by a multidisciplinary team, including a clinical occupational physician to reduce occupational disability in chronic LBP patients. The aims of this study were to describe the feasibility of the implementation of the integrated care program, to assess the satisfaction and expectations of the involved stakeholders and to describe the needs for improvement of the program. METHODS: Eligible for this study were patients who had been on sick leave due to chronic LBP. Data were collected from the patients, their supervisors and the involved health care professionals, by means of questionnaires and structured charts, during 3-month follow-up. Implementation, satisfaction and expectations were investigated. RESULTS: Of the 40 patients who were eligible to participate in the integrated care program, 37 patients, their supervisors and the health care professionals actually participated in the intervention. Adherence to the integrated care program was in accordance with the protocol, and the patients, their supervisors and the health care professionals were (very) satisfied with the program. The role of the clinical occupational physician was of additional value in the RTW process. Time-investment was the only barrier for implementation reported by the multidisciplinary team. CONCLUSION: The implementation of this program will not be influenced by any flaws in its application that are related to the program itself, or to the adherence of patients with chronic LBP and their health care professionals. This program is promising in terms of feasibility, satisfaction and compliance of the patients, their supervisors and the health care professionals. Before implementation on a wider scale, the communication and the information technology of the program should be improved.

Multidisciplinary outpatient care program for patients with chronic low back pain: design of a randomized controlled trial and cost-effectiveness study [ISRCTN28478651].

BACKGROUND: Chronic low back pain (LBP) is a major public and occupational health problem, which is associated with very high costs. Although medical costs for chronic LBP are high, most costs are related to productivity losses due to sick leave. In general, the prognosis for return to work (RTW) is good but a minority of patients will be absent long-term from work. Research shows that work related problems are associated with an increase in seeking medical care and sick leave. Usual medical care of patients is however, not specifically aimed at RTW. The objective is to present the design of a randomized controlled trial, i.e. the BRIDGE-study, evaluating the effectiveness in improving RTW and cost-effectiveness of a multidisciplinary outpatient care program situated in both primary and outpatient care setting compared with usual clinical medical care for patients with chronic LBP. METHODS/DESIGN: The design is a randomized controlled trial with an economic evaluation alongside. The study population consists of patients with chronic LBP who are completely or partially sick listed and visit an outpatient clinic of one of the participating hospitals in Amsterdam (the Netherlands). Two interventions will be compared. 1. a multidisciplinary outpatient care program consisting of a workplace intervention based on participatory ergonomics, and a graded activity program using cognitive behavioural principles. 2. usual care provided by the medical specialist, the occupational physician, the patient's general practitioner and allied health professionals. The primary outcome measure is sick leave duration until full RTW. Sick leave duration is measured monthly by self-report during one year. Data on sick leave during one-year follow-up are also requested form the employers. Secondary outcome measures are pain intensity, functional status, pain coping, patient satisfaction and quality of life. Outcome measures are assessed before randomization and 3, 6, and 12 months later. All statistical analysis will be performed according to the intension-to-treat principle. DISCUSSION: Usual care of primary and outpatient health services isn't directly aimed at RTW, therefore it is desirable to look for care which is aimed at RTW. Research shows that several occupational interventions in primary care are aimed at RTW. They have shown a significant reduction of sick leave for employee with LBP. If a comparable reduction of sick leave duration of patients with chronic LBP of who attend an outpatient clinic can be achieved, such reductions will be obviously substantial for the Netherlands and will have a considerable impact.