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Keywords:

  • Work disability;
  • Musculoskeletal disorders;
  • Intervention program

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. REFERENCES

Objective

To evaluate how an intervention program modifies the clinical course of work disability in musculoskeletal diagnoses.

Methods

All patients with temporary work disability related to musculoskeletal disorders (MSDs) in 3 health districts of Madrid, Spain were randomized into standard care (control group) or the intervention group. Intervention consisted of a specific program, run by rheumatologists, following detailed proceedings. Inclusion and followup lasted 12 months each. According to the cause, every temporary work disability episode was classified into 11 syndrome categories. For each we calculated efficacy, as the difference between groups in the number of days on sick leave per temporary work disability episode; relative efficacy, or the percentage of days saved in the intervention group; and time of maximum program effect. Analyses were performed on an intent-to-treat basis. Survival techniques were run and results were expressed as the hazard ratio (HR) in the intervention versus control group.

Results

A total of 13,077 patients were included, generating 16,297 temporary work disability episodes. The most frequent cause was back pain. Temporary work disability episodes were significantly shorter in the intervention group than in the controls in all syndrome categories except knee pain (excluding osteoarthritis). Program relative efficacy varied from 28–72%. The program was highly efficacious in carpal tunnel syndrome (HR 2.09, 95% confidence interval [95% CI] 1.17–3.75), peripheral osteoarthritis (HR 1.58, 95% CI 1.14–2.19), and inflammatory diseases (HR 1.52, 95% CI 1.09–2.12). The maximum effect of the program always took place within the first 2 months.

Conclusion

The implementation of this type of specialist-run, protocol-based early intervention program would be very beneficial in the treatment of patients with work disability related to MSDs, except for those with knee pain (excluding osteoarthritis).


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. REFERENCES

Musculoskeletal disorders (MSDs) have a large impact on the population in terms of high prevalence, morbidity, and disability potential (1, 2). MSDs in the workplace have a huge impact, emerging as a growing problem in our modern societies (3); they represent the second largest cause of short-term or temporary work disability after the common cold (4). In Spain, temporary work disability related to MSDs accounts for 20% of sick leave days (5).

Six years ago, our research group launched an early community-based intervention program offered to workers with temporary work disability related to MSDs. This clinical program was carried out by trained rheumatologists and included disease-specific educational, clinical, and administrative proceedings. We compared the efficacy and costs of such care programs with the standard health care. Global results of the program have been published elsewhere (6) and can be summarized as follows: 13,077 patients from 3 health districts in Madrid, Spain were included in the study, 7,805 in the control group and 5,272 in the intervention group, generating 16,297 episodes of MSD-related temporary work disability. These episodes were shorter in the intervention group than in the control group (mean of 26 days compared with 41 days; P < 0.001), and the groups had similar numbers of episodes per patient. Fewer patients received long-term disability compensation in the intervention group than in the control group (0.7% versus 1.3%; P < 0.005). Direct and indirect costs were lower in the intervention group than in the control group, with savings ranging from 58–88%. To save 1 day of temporary work disability, $6.00 had to be invested in the program. Each dollar invested generated a benefit of $11.00 and the program's net benefit was in excess of $5 million. Therefore, implementation of the program offered to the general population improves short- and long-term work disability outcomes and is cost effective.

The purpose of the present analysis is to determine how our intervention program influenced the course of work disability in specific clinical entities. This information can be critical both to determine which actions could be implemented in the standard care system and to help clinicians in the management of these particular conditions.

PATIENTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. REFERENCES

Study design.

This study has been described in detail elsewhere (6). In brief, it was a prospective randomized controlled study, unblinded for both patients and physicians, of an intervention offered to the general population of workers. The study protocol was approved by the Institutional Review Board of the Hospital Clínico San Carlos and was reviewed by the Fondo de Investigaciones Sanitarias (the research agency of the Ministry of Health).

Scenario.

In Spain, all workers who require a sick leave are given a temporary work disability initiation form, which entitles them to receive compensation payments from the Ministry of Work. Temporary work disability forms are started and renewed weekly by the primary care physicians until the worker recovers.

Patients.

