R e s e a rc h P a p e r

PAIN □ OPEN

Early workplace dialogue in physiotherapy practice

improved work ability at 1-year follow-up—WorkUp,
a randomised controlled trial in primary care
Charlotte P. Sennehed3,b,c'**, Sara Holmbergc,d, Iben Axene, Kjerstin Stigmarb,f, Malin Forsbranda,b'9,
Ingemar F. Peterssona,h, Birgitta Grahna,b,c

Abstract
Workplace involvement in rehabilitation for patients with musculoskeletal pain may improve work ability. Convergence Dialogue
Meeting (CDM) is a model aimed at helping the patient, the care giver, and the employer to support work ability and return-to-work.
Our aim was to study the effect on work ability when adding a workplace dialogue according to CDM in physiotherapy practice for
patients with pain in ordinary primary care. We conducted a prospective pairwise cluster randomised controlled trial (ClinicalTrials.
gov ID: NCT02609750) in primary care involving 20 primary care rehabilitation units with 1 -year follow-up. Adult patients with acute/ :
subacute neck and back pain, worked > 4 weeks past year and not currently on sick leave or no more than 60 days of sick leave and
considered at-risk of sick leave were included (n = 352). All patients received structured physiotherapy and the intervention was the
addition of CDM, delivered by the treating physiotherapist. The main confirmatory outcome, w ork ability (defined as working at least
4 consecutive weeks at follow-up), was assessed by a weekly short text message question on number of sick leave days past week.
Work ability was reached by significantly more patients in the intervention group (108/127,85%) compared with the reference group
(127/171,74% ) (P = 0.02). The intervention increased the odds of having work ability at 1-year follow-up, also after adjustment for
baseline health-related quality of life (odds ratio 1.85, confidence interval 1.01 -3.38). We conclude that an early workplace dialogue
in addition to structured physiotherapy improved w ork ability significantly.
K e y w o r d s : Work ability, Workplace dialogue, Neck and back pain, Sick leave, Primary care

1. Introduction patients with back pain used twice as much health care resources 3
compared with the overall population .27 The recurrence of suer ;
Work disability due to musculoskeletal pain is one of the main
pain is high, about one-third of patients with previous acute bac« j
causes of sick leave in western societies ,5,19,53 and these
patients constitute a large group seeking help in primary pain will have a recurrence episode within 1 y e a r 38 The odds
care .26,30 Work disability causes both personal, economic, a recurrence within 1 year triple when the patient experienc
public, and health burdens 6 as well as productivity losses .11 more than 2 previous episodes of back pain .38
During 2012, 20% to 30% of the total number of visits to primary Work ability is a concept that is described from d iffe re d
care in Sweden were patients with musculoskeletal pain ,49 and perspectives 34 but in general as a relational concept, ie, that i
individual’s capacity must be viewed in relation to different wo
demands 34 and can relate to either continuing work, avoidF
Sponsorships or competing interests that may be relevant to content are disclosed sickness absence, or returning to work after sick leave. Reports
at the end o f this article. predictors of work ability are physical demands at the wore­
a Department o f Clinical Sciences Lund, Orthopedics, Lund University, Lund, place ,45 workplace involvement and interventions,4,15,22,3F—
Sweden, b Epidemiology and Register Center South, S kine University Hospital,
income level,47 urban or rural residence 32 psychological
Lund, Sweden, 0 Department o f Research and Development, Region Kronoberg,
Vaxjo, Sweden, d Division o f Occupational and Environmental Medicine, Institute of tors 20 pain and disability levels, educational level and socic
Laboratory Medicine, Lund University, Lund, Sweden, 8 Unit o f Intervention and nomic status, workplace factors ,12,25 health-related quality
Implementation Research for Worker Health, Institute o f Environmental Medicine, life 21 and self-prediction of possible return-to-work .12,31,35
Karolinska institutet, Stockholm, Sweden,' Department o f Health Sciences, Lund
A recent review on interventions with the intention to redi*
University, Lund, Sweden, 9 Blekinge Center o f Competence, Blekinge County
Council, Karlskrona, Sweden, h S kine University Hospital, Sweden sick leave for patients with musculoskeletal pain have show
*Corresponding author. Address: Department o f Research and Development,
evidence for multidomain interventions including workp
Region Kronoberg, Box 1223, 35112 Vaxjo, Sweden. Tel:. +46720 8312978. modifications .16 The SWAP study found that a vocational ad
E-mail address: [Link]@[Link] (C.P. Sennehed). service in primary care was successful in improving work ability*
PAIN 159 (2018) 1456-1464 patients with musculoskeletal pain .54 “Convergence Dialc
Copyright © 2018 The Authorfs). Published by Wolters Kluwer Health, Inc. on behalf Meetings” (CDMs) were developed in Sweden for patients on sc
o f the International Association for the Study o f Pain. This is an open-access article leave due to burnout .29 The CDM model is a 3-step s tru c tir
distributed under the terms of the Creative Commons Attribution-Non Commercial-
interview model where the patient, the health care provider, an
No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and
share the work provided it is properly cited. The work cannot be changed in any way the employer meet for shared discussions on concrete sugg=
or used commercially without permission from the journal. tions and actions to support sustainable work ability and, v,'
[Link] applicable, return-to-work. The CDM model has been shov.'"!

