Take Home Messages:

Workplace interventions for lower back pain are a cost effective way to improve return to work outcomes.

Important elements of successful workplace interventions include:

• An assessment of the workplace;
• Subsequent ergonomic modifications; and
• Case management in consultation with all the important stakeholders (ergonomist /occupational health nurse, worker, supervisor etc.).

Clinical interventions (based on graded exercise programs) did not have a positive effect on return to work.

The advantage of workplace interventions is that they encourage communication and participation amongst the group of people with the most influence over case outcomes – the injured worker, their supervisor and medical / ergonomic professionals.

Why the research matters:

Low back pain is a common problem and causes major disability and considerable costs to society. In addition to the cost of work absenteeism, delayed return to work results in high compensation and treatment expenses.

This study asks:

• When dealing with low back pain, can return to work interventions increase the rate of return to work and reduce long-term absenteeism?
• Is it more effective to undertake a clinical intervention in conjunction with a workplace intervention, or do workplace interventions suffice?

What the research involved:

A study was conducted by a team of researchers at VU University in the Netherlands to assess whether workplace or clinical interventions (or both) are effective compared to usual care. Usual care means the everyday care that a person not involved with the research project would receive from their treating practitioners.

Participants in the study were recruited if they had been on sick leave for 2 to 6 weeks due to low back pain, and were assigned to either usual care or a workplace intervention. Workplace interventions consisted of usual care plus a workplace assessment, ergonomic modifications and case management in consultation with all important stakeholders (ergonomist /occupational health nurse, worker, supervisor etc.). This took place before the participant had reached 8 weeks of sick leave.

Those who had not achieved full return to work after 8 weeks' leave were then assigned to either usual care or a clinical intervention. The clinical intervention consisted of a gradually-increasing exercise program, ending when full return to work had been established.

The researchers were primarily interested in the cost-effectiveness of these interventions. They measured three primary outcomes:

• Lasting return to work
• Secondary indicators such as pain intensity, general health and quality of life
• The economic outcome, taking into account such costs to society as the interventions themselves, medication, health care and loss of production.
• These outcomes were assessed periodically up to 52 weeks after the first day of sick leave.

Summary of research findings:

The key findings of the study were:

The workplace intervention group returned to work on average 30 days earlier than the usual care group.
Those who underwent the workplace intervention and the clinical intervention returned to work approximately 50 days later than those who received the workplace intervention alone.
Workers who underwent the clinical intervention after usual care tended to return to work later than those who just had usual care. However, the difference was small.
There were no differences between any of these groups on the secondary outcomes such as general health and quality of life.
Though there is no major difference in cost between the work intervention and usual care (the cost of the work intervention is slightly higher), work intervention tends to be more effective, especially in terms of lasting return to work.
The clinical intervention tended to be more costly, and associated with later return to work.
These results strongly emphasise the effectiveness of workplace interventions, and are consistent with previous research on this topic. The authors note that a workplace intervention can lead to more effective guidance of workers on sick-leave due to low back pain. This is most likely due the fact that the workplace intervention aims to enhance participation and communication among the important parties (i.e. worker, supervisor, GP, occupational health professionals).

Clinical interventions, however, were not shown to be effective. When conducted after a workplace intervention, clinical interventions actually had a negative effect on lasting return to work. Therefore, combining interventions is not recommended.

Overall, workplace interventions appear to be a valuable and cost-effective means of aiding people with low back pain to return to work earlier and reducing long-term absenteeism.

Original research:

Economic evaluation of a multi-stage return to work program for workers on sick-leave due to low back pain.

Steenstra IA, Anema JR, van Tulder MW, Bongers PM, de Vet HC, van Mechelen W.

J Occup Rehabil. 2006 Dec;16(4):557-78.

Link to PubMed abstract