Background
Methods
Sick-listing in Sweden
Participants
Interventions
Cognitive-behavioural rehabilitation
Staff category |
Investigation and treatment phase, 2 – 8 weeks
| Frequency |
---|---|---|
Physician | Mapping out of medical obstacles to working. Handling of the sick-listing. If needed, prescription of drugs (antidepressants, analgesics etc.) and injections of cortisone (in shoulder- or hip-muscle attachments etc.)[25]. | 1 – 2 (consultations)/week. |
Physiotherapist | Mapping out of biomechanical obstacles to working including a visit to the work place [14]. Start of graded activity: the patient first carried out an activity measurable in minutes, metres, etc., for example a walk, until the pain increased. The starting level was about 25% below that. A gradual increase of the activity was decided on check-ups, the final aim being to manage the load in a job, for the unemployed an imaginary one [14]. If needed, manual therapy [25]. | 2 – 3 consultations. 1/week. 1/week. |
Psychologist or social worker | Mapping out of psychosocial obstacles to working. Cognitive- behavioural therapy focussed on anxiety and depression [46]. | 1/week. |
Health-care adviser | Start of education in applied relaxation [46]. | 1/week for 6 – 8 w. |
Action phase, 2 – 8 months
| ||
Team | Conference that produced a written rehabilitation plan with: 1. Final aim = the optimal degree of work ability that could be achieved and maintained for at least 30 consecutive days.
2. Partial aims concerning functioning only (for example, increase of vocational training by five hours/week); symptom aims, for example, pain reduction, were excluded [14].
3. Means of reaching the aims (for example, increase of vocational training 1/2 hour/day week 1, 1 hour/day w. 2 etc.). | At the start of the action phase. |
Team | Check-up conferences produced fresh partial aims. | 1/3 – 4 weeks. |
Team member (usually the physiotherapist) | Vocational conferences with the employer and a clerk from the Social Insurance Agency or, for unemployed patients, the Employment Office. | |
Physician | Handling of the sick-listing. | 1/3 – 4 weeks. |
Physiotherapist | Completion of graded activity. Check-ups less frequent. | 1/3 – 4 weeks. |
Health-care adviser | Completion of education in applied relaxation. | 1/week (f. 6 – 8 w.) |
Psychologist or social worker | If needed: cognitive-behavioural therapy as support during the re-training process. | 1/week. |
When the final aim was reached, or when it was obvious that return-to-work would not be achieved. | The end of rehabilitation. |
Primary care
Outcome measures
Return-to-work share
Return-to-work chance
Net days
Visits
Analyses and statistics
Blinding
Data collection
Power calculation
Inclusion procedure
Rehabilitation group (n = 63) | Primary-care group (n = 62) |
p-value | |
---|---|---|---|
Women | 33 (52 [40 – 65]%) | 35 (56 [44 – 69]%) | NS |
Age (years) | 42.2 [39.8 – 44.6] | 43.0 [40.4 – 45.7] | NS |
Neck-pain domination | 17 (27 [16 – 38]%) | 21 (34 [22 – 46]%) | NS |
Widespread (= back + neck) pain | 55 (87 [79 – 96]%) | 45 (73 [61 – 84]%) |
.04
|
Pain score (VAS, 0 – 100; median (IQR))[48]: | |||
"Just now" | 61 (30) | 53 (30) | NS |
"Worst last week" | 77 (29) | 73 (26) | NS |
Health-related quality of life (EQ-5D)[49] | |||
(median (IQR)) | .489 (.332) | .497 (.332) | NS |
Immigrants (= born outside Sweden) | 19 (30 [19 – 42]%) | 15 (24 [13 – 35]%) | NS |
Single life | 19 (30 [19 – 42]%) | 21 (34 [22 – 46]%) | NS |