1456 C.P. Sennehed et al. • 159 (2018) 1456-1464

 A * x s t 2018 • Volume 159 • Number 8 [Link] 1457

■ t r o v e return-to-work for patients on long-term sick leave due as possible, based on the criteria above, were matched in pairs.
- 30 burnout.28 The CDM model has so far not been tested for The randomisation process was performed by an independent
osoents with musculoskeletal pain consulting in primary care. statistician who used a computer-generated program (random
Most patients in working age with musculoskeletal pain sample uniform distribution). The primary care rehabilitation units’
~zconsulting physiotherapy in primary care are in early stages of pairs were randomised pairwise to 10 intervention primary care
iness/disease and mostly in work. Traditionally, the treatments in rehabilitation units and 10 reference primary care rehabilitation
r m a r y care have focused on pain reduction and promotion of units (Fig. 1). The primary care rehabilitation units’ staff (including
Ir c rio n . Despite the fact that musculoskeletal pain is a strong physiotherapists) and the patients could for obvious reasons not
•S'. T'actor for disability and w ork loss 5 ,19 ,2 6 ,30,53 primary care has be blinded to allocation. Each included primary care rehabilitation
p o t so far focused on promoting work ability in early stages of unit, and all physiotherapists working at the unit were either an
•■•ess. The aim was to study the effect of an early workplace intervention unit or a reference unit, never mixed.
■p e rve n tio n with CDM on w ork ability for patients with acute/
subacute neck/back pain in ordinary primary care when added to
2.5. Population
jred physiotherapy.
Patients, 18 to 67 years of age, seeking physiotherapy in ordinary
primary care due to acute or subacute (<12 weeks) neck and/or
2. Methods back pain were eligible for inclusion. It could hence be either a first
2.1. Design episode or a recurrent episode of neck and/or back pain after
a period of at least 3 months of no substantial pain. Patients not
conducted a pairwise prospective cluster randomised on sick leave or with no more than 60 days of sick leave and
oiled trial, with inclusion of patients from January 2013
considered at-risk by scoring > 4 0 points at the “OMPSQ-
h December 2014, [Link] ID: NCT02609750. short”37 and who had been working at least 4 consecutive weeks
fee vVorkUp study was approved by the Regional Ethical Review the past year were asked to participate in the study. The cutoff for
erd in Lund Dnr 2012/497 (September 28, 2012), Dnr 2012/
the OMPSQ short is normally set at > 5 0 points, but we decided to
(October 30, 2012), and Dnr 2012/833 (January 9, 2013).
lower this cutoff to & 40 points. The lower cutoff was chosen
because we wanted to include patients at-risk for w ork disability
O utcom e at an early stage and clinically relevant for treatment in primary
care. Exclusion criteria were: full time disability pension, addiction
predefined main confirmatory outcome was w ork ability diagnose, on-going medical treatment of acute disease, preg­
jred as no days of sick leave or disability pension for 4 nancy, and not able to understand the Swedish language. After
utive weeks at 1 year after baseline .23 In this study, having screening, inclusion resulted in 146 intervention patients and 206
ability was defined as working or being eligible to the labor reference patients (Fig. 1).
:et. Thus, we defined work ability as any paid work,
'dless of any adjustments in work duties or of working time.
se this study includes early cases, work adjustments are 2.6. P rocedure
'te d to be few. Patients meeting inclusion criteria were invited consecutively to
participate. No record was kept regarding the number of ineligible
and nonconsenting patients, or the reasons for this. Eligible and
Setting
consenting patients were informed about the study verbally and in
existing public and private primary care centers in Southern writing including the fact whether their primary care rehabilitation
cn (n = 210) that were accredited and tax-financed by the unit was randomised to either intervention or reference. The
1councils in Skane, Kronoberg, and Blekinge were invited patients signed an informed consent. All patients were examined
participate in the study. Within these centers, primary care by a physiotherapist, red flags were considered and all patients
"ts have open access to physiotherapy, and in Swedish answered a baseline questionnaire. Based on needs, contacts
care, physiotherapy is often the first-line treatment for with other professionals could be included, such as doctor,
nts with musculoskeletal pain. Primary care physiotherapy is psychologist, occupational therapist, employee, or staff man­
nised in different ways, some centers have their own ager. Further remittance to these professions was based on
sictherapists, but most have it in common with others at ordinary clinical assessments, such as red and yellow flags. The
’ care rehabilitation units. If the patient is unable to work, treatment was structured (including examination, assessment,
i is a need for a doctor’s certificate from day 8 that confirms diagnosis, evidence-based treatment, and follow-up as a stan­
ciagnosis, the functional limitation, and activity restriction. In dard procedure among physiotherapists in Sweden) and
n, the first 14 days of sick leave are paid by the employer, individualised in terms of content and duration in both groups
sick leave longer than 14 days is economically compensated according to each patient’s condition. Within the framework of
•be Swedish Social Insurance Agency. the study, all participants in both the intervention and the
reference groups were offered visits to the physiotherapist for
follow-up examinations at 3, 6 , and 12 months after baseline
2.4. Random isation
(number not shown). The follow-ups were for monitoring and for
Is total, 32 primary care centers corresponding to 20 primary care measuring function, which will be reported in future articles. The
ilitation units stated an interest in participating in the patients had the opportunity to discuss issues relating to their
'p study. These rehabilitation units were classified based pain and to get advice if needed. Both the intervention and the
size (registered population), community size of the units’ reference group also received a short text message every week
:on, and the patients’ morbidity; Adjusted Clinical during 52 weeks after baseline for follow-up of study outcome.
pSi3,44,52 ancj socioeconomic status; and Care Need The short text messages were for monitoring self-reports on sick
39,4 8 p r jm a r y care rehabilitation units that were as similar leave.
1458 C.P. Sennehed et al. • 159 (2018) 1456-1464 PAIN®