A total of 98% of the 5.5 million inhabitants of Madrid, Spain receive health coverage from the Instituto Madrileño de Salud. Care is organized in 11 health districts, with direct access to primary care physicians. Health districts 4, 7, and 9 were selected from Madrid, with a total population of 1,402,285, of whom 35% were active workers (7). All workers from these 3 health districts who began sick leave with a diagnosis of an MSD during the study period (1998–2001) were included. Sick leave episodes secondary to trauma, surgery, or work accidents were excluded.

Randomization.

Every week, patients fulfilling the inclusion criteria were randomized into the control group, in which patients received the standard care, and the intervention group, in which patients were offered our specific care program. Group assignments were done randomly with intervention: control ratios of 1:1 in district 7 and 2:3 in districts 4 and 9. This was done so that similar numbers of patients would be seen by the rheumatologists in all areas. The ratios were based on the number of episodes of MSD-related temporary work disability registered in previous years.

Inclusion and randomization of patients took place during the first year of the study in each district, and followup was prolonged for another full year. Patients maintained their group assignments in the successive episodes of MSD-related temporary work disability during followup.

Care in the intervention group.

A secretary contacted all patients assigned to the intervention group after the initiation form was issued, offering them an appointment in the program. Patients who voluntarily decided to enter the program were attended by 2 trained rheumatologists in each health district, who were working full time for the program. The rheumatologists acted as principal care providers in regular visits. The visits were structured following specific proceedings for the different diagnoses based on previously demonstrated approaches (8–12). Such proceedings included education (13–18), pharmacologic and nonpharmacologic treatment (19), and timing of diagnostic tests in a stepwise manner (see Table 1). The program also incorporated administrative duties such as the prescription of medication and the filling out of the corresponding temporary work disability forms by the patients. Patients were seen as often as necessary until the episode of temporary work disability was resolved or recovery was deemed unrealistic. Patients who were assigned to the intervention group but were unable or unwilling to participate, were already working, or could not be located were considered to be assigned to the intervention group throughout the study for statistical purposes.

Table 1. Clinical proceedings of the intervention program: stepwise scheme for diagnostic and therapeutic procedures*
  • *

    CT = computed tomography; MRI = magnetic resonance imaging; EMG = electromyogram.

  • Age >50 years for axial pain, previous trauma, cancer, serious medical illness, fever, weight loss, inflammatory pain, night pain, drug abuse, corticosteroid use, progressive deteriorating function, or neurologic deterioration. The presence of 1 red flag precluded the use of the level system, the patient being managed according to individual clinical criteria, to exclude serious illness.

  • Psychiatric illness, family and social or professional conflicts, unemployment, or occupational etiologies. The presence of any 1 yellow flag warranted a conservative approach to the more aggressive therapeutic procedures.

Level 1
 Diagnosis based on clinical criteria: look for red flags
 Pharmacologic treatment of pain, inflammation, anxiety,   and depression
 Peripheral intra- and periarticular injections
 Education:
  Explanation of their specific diagnosis
  Insistence that a serious disease was not present
  Instructions on self-management
   Avoidance of bed rest, promotion of early    mobilization
   Training for stretching/strengthening exercises
   Teaching ergonomic care
   Delivery of booklets for the different diagnosis
   Indication of optimal levels of physical activity
  Instructions on how to take medications
  Indications for early return to work before a complete    symptom remission
Level 2 (no improvement after 2–6 weeks on level 1)
 Maintenance of the therapy plus referral for formal   rehabilitation
 Look for red and yellow flags, carry out laboratory   tests, radiographs, CT/MRI, and EMG
Level 3 (no improvement after 4–8 weeks on level 2)
 Further diagnostic procedures, look for red and yellow   flags
 Referral for surgical advice or other specialized care

Care in the control group.

Standard care was that provided by the primary care physicians, with weekly administrative duties plus basic diagnostic and therapeutic procedures without prespecified protocols. Primary care physicians could send the patients to specialized care at any time.

Measurements and variables.

Case definition.

