Long-term effects on function, health-related quality of life and work ability after structured physiotherapy including a workplace intervention. A secondary analysis of a randomised controlled trial (WorkUp) in primary care for patients with neck and/or back pain.

Objective: To study the long-term effects of a workplace intervention in addition to structured physiotherapy regarding self-reported measures in patients with acute/subacute neck and/or back pain.Design: WorkUp - a cluster-randomised controlled trial in 32 primary care centers in Sweden, from January 2013 through December 2014 (ClinicalTrials.gov ID: NCT02609750).Intervention: Structured physiotherapy with the workplace dialogue 'Convergence Dialogue Meeting' (CDM), conducted by the treating physiotherapist as an add-on. Reference group received structured physiotherapy.Subjects: Adults, 18-67 years (mean 43.7, standard deviation (SD) 12.2), 65.3% women with acute/subacute neck and/or back pain who had worked ≥4 weeks past year, considered at risk of sick leave or were on short-term sick leave (≤60 days) were included (n = 352).Outcome measures: Self-reported function, functional rating index (FRI), health-related quality of life (EQ-5D-3L) and work ability (Work Ability Score, WAS) at 12 months follow-up.Results: The mean differences in outcomes between intervention and reference group were; -0.76 (95% confidence interval (CI): -2.39, 0.88; FRI), 0.02 (95% CI: -0.04, 0.08; EQ-5D-3L) and -0.05 (95% CI: -0.63, 0.53; WAS). From baseline to 12 months, the intervention group improved function from 46.5 (SD 19.7) to 10.5 (SD 7.3) on FRI; health-related quality of life from 0.53 (SD 0.29) to 0.74 (SD 0.20) on EQ-5D and work ability from 5.7 (SD 2.6) to 7.6 (SD 2.1) on WAS.Conclusion: Despite a clinically relevant improvement over time, there were no significant differences in improvement between groups, thus we conclude that CDM had no effect on self-reported measures in this study.Key pointsIn earlier analysis of the primary outcome (work ability measured by absenteeism) in this trial, a positive effect was found when the workplace intervention 'Convergence Dialogue Meeting' (CDM) was added to structured physiotherapy for patients with neck or back pain.By contrast, in this new analysis of secondary outcomes (self-reported function, health and perceived work ability), there was no added effect of CDM above structured physiotherapy alone, although patients in both the intervention and reference group improved over time.The addition of CDM to physiotherapy is therefore justified by its specific effect on behavior (work absence) rather than any effect on clinical outcomes.

Structured physiotherapy including a work place intervention for patients with neck and/or back pain in primary care: an economic evaluation.

A cluster-randomized controlled trial, WorkUp, was conducted for working-aged patients at risk of sick leave or on short-term sick leave due to acute/subacute neck and/or back pain in Sweden. The purpose of WorkUp was to facilitate participants to stay at work or in case of sick leave, return-to-work. The aim of this study was to study whether the WorkUp trial was cost-effective. Patients in the intervention and reference group received structured evidence-based physiotherapy, while patients in the intervention group also received a work place dialogue with the employer as an add-on. The participants, 352 in total, were recruited from 20 physiotherapeutic units in primary healthcare in southern Sweden. The economic evaluation was performed both from a healthcare and a societal perspective with a 12-month time frame with extensive univariate sensitivity analyses. Results were presented as incremental cost-effectiveness ratios (ICER) with outcomes measured as quality-adjusted life-years (QALY) and proportion working for at least 4 weeks in a row without reported sick leave at 12-month follow-up. From the healthcare perspective, the ICER was €23,606 (2013 price year) per QALY gain. From the societal perspective the intervention was dominating, i.e.. less costly and more effective than reference care. Bootstrap analysis showed that the probability of the intervention to be cost-effective at €50,000 willingness-to-pay per QALY was 85% from the societal perspective. Structured evidence-based physiotherapeutic care together with workplace dialogue is a cost-effective alternative from both a societal and a healthcare perspective for acute/subacute neck and/or back pain patients.Trial registration ClinicalTrials.gov: NCT02609750.

Can the STarT Back Tool predict health-related quality of life and work ability after an acute/subacute episode with back or neck pain? A psychometric validation study in primary care.