Figure 1. Flowchart of inclusion and follow-up of primary care rehabilitation units. The proportion of patients who reported days on sick leave past
answering the text message.
Tjhn . r t 2018* Volume 159 • Number 8 [Link] 1459

I Baseline a n d follow -up m easurem ents

R f e n t s in both groups answered a baseline questionnaire

^ B a rd in g sex, age, marital status, education, employment,
S k» eave, and health-related quality o f life. Health-related
K e f i y o f life w as measured with the EQ-5D question-
S&ne 41,41 We used the 5-question part of the EQ-5D, where
*acfc question has 3 options from 1 to 3, where 1 corresponds
J R * * health-related quality of life. The answers w ere merged
js o a total score from - 0 . 5 9 to 1, according to the UK tariff,
M e r e 1 corresponds to full health-related quality of life .9,10,17
j I L r r e r patient-reported outcom es and clinician-reported
■jo o c m e s were collected at the different follow -ups, but is to
S e published elsewhere.

IS. Short text m essage

fetjsed a software called SMS-Track Questionnaire to collect data

text message concerning past week’s number of days on
leave.1 Collecting self-reported weekly data using short text
Figure 2. Proportion of text message answers per week after baseline, during
has been used in previous clinical studies and worked 52 weeks, intervention n = 146 and reference n = 206.
* iih high-response rates.1-3,33 It has been shown that patient-
outcomes, directly from patients, can provide more
and specific measurements of treatment effects .40,50 All 2.10. Statistics
and answers were encrypted and stored in a secure Statistical power calculations were based on a significance level
, accessible to the first author through the web, password, of 5% and a power of 80%. To detect a 30% reduction of sick
firewall protected. The patients answered the question "Last leave in the intervention group and a 10% reduction of sick leave
how many days were you on sick leave? Please answer with
r between 0 and 7.” They responded with a number and all
-.•.•ere immediately collected in the database for subsequent
", Reminders were automatically sent to nonresponders after
■days by sending the question a second time. If there was no
to the second message, the database recorded it as
3. In case of missing answers also in the following week, the
was contacted by phone and if the patient could not be
a reminder letter was sent. The flowchart shows the
rate (Figures 1 and 2).

Intervention

=3 D=r!ts in the intervention group were offered CDM by their treating

herapist in addition to the structured physiotherapy care. The
herapist started CDM by inviting the patient to an individual
where the patient gave her/his informed consent of
Tig the employer. In the second step, the employer was
to talk to the physiotherapist, either in person or by phone,
e conversations with the patient and the employer focused on the
k pain in relation to work and on possible or already
•ted workplace adjustments to support retum-to-work or to
at work. Finally, the patient and the employer were invited to
ting together with the physiotherapist. This meeting aimed at
dan of action with a written record of suggested workplace
improvements as well as changes to the patient’s daily life
the aim of strengthening the patient’s work ability and/or
ting retum-to-work (Fig. 3). This agreement was followed up