Every temporary work disability episode was assigned a diagnostic code (by the International Classification of Diseases, Ninth Revision [ICD-9] coding system) according to the cause reported by the primary care physician in the temporary work disability form prior to randomization. We grouped the ICD-9 codes into 11 syndrome categories based on clinical management and localization of the MSD: neck pain; back pain, including low back pain and thoracic back pain; sciatica, including discopathies and sciatica; muscular pain, including contractures, joint pain without arthritis, fibromyalgia, and other noninflammatory muscle disorders; peripheral osteoarthritis; tendinitis, which included tendinitis/bursitis, peripheral sprains, tenosynovitis, and ganglions; inflammatory diseases, such as rheumatoid arthritis, spondylarthropathies, systemic lupus erythematosus, and vasculitis; microcrystalline and undifferentiated arthritis; knee pain (excluding osteoarthritis); carpal tunnel syndrome; and other, which comprised avascular necrosis, osteoporosis, other neuropathies, complex regional pain syndromes, infections, fractures, tumors, Paget's bone disease, or osteomalacia.

Efficacy was defined as the difference between the intervention group and the control group in the number of days on sick leave per temporary work disability episode, and was determined for each syndrome category. We expressed the efficacy in terms of 1) differences in mean and median duration of temporary work disability episode; 2) total number of days of temporary work disability per 1,000 patients; 3) days saved per patient, calculated as (mean duration in control group) − (mean duration in intervention group); 4) relative efficacy expressed as the percentage of days of sick leave saved per episode in the intervention group; 5) total number of days saved in the intervention group obtained by multiplying the total number of episodes in the intervention group by the days saved per patient; and 6) relative rate of return to work.

The effect of the program over time was calculated as the daily differences in the percentage of return to work between groups ([percentage of return to work in intervention group] − [percentage of return to work in control group] each day). We also obtained the time of maximum effect of the program, defined as the period of time where the difference in the percentage of return to work between the intervention group and control group was maximal. The specific health district, age at the beginning of a temporary work disability episode, sex, and employment status (general worker, self-employed, or house cleaners) were included as secondary and confounding variables.

Statistical analysis.

All randomized patients were followed up and their data were analyzed on an intent-to-treat basis. Differences between groups regarding baseline characteristics were tested by Student's t-test and contingency tables. In each syndrome category, the differences in duration of temporary work disability episodes were tested by survival techniques (log rank test). Kaplan-Meier curves were calculated to account for the correlation in temporary work disability duration of patients (multiple-failure data). Smooth bivariate curves were used to demonstrate the period of maximum effect of the program. Cox regression analyses were performed to adjust for confounding variables. In Cox models, the dependent variable was the number of days off work, and the results were expressed as the hazard ratio (HR, or relative rate to return to work) in the intervention group versus the control group. Analyses were performed with Stata 7.0 (StataCorp, College Station, TX). For all comparisons, a 2-tailed P value lower than 0.01 was considered to indicate statistical significance.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. REFERENCES

Characteristics of the study population.

The flow of the study has been described elsewhere (6). Briefly, a total of 13,077 patients were included, and they generated 16,297 temporary work disability episodes related to MSDs during the 2 years of the study. A total of 7,805 patients were allocated to the control group and 5,272 patients were invited to participate in the intervention group, of whom 3,311 (62.8%) attended the program.

The frequency and baseline characteristics of patients by diagnostic category are shown in Table 2. Back pain (including 90% of patients with low back pain and 10% of patients with thoracic back pain), tendinitis (tendinitis/bursitis in 46%, peripheral sprains in 36%, tenosynovitis in 14%, and ganglions in 4%), and sciatica (92% with sciatica and 8% with discopathies) were the leading causes of temporary work disability in the total population. As expected, sociodemographic characteristics varied among diagnostic categories. We observed that the rate of some pathologies such as peripheral osteoarthritis and microcrystalline and undifferentiated arthritis increased with age (0.41%, 1.16%, and 4.26% in patients ages <30 years, 30–50 years, and >50 years, respectively, in the case of peripheral osteoarthritis and 2.6%, 7.2%, and 8.1% in patients ages <30 years, 30–50 years, and >50 years, respectively, in the case of microcrystalline and undifferentiated arthritis). However, tendinitis decreased progressively with increasing age (38% of patients <25 years of age, 27% of patients 25–34 years, 23% of patients 35–44 years, 21% of patients 45–54 years, and 18% in patients 55–64 years). When we looked at sex, patients with neck pain and carpal tunnel syndrome were more frequently women, while microcrystalline and undifferentiated arthritis was more common in men.