OBJECTIVES: The predictive ability of the STarT Back Tool (SBT) has not yet been examined among acute/subacute back and/or neck pain in a primary care setting in respect to health-related quality of life (HRQoL) and work ability outcomes. The aim of this study was to evaluate the SBT's predictive validity for HRQoL and work ability outcomes at long-term follow-up in a population with acute/subacute back and/or neck pain. SETTING: Prospective data from 35 primary care centres in south Sweden during 2013. PARTICIPANTS: Patients (n=329) with acute/subacute back and/or neck pain, aged 18-67 years, not on sick leave or <60 days of sick leave completed the SBT when applying for physiotherapy treatment. Long-term follow-up measures (median 13 months, range 11-27 months) of HRQoL (EQ-5D) and work ability (Work Ability Score) was completed by 238 patients (72%). OUTCOMES: The predictive ability of the SBT for HRQoL and work ability outcomes was examined using Kruskal-Wallis test, logistic regression and area under the curve (AUC). RESULTS: Based on SBT risk group stratification, 103 (43%), 107 (45%) and 28 (12%) patients were considered as low, medium and at high risk, respectively. There were statistically significant differences in HRQoL (p<0.001) and work ability (p<0.001) at follow-up between all three SBT risk groups. Patients in the high risk group had a significantly increased risk of having poor HRQoL (OR 6.16, 95% CI 1.50 to 25.26) and poor work ability (OR 5.08, 95% CI 1.75 to 14.71) vs the low risk group at follow-up. The AUC was 0.73 (95% CI 0.61 to 0.84) for HRQoL and 0.68 (95% CI 0.61 to 0.76) for work ability. CONCLUSIONS: The SBT is an appropriate tool for identifying patients with a poor long-term HRQoL and/or work ability outcome in a population with acute/subacute back and/or neck pain, and maybe a useful adjunct to primary care physiotherapy assessment and practice. TRIAL REGISTRATION NUMBER: NCT02609750; Results.

Comparison of the Swedish STarT Back Screening Tool and the Short Form of the Örebro Musculoskeletal Pain Screening Questionnaire in patients with acute or subacute back and neck pain.

BACKGROUND: Patients with back and neck pain are often seen in primary care and it is important to provide them with tailored interventions based on risk stratification/triage. The STarT Back Screening Tool (SBT) is a widely used screening questionnaire which has not yet been validated for a population with back and/or neck pain with short duration. Our aim was to compare the concurrent validity of the SBT and the short form of the ÖMPSQ including psychometric properties and clinical utility in a primary care setting. METHODS: Patients who applied for physiotherapy by direct access (January 2013 to January 2014) at 35 primary care centers in south Sweden, with acute or subacute back and/or neck pain, aged 18-67 years, who were not currently on sick leave or had been on sick leave less than 60 days were asked to complete the SBT and ÖMPSQ-short questionnaire (n = 329). We used the Spearman's rank correlations to study correlations, cross tabulation and Cohen's kappa to analyze agreement of patient classification. Clinical utility was described as clinician scoring miscalculations and misclassifications of total and/or subscale scores. RESULTS: Completed SBT (9-items) and ÖMPSQ-short (10-items) data were available for 315/329 patients respectively. The statistical correlation for SBT and ÖMPSQ-short total scores was moderately strong (0.62, p < 0.01). In subgroup analyses, the correlations were 0.69 (p < 0.01) for males and 0.57 (p < 0.01) for females. The correlations were lower among older age groups, especially females over 50 years (0.21, p = 0.11). Classification to high or low risk for long-term pain and disability had moderate agreement (κ = 0.42). Observed classification agreement was 70.2%. The SBT had fewer miscalculations (13/315) than the ÖMPSQ-short (54/315). CONCLUSIONS: The correlation between the SBT and the ÖMPSQ-short scores were moderately strong for individuals with acute or subacute back and/or neck pain. SBT seemed to be clinically feasible to use in clinical practice. We therefore suggest that SBT can be used for individuals with both BP and/or NP in primary care settings but it is important to be aware of that SBT's agreement with the ÖMPSQ-short was poor among females aged over 50 years. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT02609750 Registered: November 18, 2015.

Sick leave in Sweden before and after total joint replacement in hip and knee osteoarthritis patients.