1the patient met the physiotherapist at follow-up visits at month
5, and 12 after baseline. At the intervention units, all
herapists were educated and trained in the CDM model by
~ced personnel from the research group with background in
-tional health. This training consisted of 2 half-day theoretical
practical sessions. In addition, continuous support was provided
W eek
jth e implementation of the study by the same personnel, who
Figure 3. Self-reported sick leave days per week, collected using weekly text
available by telephone if matters should arise that needed
messages, intervention n = 146, and reference n = 206.
ion.
1460 C.P. Sennehed et al. • 159 (2018) 1456-1464 PAINa

in the reference group and an intraclass range between 0.1 and ratio of w ork ability (no sick leave or disability pension) 4
0.4 ,18 we needed a minimum of 20 clusters/primary care consecutive weeks at 1 year after baseline. The tested in
rehabilitation units. The estimated sample size was slightly more dependent variables were sex, education level (high/low), ana
than 500 patients in total (259 patients per group). health-related quality of life (EQ-5D < /> 0 .6 at baseline). The
Age was categorised into 3 groups (< 39 years, 40-49 years, significance level was P < 0.05.
and > 5 0 years). Marital status was categorised into married/
cohabitation vs single. Education level was categorised into 4
3. Results
groups (primary school, upper secondary school 2-3 years,
university > 3 years, and other). Diagnoses were categorised into The randomisation was successful and at baseline, the in-,
4 groups (cervicobrachial syndrome, cervico and lumbar tervention group and the reference group were largely compa­
syndrome, lumbago-ischias, and myalgia). Employment was rable, ie, no significant differences were seen for any variable. The
categorised as yes or no. The EQ-5D score was categorised into study included 230 women and 122 men, they were equalt,
2 groups < and > 0 .6 , based on previous findings on how health- distributed in the 3 age groups (< 3 9 ,40-49, and > 5 0 years) anc
related quality of life relates to work ability .7,8,21 Sick leave was 76% were married/cohabiting. Approximately half the patients
categorised into yes or no. Descriptive statistics for baseline had secondary education and approximately one-fifth hac
variables were analysed with the x 2 test for proportions. university education. Nearly 70% had lumbar pain and abou
Comparisons were made between the groups over time and 30% neck pain. About 96% reported that they worked (employed j
were analysed at baseline and at 3, 6 ,9 , and 12 months with the n = 313, self-employed n = 12, and students n = 12). The;
X2 test with a significance level P < 0.05. In addition, a strict remaining 4% (n = 15) were at baseline, unemployed. A third
intention-to-treat analysis was performed, patients with missing 35%, were on sick leave at baseline (point prevalence self-rep
data for the confirmatory outcome were allocated outcomes in with a dichotomous answer yes/no) and most of these individuals
accordance with baseline data, in that no sick leave at baseline were on 100% sick leave. Health-related quality of life wa
was assigned as w ork ability at 1 year. Finally, a forward stepwise impaired in both groups (Table 1). The OMSPQ-short mean score
logistic regression analysis was performed to assess the odds at baseline was in the intervention group 52 (SD 9, range 40-81