Table 2. Baseline characteristics of the study groups*
 Total episodesWomenSelf-employedAge, mean
CGIGCGIGCGIGCGIG
  • *

    Values are the percentage unless otherwise indicated. CG = control group; IG = intervention group; n = number of episodes.

  • P < 0.01.

  • Includes 799 (58%) contractures, 505 (37%) joint pain without arthritis, 64 (5%) fibromyalgia, and 8 (0.7%) other muscle disorders.

  • §

    Includes 169 (65%) hands, 43 (18.5%) knees, 36 (14%) not specified, 5 (2%) foot, and 1 (0.5%) hip.

  • Includes 77 (41%) rheumatoid arthritis, 71 (38%) spondylarthritis, 21 (11%) systemic lupus erythematosus, and 18 (9%) vasculitis.

  • #

    Includes 16 (32%) avascular necrosis, 13 (26%) osteoporosis, 7 (14%) other neuropathies, 5 (10%) Sudeck's disease, 2 (4%) joint infections, 2 (4%) bone fractures, 1 (2%) tumors, 1 (2%) Paget's disease, and 1 (2%) osteomalacia.

Back pain (n = 5,441)32.934.047.046.04.13.640.840.6
Tendinitis (n = 3,408)21.320.347.647.26.25.237.838.2
Sciatica (n = 2,579)16.514.752.453.65.64.941.842.1
Neck pain (n = 1,605)9.310.667.267.12.73.738.137.4
Muscular pain (n = 1,376)8.38.650.654.74.52.138.539.2
Microcrystalline + undifferentiated arthritis (n = 1,050)5.97.121.218.24.05.146.145.5
Peripheral osteoarthritis (n = 258)§1.81.349.745.810.411.754.853.1
Inflammatory diseases (n = 187)1.11.247.660.27.66.044.543.6
Knee pain (not osteoarthritis) (n = 142)1.00.645.943.29.24.539.137.3
Carpal tunnel syndrome (n = 74)0.440.4772.177.49.36.444.439.6
Other (n = 50)#0.370.236.128.58.37.143.940.3

There was a discrete imbalance between the intervention and control groups regarding the distribution of patients under the various syndrome categories (Table 2). Both groups were otherwise comparable with regard to sociodemographic characteristics, but there was a lower percentage of self-employed patients under the muscular pain category in the intervention group.

Efficacy of the program.

In both groups, the duration of temporary work disability episodes varied among the different syndrome categories (Table 3). As a whole, episodes due to peripheral osteoarthritis and inflammatory diseases (median [25th–75th percentile] 32 [11–112] and 25 [11–76], respectively) were longer than episodes in other categories. Alternatively, episodes due to microcrystalline and undifferentiated arthritis were the shortest in duration (median [25th–75th percentile] 10 [5–18]).

Table 3. Duration of temporary work disability (TWD) episode by diagnosis*
 Mean duration of episodes (days)Median (25th–75th percentile) duration of episodes (days)Total number of TWD days per 1,000 patients
GlobalCGIGGlobalCGIGCGIG
  • *

    CG = control group; IG = intervention group; n = number of episodes.

  • P < 0.001 by Student's t-test.

  • P < 0.001 by log rank test.

Back pain (n = 5,441)29.034.521.311 (5–22)11 (6–25)10 (5–19)14,0569,154
Tendinitis (n = 3,408)31.536.723.514 (8–26)15 (8–31)12 (7–22)9,6686,030
Sciatica (n = 2,579)46.151.637.118 (8–43)18 (8–50)16 (8–36)10,5716,891
Neck pain (n = 1,605)30.537.421.911 (5–25)12 (5–31)11 (5–21)4,3002,936
Muscular pain (n = 1,376)35.142.924.210 (5–25)11 (5–30)9 (4–21)4,3982,645
Microcrystalline + undifferentiated arthritis (n = 1,050)24.629.718.410 (5–18)10 (5–23)9 (5–15)2,1971,653
Peripheral osteoarthritis (n = 258)89.3104.358.830 (11–96)40 (13–138)17 (10–36)1,285948
Inflammatory diseases (n = 187)73.889.554.125 (11–76)41 (15–109)18 (8–61)1,192852
Knee pain (not osteoarthritis) (n = 142)61.964.256.925 (11–64)26 (13–68)24 (8–39)806474
Carpal tunnel syndrome (n = 74)70.0100.427.825.5 (10–74)48 (15–150)15 (8–27)553164

