Work Modification as a Treatment for Low-Back Pain

By Viikari-Juntura, Eira; MacEachen, Ellen | Scandinavian Journal of Work, Environment & Health, May 1, 2015 | Go to article overview

Work Modification as a Treatment for Low-Back Pain


Viikari-Juntura, Eira, MacEachen, Ellen, Scandinavian Journal of Work, Environment & Health


Work modification is considered as an essential element in enhancing return to work (RTW) among persons with musculoskeletal problems (1) although systematic reviews have called for more studies (2) and pointed out that the net gain in sickness absence days has been only modest and economic effects uncertain (3). Loisel and his co-workers (4) showed for the first time that an occupational intervention - and especially an occupational intervention combined with a clinical intervention - was associated with a faster RTW compared with clinical intervention alone or usual care. The developed Sherbrooke model has been tested with a randomized controlled trial (RCT) in the Netherlands. Workers sick-listed for 2-6 weeks due to low-back pain (LBP) were first randomized into a workplace intervention or usual care, and those who had not returned to work by 8 weeks were further randomized to graded activity or usual care. Workplace intervention was shown to enhance RTW, whereas graded activity did not (5). Loisel has suggested that the subacute phase of low-back disability is the "golden hour" for prevention of further disability, when unnecessary measures can be avoided and focus can be placed on those with risk for prolonged disability (6). Van Duijn et al (7) calculated the potential gain in sickness absence days and the cost-benefits of hypothetical interventions based on information of RTW rates and effectiveness of various types of interventions. They concluded that only low-cost and quickly administered interventions (eg, workplace modifications) have the potential to be cost-beneficial at an early stage of disability, whereas the optimal time window for more complex interventions would be 8-12 weeks (7).

Currently many healthcare providers agree that the Sherbrooke model has a sound basis. However, refraining at an early stage of disability from larger diagnostic procedures to arrive at a specific diagnosis at tissue level and medication believed to cure or alleviate a disease, and instead providing suitable workload through work modification to prevent further disability has not yet been adopted into medical practice. Prescribing work modification as a treatment is not straightforward either. In this issue of the Scandinavian Journal of Work Environment & Health, the Fassier et al paper (8) looks at the barriers and facilitators in the implementation of the Sherbrook model with a qualitative approach. Representatives of the healthcare, health insurance, and the workplace systems each identified barriers and facilitators that were structured in their external, organizational, and individual context. The authors note that, due to the existence of barriers at multiple levels (from workplace to broader systems), interventions that are limited to one particular level are unlikely to be successful. They draw attention to the importance of a systems approach in RTW interventions in order to address the interplay between local behavior and broader structural conditions. The result is that the implementation of the model is discussed in detail, demonstrating well the complexity of the issue and all phases where the implementation may fail.

The healthcare providers - paid by time or "piece-rate" have to decide on a trade-off between diagnostic examinations and documentation, on the one hand, and searching and discussing solutions at the workplace, on the other. Adopting this kind of social role may be felt as a proper professional role for some but not all, and it may come at a cost to physician income. For the health insurance system, there is the challenge of keeping on track in order not to lose the appropriate time window for potentially effective interventions. At the workplace, crucial aspects are having enough competence in ergonomics and policies of work accommodation, providing responsibility, and maintaining well-functioning interpersonal collaborations.

Goodwill and trust at all levels can facilitate RTW interventions (9). …

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