T a b le 1
Baseline data intervention and reference group.
Intervention (n = 146) Reference (n = 206) P
n % n %
Men 54 37.0 68 33.0 0.426
Women 92 63.0 138 67.0

Age 0.742 ;
=£39 y 50 34.2 73 35.4
40-49 y 45 30.8 56 27.2
>50 y 50 34.2 76 36.9

Marital status* 0.490 3

Married/cohabitation 34 23.3 47 22.8
Single 112 76.7 157 76.2

Education! 0.425
Primary school 16 11.0 14 6.8
69 47.3 107 51.9
University >3 y 28 19.2 49 23.8
Other 33 22.6 35 16.9

Diagnoses 0.812
Cervicobrachial syndrome! 27 18.5 49 23.8
Cervical and lumbar syndrome§ 9 6.2 12 5.8
Lumbago-ischias || 102 69.9 140 68.0
Myalgia^ 8 5.5 5 2.4

Employed! 0.290'
Yes 142 97.2 194 94.6
No 4 2.8 11 5.4

Sick leave# 0.910 ;

Yes 51 34.9 74 35.9
If yes, 100% sick leave 40 78.4 62 83.8

EQ5D grouped# 0.223

>0.6 93 63.7 119 57.8
* Reference-2 missing,
f Reference-1 missing.
JM530, M531, and M542.
# Intervention-2 missing and reference-1 missing.
§ Combination 4 and 5.
|| M543, M544, M545, and M546.
1M791.
B n -st 2018 • Volume 159 • Number 8 [Link] 1461

■ = d in the reference group 54 (SD 9, range 40-83), P = 0.131.