Temporary work disability episodes were significantly shorter in the intervention group compared with the control group in all syndrome categories except for knee pain (excluding osteoarthritis) (Table 3). The greatest difference between groups was observed for carpal tunnel syndrome, in which the median duration was 3 times greater in the control group than in the intervention group.

The total number of days of temporary work disability per 1,000 patients in each syndrome category is also shown in Table 3. This parameter largely depended on the prevalence of the illness; therefore back pain had the greatest number of days in both groups. Related to differences between groups, all diagnostic categories had a lower number of total days of temporary work disability per 1,000 patients in the intervention group than in the control group.

The relative efficacy of the program varied from 28–72%, depending on the diagnosis (Table 4). In the Cox models, after adjusting for sociodemographic variables to account for differences at baseline, all syndrome categories showed a higher rate of return to work in the intervention group compared with the control group, except for knee pain (excluding osteoarthritis), for which the difference between groups did not reach statistical significance. The greatest level of efficacy was observed in carpal tunnel syndrome, peripheral osteoarthritis, and inflammatory diseases, with a high level of efficacy in muscular pain, neck pain, and microcrystalline and undifferentiated arthritis. Efficacy was moderate in tendinitis, back pain, and sciatica, whereas the lowest level was observed in knee pain (excluding osteoarthritis).

Table 4. Temporary work disability (TWD): short-term efficacy of the program by diagnosis*
 No. TWD days savedNo. TWD days saved per patientRelative efficacyRelative rate to RTW (95% CI)
  • *

    RTW = return to work; 95% CI = 95% confidence interval.

  • The percentage of sick leave days saved per episode by the program.

  • Adjusted for sex, age, contractual form, and district.

  • §

    P < 0.001.

Back pain29,87213.238.21.36 (1.28–1.44)§
Tendinitis17,90013.236.01.37 (1.27–1.48)
Sciatica14,14614.428.01.28 (1.18–1.40)§
Neck pain11,01715.541.61.49 (1.33–1.66)§
Muscular pain10,77718.743.61.49 (1.33–1.68)§
Microcrystalline + undifferentiated arthritis5,34511.338.01.44 (1.26–1.65)§
Peripheral osteoarthritis3,86345.443.61.58 (1.14–2.19)§
Inflammatory diseases2,93535.439.51.52 (1.09–2.12)§
Knee pain (not osteoarthritis)3237.311.21.33 (0.84–2.08)
Carpal tunnel syndrome2,24772.572.22.09 (1.17–3.75)§

We also attempted to analyze differences among the intervention and control groups in some specific diagnoses such as rheumatoid arthritis or fibromyalgia that were categorized within wider diagnostic categories (see Table 2 footnote). Although differences existed in the mean duration of temporary work disability episodes in both conditions (56.3 days versus 127 days in the intervention and control groups, respectively, for rheumatoid arthritis and 53 days versus 69 days in the intervention and control groups, respectively, for fibromyalgia), the relative rate of return to work was not statistically different between groups (HR 1.98, 95% confidence interval [95% CI] 0.99–3.91, P = 0.05 for rheumatoid arthritis and HR 1.58, 95% CI 0.72–3.45, P = 0.2 for fibromyalgia). Inability to reveal statistical differences in these subgroups might be related to the small number of patients included within these specific conditions (77 with rheumatoid arthritis and 54 with fibromyalgia).

The clinical course of disability in both groups by diagnostic category is shown in Figure 1. Most patients returned to work within the first 2 months. The survival curves were markedly different between the intervention and control groups in each syndrome category, with all log rank test P values less than 0.001, except for knee pain (excluding osteoarthritis) (Figure 1).

thumbnail image

Figure 1. Failure curves showing the rate of return to work over time, by study group, in every syndrome category. X-axis: days taken to return to work.