Low education (= at most junior high school) | 37 (60 [47 – 72]%) | 35 (56 [44 – 69]%) | NS |
Blue-collar work (of the non-unemployed) | 41 (87 [77 – 97]%) | 47 (87 [77 – 97]%) | NS |
Unemployed | 14 (22 [12 – 33]%) | 15 (24 [13 – 35]%) | NS |
Previous sick-listing (days)* | 223 [189 – 257] | 222 [188 – 256] | NS |
Lifting capacity (kg; mean): | |||
PILE lumbar [36] | 12.3 [10.4 – 14.2] | 12.4 [10.3 – 14.6] | NS |
PILE cervical [36] | 11.5 [9.7 – 13.3] | 11.6 [9.6 – 13.6] | NS |
Ethical approval
Premature cessation of recruitment
Follow-up
Results
Response rate and missing data
Follow-up | Six months |
p-value | 12 months |
p-value | 18 months* | All forms |
p-value |
---|---|---|---|---|---|---|---|
Rehabilitation group (n = 61) | |||||||
Previous sick-listing (days)** | 397 vs. 215 | .008 | 371 vs. 214 | .01 | - | - | |
Current sick-listing at baseline (days) | 367 vs. 158 | < .001 | 346 vs. 156 | < .001 | - | 275 vs. 151 | .003 |
Unemployment (%) | - | - | 60 vs. 18 | .03 | - | - | |
Primary-care group (n = 62) | |||||||
Age (years) | 35.8 vs. 44.8 | .006 | - | - | 38.3 vs. 45.3 | .01 | |
Single (%) | 58 vs. 28 | .046 | - | - | - | ||
EQ-5D [49] | - | - | .357 vs. .562 | .046 | - | - |
Baseline characteristics and participant flow
Outcome measures
Return-to-work share
Patients | Rehabilitation group | Primary-care group | |
---|---|---|---|
Return-to-work share (%) | All | 35/61 (57 [45 – 70]) | 35/62 (57 [44 – 69]) |
Subacute | 18/20 (90 [76 – 104]) | 15/18 (83 [64 – 102]) | |
Chronic | 17/41 (42 [26 – 57]) | 20/44 (46 [30 – 61]) | |
Net days
| All | 397 [354 – 440] | 391 [345 – 436] |
Subacute | 327 [261 – 392] | 292 [194 – 391] | |
Chronic | 431 [377 – 486] | 431 [383 – 478] | |
Visits
| All | 55.7 [49.3 – 62.2] | 52.0 [38.1 – 66.0] |
Subacute | 48.3 [38.5 – 58.1] | 40.6 [23.1 – 58.1] | |
Chronic | 60.1 [51.6 – 68.7] | 56.6 [38.1 – 75.2] |
Return-to-work chance
Rehabilitation group | Six months | 12 months | 18 months |
---|---|---|---|
All patients (n = 61) | .9 [.6 – 1.4] | 1.2 [.7 – 2.0] | 1.6 [.7 – 3.6] |
Subacute patients (n = 20) | .9 [.5 – 1.6] | 1.8 [.8 – 3.9] |
3.5 [1.001 – 12.2]
|
Chronic patients (n = 41) | .9 [.5 – 1.6] | .9 [.4 – 2.1) | 1.0 [.3 – 3.9] |
Net days
Visits
Interventions
Cognitive-behavioural rehabilitation
Rehabilitation period (days) | Total period 328 (± 195); median 283 (IQR215) | Investigation and treatment phase 42 (± 18); median 40 (IQR22) | Action phase 287 (± 193); median 249 (IQR232) | |
---|---|---|---|---|
Consultations | ||||
One-to-one | Treatment measure | At conferences | In total | |
Physician | 7.3 (± 5.2) | Administration of sick-listing 61/61 (100%) | 10.6 (± 6.8) | 17.9 (± 11.0) |
Prescription of drugs 53/61 (87%) | ||||
Cortisone injections 9/61 (15%) | ||||
Physiotherapist | 7.8 (± 4.9) | Graded activity 61/61 (100%) | 4.6 (± 3.4) | 12.4 (± 7.1) |
Orthopaedic manual therapy 15/61 (25%) | ||||
Psychologist or social worker | 4.8 (± 5.2) | Cognitive-behavioural therapy 58/61 (95%) | 3.4 (± 3.0) | 8.2 (± 7.8) |
Health-care adviser | 6.2 (± 4.8) | Applied relaxation 48/61 (79%) | .3 (± .8) | 6.6 (± 5.3) |
Conferences: | ||||
Team conferences | 8.6 (± 5.7) | |||
Vocational conf. (incl. workpl. visits) | 2.4 (± 2.4) | Vocational training 32/61 (52%) | ||
__________ | __________ | |||
Sum of treatment occasions | 37.1 (± 19.2) | Sum of consultations | 45.1 (± 22.8) | |
Physical activity (days/week): | ||||
Exercise programme | 5.5 (± 2.2) | |||
Gym training | 1.0 (± 1.3) |