The response rates for the short text messages were high for both
S11S33
Work ability (no sick leave or disability pension) at baseline
B e intervention and the reference groups throughout the follow- and 4 consecutive weeks at 3, 6, 9, and 12 months after
K .ear, 84% to 99% of patients responded weekly (Figs. 1 baseline, intervention = 146, reference n = 206.
Baseline and follow-up Intervention Reference P*
= Days of sick leave decreased in both groups during the follow-
n = work %t n = work %t
3 : a r .9 (Fig. 3). The number of individuals with work ability over 4
ability ability
Xansscutive weeks (no sick leave days) decreased 3 months after
sesame and increased successively thereafter in both groups. At Baselinef 93 65 131 64 0.89
S h e a r follow-up, more patients in the intervention group had 3-mo follow-up§ 75 58 104 59 0.85
W orkability compared with the reference group (108/127,85% vs 95 77 138 77 0.85
p Z ^ - U I , 74%, P = 0.02, crude odds ratio 1.97 confidence
9-mo follow-up§ 96 77 125 74 0.58
fcsrva i [Cl] 1.08-3.57) (Fig. 4 and Table 2). The forward stepwise
keys-ic regression analysis showed that patients in the in- 12-mofollow-up§ 108 85 127 74 0.02
W pe n tio n group reported work ability to a higher extent at 1 year * x2test between intervention and reference,
■Compared with the reference group, also after adjustment for t Proportion in percent with work ability.
$ Baseline point prevalence.
J fc ro ln e health-related quality of life (odds ratio 1.85, Cl 1.01- § No days of sick leave for 4 consecutive weeks.
S 3 S . Data were missing for 54 patients for the main confirmatory
■ajcam e. care in specialised rehabilitation clinics. It is unusual for primary
There were no differences at baseline in any of the studied care to contact the employer at early stages of ill health. Generally,
Basactes between nonresponders (n = 54) and responders (data employer contacts are taken through occupational health
BBC shown). A strict intention-to-treat analysis showed the same services and when actualised in primary, it is usually at later
5 e s x for work ability at 1 -year follow-up (119/146, 82% vs 147/ stages when the patient has a more pronounced morbidity or
jDfc- 72%, P = 0.02). impaired work ability and it might be necessary to change work. If
B Parents with EQ-5D > 0 .6 at baseline were more likely to report physiotherapists in primary care will address workplace issues, it
r p o r . ability at 1 year compared with patients with EQ-5D <0.6, is important that the physiotherapists have sufficient knowledge
p g a ra e s s of which group they belonged to (odds ratio 1.92, Cl in the area of work and worker health and also useful tools to
.40) (Table 3). There were no significant associations manage the questions and initiate actions. It must be emphasized
i sex or education level with w ork ability, and there were that the effect of early workplace dialogue on w ork ability was
[significant interactions between sexes, education level, or shown at the end of the follow-up year. Whether this effect is
h-related quality of life. sustainable in the long term will be analysed in a 3 year follow-up
including also register data on sick leave. The result shows that
employer contact in early phases of musculoskeletal pain may
Discussion
promote work ability at 1-year follow-up. This finding may indicate
found that CDM in addition to structured physiotherapy the importance of employer involvement early in the process. That
! in significantly improved work ability at 1 year compared the effect,on work ability emerges first after 1 year may partly be
i physiotherapy only. This is in line with previous studies that due to the fact that workplace modifications are demanding
’se the importance of workplace interven- processes involving patients/employees, workplace employers,
|« .1 5 .2 2 ,3 6 ,5 1 ,54 j h e e ffe c t 0 f intervention was indepen- other employees, and the social insurance system. Therefore,
c* health-related quality of life. such interventions may take some time to be implemented.
2 primary care model with “open access" to physiotherapy, The WorkUp research project tested whether it was possible
with musculoskeletal pain are guided directly to for physiotherapists in primary care to be the point of contact with
srapists, as a first-line treatment. The patients in primary the employer and if this was a successful method to initiate
thus often meet the physiotherapist at an early stage of the a dialogue about adjustments at the workplace to strengthen the
keletal pain problems contrary to physiotherapeutic employee’s work ability or return-to-work. Our results showed
that CDM can be used for patients with musculoskeletal pain in
primary care as previously tested only in patients with burnout.28
In WorkUp, the method was modified and unimodal, in that 1
profession, the physiotherapist, was responsible for assessment,
treatment, and the structured CDM model. However, several
physiotherapists were performing the intervention, which is
a strength. We considered involving other professions in the
study, but the patients were in early stages of back/neck pain,
working, or on short-term sick leave. At such early stages,
engagement of more team members in primary care might give
the patient indications that the problems are extensive and may
therefore contribute to nocebo effects or medicalizations. In­
volvement of several professions might also have resulted in
prolonging the time for treatment to start, which may be a risk
factor for the development of long-term problems. To stratify care
4. Proportion with work ability (no sick leave days) at baseline and 4 based on baseline, screening has shown positive effects on
! weeks month 3 (week 9-12), month 6 (week 23-26), month 9 disability and is cost-effective .24 Carlsson et al.14 reported that
-39), and month 12 (week 49-52) after baseline, intervention n = 146,
n = 206. BL, baseline.
early multidisciplinary assessment for patients with short sick
leave resulted in increased sick leave compared with a reference
1462 C.P. Sennehed et al. • 159 (2018) 1456-1464 PAIN®