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The maximum effect of the program.

The effect of the program over time is highlighted in Figure 2 for each diagnostic category. The greatest effect of the program was obtained in carpal tunnel syndrome.

thumbnail image

Figure 2. Effect of the program during a 1-year period. All relevant syndrome categories are shown, excluding knee pain. NP = neck pain; BP = back pain; Sci = sciatica; MP = muscular pain; POA = peripheral osteoarthritis; Ten = tendinitis; ID = inflammatory diseases; MA = microcrystalline and undifferentiated arthritis; CTS = carpal tunnel syndrome.

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We would like to point out that the effect of the program varies over time. In each syndrome category, these differences appeared from the first days of temporary work disability episode, and rapidly increased until they reached the highest difference or the maximum effect of the program. This period always occurred before the first 2 months and depended on the mean duration of the temporary work disability episodes. For example, for microcrystalline and undifferentiated arthritis, the maximum difference was reached on day 15; for back pain, the maximum difference was reached on day 25; and for pathologies with higher mean durations such as peripheral osteoarthritis, the maximum difference was obtained after the first month. After the moment of maximum effect of the program the differences decreased progressively, and they were minimal after the sixth month, except for carpal tunnel syndrome, peripheral osteoarthritis, and inflammatory diseases.

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. REFERENCES

The results demonstrate that our specific care program improves the clinical course of work disability in nonselected patients with almost any MSD diagnosis. We have also demonstrated that the grade of effectiveness varies among clinical entities. This information would be useful in the daily clinical treatment of individual patients with these conditions.

Patients in the study well represented the general population of workers with MSDs. They were middle-aged men or women, and back pain was the most prevalent entity (20, 21). Epidemiologically, workers with MSD do not differ much from other patients in the same age range treated for MSD. In this sense, the various syndrome categories had their own expected sociodemographic profile (22): peripheral osteoarthritis and microcrystalline and undifferentiated arthritis were age-dependent diseases whereas tendinitis was more frequent among the young patients, and carpal tunnel syndrome was more frequent among women whereas microcrystalline arthritis was more frequent in men. Despite the occupational, social, or administrative roll of work disability, these patients have a clinical problem that has a large impact on their lives, and it is mandatory to control these problems properly in daily clinical practice.

As physicians usually perceive, the duration of temporary work disability episodes varied in the different MSDs. Episodes due to peripheral osteoarthritis and inflammatory diseases were the longest, followed by knee pain and sciatica. Alternatively, the shortest duration of temporary work disability episodes was for patients with microcrystalline and undifferentiated arthritis. Eventually, this detailed information could facilitate the treatment of individual patients with MSDs.

Our program achieved a significant reduction in the total days of temporary work disability for patients in all disease categories, except knee pain (excluding osteoarthritis), as compared with patients included in the control group. Several factors might explain the success of this program. First, we considered work disability as an indicator of health status and quality of life (23–25), thereby implying the need for particular clinical and therapeutic procedures (Table 1) for each diagnosis. The program integrated different actions and treatments that have already been tested and have been proven to be beneficial in the management of MSDs. Second, special efforts were made to include education as a principal aspect of care. Patients needed to understand their episode, and they learned how to improve progressively with specific instructions in self-management or in the use of medications. Finally, rheumatologists became the primary care physician during the temporary work disability episode, with specific duties well beyond the traditional role of specialized care. This allowed the integration, early in the disability process, of expert clinical management, education, promotion of self-care, and administrative aspects into a 1-step scheme, avoiding the inherent inefficiencies of multiple health care providers. All of these factors supported the full implementation of the program and patients benefited from a decrease in the number of visits, therapeutic procedures, and waiting lists.

The efficacy of this program was at least as great as the most successful interventions for specific MSDs (26–33). Carpal tunnel syndrome was the diagnosis in which the program obtained the greatest efficacy, probably as a consequence of the use of night splints and seriated steroid injections per protocol. In the short term, these latter have been shown to produce dramatic relief of symptoms (34).