Background and purpose - Little is know about patterns of sick leave in connection with total hip and knee joint replacement (THR and TKR) in patients with osteoarthritis (OA). Patients and methods - Using registers from southern Sweden, we identified hip and knee OA patients aged 40-59 years who had a THR or TKR in the period 2004-2012. Patients who died or started on disability pension were excluded. We included 1,307 patients with THR (46% women) and 996 patients with TKR (56% women). For the period 1 year before until 2 years after the surgery, we linked individual-level data on sick leave from the Swedish Social Insurance Agency. We created a matched reference cohort from the general population by age, birth year, and area of residence (THR: n = 4,604; TKR: n = 3,425). The mean number of days on sick leave and the proportion (%) on sick leave 12 and 24 months before and after surgery were calculated. Results - The month after surgery, about 90% of patients in both cohorts were on sick leave. At the two-year follow-up, sick leave was lower for both cohorts than 1 year before surgery, except for men with THR, but about 9% of the THR patients and 12-17% of the TKR patients were still sick-listed. In the matched reference cohorts, sick leave was constant at around 4-7% during the entire study period. Interpretation - A long period of sick leave is common after total joint replacement, especially after TKR. There is a need for better knowledge on how workplace adjustments and rehabilitation can facilitate the return to work and can postpone surgery.

Promoting work ability in a structured national rehabilitation program in patients with musculoskeletal disorders: outcomes and predictors in a prospective cohort study.

BACKGROUND: Musculoskeletal disorders (MSDs) are a major reason for impaired work productivity and sick leave. In 2009, a national rehabilitation program was introduced in Sweden to promote work ability, and patients with MSDs were offered multimodal rehabilitation. The aim of this study was to analyse the effect of this program on health related quality of life, function, sick leave and work ability. METHODS: We conducted a prospective, observational cohort study including 406 patients with MSDs attending multimodal rehabilitation. Changes over time and differences between groups were analysed concerning function, health related quality of life, work ability and sick leave. Regression analyses were used to study the outcome variables health related quality of life (measured with EQ-5D), and sick leave. RESULTS: Functional ability and health related quality of life improved after rehabilitation. Patients with no sick leave/disability pension the year before rehabilitation, improved health related quality of life more than patients with sick leave/disability pension the year before rehabilitation (p = 0.044). During a period of -/+ four months from rehabilitation start, patients with EQ-5D ≥ 0.5 at rehabilitation start, reduced their net sick leave days with 0.5 days and patients with EQ-5D <0.5 at rehabilitation start, increased net sick leave days with 1.5 days (p = 0.019). Factors negatively associated with sick leave at follow-up were earlier episodes of sick leave/disability pension, problems with exercise tolerance functions and mobility after rehabilitation. Higher age was associated with not being on sick leave at follow-up and reaching an EQ-5D ≥ 0.5 at follow-up. Severe pain after rehabilitation, problems with exercise tolerance functions, born outside of Sweden and full-time sick leave/disability pension the year before rehabilitation were all associated with an EQ-5D level < 0.5 at follow-up. CONCLUSIONS: Patients with MSDs participating in a national work promoting rehabilitation program significantly improved their health related quality of life and functional ability, especially those with no sick leave. This shows that vocational rehabilitation programs in a primary health care setting are effective. The findings of this study can also be valuable for more appropriate patient selection for rehabilitation programs for MSDs.

Work ability--experiences and perceptions among physicians.

PURPOSE: To describe experiences and perceptions of work ability and how it can be assessed among Swedish physicians. METHOD: We interviewed eight men and six women in the fields of general practice, occupational health, rehabilitation and orthopaedic surgery. Qualitative content analysis was applied to the data. RESULTS: The approach striving to support the patient in mutual confidence was what primarily affected how work ability was understood and how it could be assessed. Two main categories, with sub categories were settled: familiar but vague, with subcategories conflicting expectations and relations and consensus within speciality and the second main category relying on intuition and examinations, with sub categories life as a whole, reasonableness, progression plan, external obstacles and need for knowledge and collaboration. CONCLUSIONS: We found that physicians mainly rely on what patients were telling about their work situation when assessing work ability. But it was not clear if they should consider the patient's whole life situation, motivation and wishes. Protecting the physician-patient relationship was seen as important as well as the need for teamwork assessments and increased work place knowledge.