T a b le 3 Agency are usually used when studying sick leave in Sweden, but
Result of logistic regression analysis. this is a rough measure since short-term sick leave is not
included.
Model* OR 95% Cl for OR P
In this study, we used frequent weekly self-reports during 1
Lower Upper
year which therefore covered all sick leaves, also the occasional
Step 1 days. Data retrieval using mobile phones/sm art phones is
Reference 1 a technology with new opportunities to retrieve frequent
CDM intervention 1847 1011 3376 0.046
responses from respondents in research. The technology is
EQ-5Df <0.6 1
cheap, takes a minimum of time, and involves minimal data
EQ-5D >0.6 1921 1086 3398 0.025
handling. The use of short text messages has previously been
Variables tested for, but not meeting the inclusion criteria, were sex and education level.
Odds ratio for having work ability 1 year after baseline. tested and reported to be reliable when collecting weekly data in
* Forward stepwise logistic regression with P < 0.05 as inclusion and P > 0.1 as removal criterion, long-term follow -ups .1-3 The method is recommended when
t Health-related quality of life.
studying conditions where individual variation, details
CDM, Convergence Dialogue Meeting; Cl, confidence interval; OR, odds ratio.
fluctuation, or periodicity are wanted. This study confirms that
this was a successful method of collecting data on short-term,
group, w hich strengthened our decision of the unimodai sick leave over 1-year follow-up, as it resulted in high-response
W orkUp design. In cases where patients’ needs increased rates for both the intervention and the reference groups. Th’
during treatm ent, there were no obstacles to interact with was a methodological achievement and contribution of this trial.
multimodal interventions or to contact occupational health There was as small proportion of patients who had trouble in
care or other specialised care. In the recent review of Cullen managing smart phones or had poor mobile connection. These
et al .,16 a multidomain treatm ent approach is considered as individuals were offered to respond by letter or by em
having the best evidence for reducing tim e off work. According alternatively they were called weekly during the follow-
to the results of our study, inclusion of workplace intervention period. Their answers were then manually entered in
is im portant. We included a w orkplace intervention in database. This alternative data collection was needed for i -
physiotherapy practice, and this w as found beneficial for patients. Six patients responded by letter, 4 through ph
patients with neck an d /o r back pain fo r return-to-w ork or calls, and 5 responded by email. The high-response rate dun
staying at w ork after 1 year. It is conceivable fo r interventions the follow -up was the result of the simplicity of the method
like this to take some tim e to show effect, probably because some flexibility to offer alternative solutions to receive w~
new routines at the w orkplace take some tim e to be fully responses.
operational. The final logistic regression analyses regarding w ork a
were based on the past 4 weeks of text message answers 1 y
after baseline. There were some missing data for the confirmat*
4.1. M etho d o lo g ical discussion
outcome collected by short text messages. We perfon
Few drop-outs over the follow-up indicate that the study was well analyses on the patients reporting 1-year outcome, and
designed and well implemented within the participating primary addition, we performed a strict intention-to-treat analysis
care rehabilitation units. Providing physiotherapy for both groups eluding all patients. The results were similar strengthening
limited treatment bias and strengthens the clinical results of the validity of our study.
trial. It was a new challenge for the physiotherapists to have To help patients to maintain work ability or support patients
contact with employers to discuss patients’ needs for workplace return-to-work, actions directed towards both the individual;
action .46 However, the implementation of CDM worked well at the the working conditions are usually needed. Most pre
majority of units with minor exceptions. In cluster trials, a potential rehabilitation studies focus on patients with chronic neck
problem is selection bias if inclusion is systematically different in or back pain and return-to-work after sick leave.42 In the W
intervention and control arms. A weakness of this study is that no study, we focused interventions for patients with acute
record was kept regarding eligible but nonconsenting patients, subacute neck and/or back pain active on the labor ma
thus hindering an evaluation of such bias. However, the high Our results showed that adding the CDM intervention
baseline comparability of the groups argues against any sub­ structured physiotherapy care was a successful interventic*-
stantial selection bias. ensure work ability at 1-year follow-up. In parallel, an ec
The population of southern Sweden, where the study was evaluation of the WorkUp study is under way. Patients’, e
conducted, represents approximately 20% of the Swedish ers’ , and physiotherapists’ experiences of early co
population, and the characteristics of people living in the region between health care professionals and the workplace n
are comparable with Sweden as a whole .43 The primary care be further explored. Within the WorkUp trial, these questi
rehabilitation units had good geographical spread with localiza­ be addressed.
tion in both smaller and larger communities as well as private and
public modes of operation. The interventions were performed
5. Conclusions
within the framework of regular clinical activities further strength­
ening the generalizability of results. The intended power for the An early dialogue with the employer in addition to physio"
study was not achieved, although the recruitment period was significantly improved work ability in comparison with str
prolonged by 1 year. Despite this, significant results with higher physiotherapy only.
w ork ability at 1 year after the CDM intervention were observed.
This indicates an even higher potential for treatment effect than
Conflict of interest statem ent
anticipated.
In Sweden, sick leave longer than 14 days is economically The authors have no conflict of interest to declare.
compensated by the Swedish Social Insurance Agency. The first This article presents independent research funded by
14 days are paid by the employer. Data from Social Insurance Scientific Committee of Region Kronoberg,” Sweden
Utogust 2018 • Volume 159 • Number 8 [Link] 1463

i^EHSAM project, Sweden, and the county councils in Skane, term sick leave: a systematic review of the effectiveness and cost-
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