The program was also clearly effective in managing inflammatory diseases, such as rheumatoid arthritis. It should be noted that the diseases of patients with inflammatory arthropathies included in the so-called standard care or control group were usually already under control by rheumatologists outside this program, which could have decreased differences between groups in inflammatory conditions. Key aspects of early return to work in inflammatory diseases, such as rheumatoid arthritis, included patient education and early control of flares by means of adding low doses of corticosteroids, full-dose nonsteroidal antiinflammatory drugs, joint injections, analgesics, and early adjustment of disease-modifying antirheumatic drugs. Most recent studies have demonstrated the benefits of education and early treatment in reducing disability (35, 36).

The third diagnostic category in which the program was highly efficacious was peripheral osteoarthritis. Basically, patients with this condition were treated symptomatically as well as with early regular joint injections in the case of knee or thumb base osteoarthritis. The promotion of exercise and physical activity and the importance of reducing obesity were also mandatory for primary and secondary prevention (37, 38).

Patients with other high-impact conditions such as back pain also benefited from the program. We emphasized the importance of primary and secondary prevention due to the frequency of this condition (21) and the possibility of relapses in active workers (39–41). Simple educational interventions, which specifically address beliefs and attitudes, might reduce future work loss due to back pain (26, 42). Patients learned the importance of trying to continue ordinary activities of daily living as normally as possible despite the pain, and to obtain faster symptomatic recovery for acute symptoms (40). Patients were carefully trained for the management of medications, analgesic and ergonomic positions, and the performance of specific exercises, and were encouraged to start walking as soon as possible for at least half an hour each day (8–10). Finally, we suggested the performance of regular exercise owing to its preventive effect in the incidence of low back disability (43).

The program, however, did not obtain such successful results for other conditions. Patients with knee pain (excluding osteoarthritis) did not specifically benefit from the program intervention, probably as a consequence of the need for arthroscopic surgery, which required a longer waiting time and the intervention of other specialists rather than referral to rheumatologists. In contrast, in the “other” category, which included miscellaneous conditions such as avascular necrosis, osteoporosis, Sudeck's disease, joint infections, bone fractures, tumors, Paget's bone disease, and osteomalacia, we were not able to draw any conclusions about the efficacy of the program. The efficacy results of these conditions collectively had no clinical relevance because of their heterogeneity, low incidence, and different natural course, and we could not analyze them separately, due to the small sample in each diagnosis.

This study also demonstrated the period in each syndrome category where the program is able to modify the course of disability in patients with recent-onset work disability related to MSDs. The maximum effect always occurred before the first 2 months of followup. From this point onward, the effect of the program progressively decreased until the sixth month. At this point the differences were minimal, except for carpal tunnel syndrome, peripheral osteoarthritis, and inflammatory diseases, reflecting the utility of this program in these diagnoses beyond the time where others would consider intervention unrealistic. The period of maximum effect, which occurs early in the disability episode, could be considered the window of opportunity for each syndrome category. Losing this window of opportunity might lead, at least in some cases, to a complex interaction between physical, emotional, and social factors that result in long-lasting temporary work disability or permanent work disability.

In conclusion, we have demonstrated that a program based on simple clinical protocols, in our case run by rheumatologists, is highly effective in reducing the burden of MSDs in the working population, and that such intervention is dramatically effective in specific diagnoses within the first 2 months of disability. Our findings suggest that implementing this type of specialist-run, protocol-based early intervention program would be very beneficial in the treatment of most patients with work disability related to MSDs, except for those with knee pain who would need different approaches.

This program was targeted at the active working population. Similar programs could be useful for other persons in the population with recent disability due to MSD, such as housewives, or individuals who have retired. Almost certainly the socioeconomic impact of MSDs could also be reduced, although further studies would be necessary.

AUTHOR CONTRIBUTIONS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. REFERENCES

Dr. Jover had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study design. Hernández-García, Jover.

Acquisition of data. Abásolo, Lajas, Blanco, Candelas.

Analysis and interpretation of data. Abásolo, Carmona, Hernández-García, Lajas, Loza, Fernández-Gutiérrez, Jover.

Manuscript preparation. Abásolo, Carmona, Hernández-García, Lajas, Blanco, Candelas, Jover.

Statistical analysis. Abásolo, Carmona.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. REFERENCES
  • 1
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