Occupational medical assistance
After randomisation, the patient is seen by an occupational physician from the research team, who assesses the patient’s work instability using a gold standard approach [
24]. Work instability is characterised by a mismatch between an individual’s functional capabilities (in this case shoulder function) and job demands (in this case biomechanical shoulder load) to an extent where job retention is threatened [
24]. Shoulder function is assessed by clinical examination and shoulder load is assessed using a job exposure matrix (JEM), both combined with a semi-structured interview. Depending on the degree of work instability, a three month action plan is constructed. The plan is attuned to the patient’s most important barriers against continuing or resuming work, in agreement with the biopsychosocial model [
25,
26].
A JEM based on expert ratings is used [
27]. The JEM comprises shoulder force requirements using a 5-point force score scale, postural load in terms of daily duration of work with the arm elevated >90°, daily duration of moderately repetitive work with ≥4-<15 upper arm movements per minute, and highly repetitive work with ≥15 upper arm movements per minute. Jobs are classified as having
high shoulder load (indicated by a red colour code) if they fulfil at least one of the following criteria: a force-score ≥3, upper arm elevation >90° ≥1 hour/day, highly repetitive work ≥½ hour/day, and moderately repetitive work ≥4 hours/day. Remaining jobs are classified as having
medium shoulder load (indicated by a yellow colour code) in case of highly repetitive work <½ hour/day and at least one of the following: a force-score >1.5-<3, upper arm elevation >90° ≥½-<1 hour/day, and moderately repetitive work ≥2-<4 hours/day. Those jobs, which fulfil all of the following criteria, are classified as having
low shoulder load (indicated by a green colour code): a force-score ≤1.5, upper arm elevation >90° <½ hour/day, highly repetitive work <½ hour/day, and moderately repetitive work <2 hours/day. In the semi-structured interview, the physician gets a description of the patient’s primary work tasks in order to individualise the JEM-based exposure assessment and to identify work tasks with relatively high shoulder load. The interview also covers shoulder symptoms, general health status, and the patient’s assessment of the most important barriers against continuing or resuming work. The physician interprets and scores the patient’s 1) shoulder function, 2) shoulder load, 3) worries that the work may harm the shoulder, even though the job entails low shoulder load, 4) influence on the way work tasks are performed and on task distribution, and 5) support from employer/supervisor or colleagues with respect to work modifications. Each of these five items is scored on an 11-point numeric rating scale ranging from 0 (no problem) to 10 (the largest possible problem).
Table
2 presents our algorithm to assess work instability, indications for workplace visits, and intervention levels. An indicated workplace visit may be omitted if the patient can arrange workplace adaptations him-/herself, or if the employer is against a visit. In some cases, it may suffice that the physician contacts the workplace by telephone. Workplace visits are performed within 10 working days, attended by the occupational physician, the patient, and the employer/supervisor. The duration is around one hour. The physician assesses the patient’s shoulder load by observation. Tasks with relatively high shoulder load are identified, and potential solutions are discussed in order to reach an agreement on work adaptations that are feasible within a short time horizon, i.e. adaptations characterised by low costs, low complexity, and compatibility with existing work structures. Deadlines are set for implementation of the adaptations and their duration is stipulated. Advice on far-reaching, long-term adaptations may be passed on. The physician classifies the planned workplace adaptations as technical solutions, reductions of working hours (part-time sick-listing), or modifications of task distribution [
28]. The plan may represent more than one of these categories. To enable coordination of workplace-oriented efforts, the physician may contact the patient’s municipal job centre.
Table 2
Algorithm to assess work instability, indications for workplace visits, and intervention levels, modified from [
24]
Level 0 | Shoulder function is adequate to perform all work activities, pain is under control, work activities do not imply a risk to the shoulder (job colour code: green), and the patient does not worry that this is the case. | No |
Level 1 | As above, but from time to time pain is a problem, work activities do not imply a risk to the shoulder (job colour code: green), but the patient worries that this may be the case, and/or the patient experiences that the employer hesitates to let the patient do his or her ordinary work activities in order to protect the shoulder. | Maybe – the indication is relative. Reassure the patient (and the employer) that work can be continued/resumed. |
Level 2 | Work activities do not imply a risk to the shoulder (job colour code: green), but pain is aggravated to an unacceptable level, and/or shoulder function does not match all work activities. The shoulder problems are expected to resolve within 6–12 months. | Yes, temporary solutions have to be established at the workplace. |
Level 3 | Some work activities imply a risk of worsening the shoulder condition (job colour code: yellow or red), pain is aggravated to an unacceptable level, and/or shoulder function does not match all work activities. The shoulder problems are not expected to resolve within 6–12 months. | Yes, permanent solutions have to be established at the workplace. |
Level 4 | Major work activities imply a risk of worsening the shoulder condition (job colour code: yellow or red), pain is aggravated to an unacceptable level, and/or shoulder function does not match the work demands. The shoulder problems are not expected to resolve within twelve months. | Yes, a permanent shift to another job may be necessary. |
Undetermined | A workplace visit is necessary to assess work instability. | Yes, shoulder load has to be assessed. |
The patient receives a note with the agreed plan, advice on general physical activity, and transference of questions concerning analgesics to the patient’s general practitioner. If warranted, the physician notifies the shoulder disorder as a possible industrial injury in accordance with Danish legislation.
After six weeks, the physician contacts the patient by telephone to assess adherence to the plan. If needed, the employer/supervisor is contacted. Three months after baseline, the patient is seen for final evaluation and workplace-oriented advice. The patient’s assessment of factors facilitating or hindering the plan is registered, and any adverse events are noted. The intervention is described in a detailed manual.
Physiotherapy exercises
A standardised physiotherapy exercise intervention has been developed based on a systematic literature review and meetings with clinical physiotherapists working in the field to combine evidence and practical experience. The process of developing the intervention and the intervention itself are presented in a separate publication (Christiansen et al., in prep). The programme is described in a detailed manual that presents the exercises, the number of repetitions at each training level, and criteria for progression.
Depending on their need for supervision, the patients attend a physiotherapist at a municipal training centre 8–15 times within a period of eight weeks, including an initial and a final clinical evaluation. The physiotherapist-supervised individual training sessions last up to 60 minutes each. The patients are instructed to perform additional self-training. At baseline, advice is given on general physical activity, questions concerning analgesics are transferred to the patient’s general practitioner, and the patient is advised to refrain from other specific shoulder training during the intervention period. The patient keeps a self-training diary, and the physiotherapist registers any deviations from the manual and scores patient adherence. Any adverse events are noted.