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Multidisciplinary or brief intervention in the low back clinic to sustain return to work?
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August 2013
Multidisciplinary or brief intervention in the low back clinic to sustain return to work?
Study Type:Therapy
OE Level Evidence:2
Journal Level of Evidence:N/A
Sustainability of return to work in sick-listed employees with low-back pain. Two-year follow-up in a randomized clinical trial comparing multidisciplinary and brief intervention
BMC Musculoskelet Disord. 2012 Aug 25;13:156. doi: 10.1186/1471-2474-13-156.Did you know you're eligible to earn 0.5 CME credits for reading this report? Click Here
Synopsis
351 patients on sick leave for 3 to 16 weeks due to low back pain were randomized to receive a brief hospital-based intervention or a multidisciplinary intervention. The results of the study indicate that the patients that underwent a brief hospital-based intervention required significantly fewer sick leave weeks than the patients that underwent the multidisciplinary intervention during the first year follow-up. The difference became insignificant by the second year follow-up. Work related autonomy and security modified the effects of the interventions on return to work rates. No significant differences in return to work rates, return to work status, and sick leave relapse were found.
Publication Funding Details
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Funding:
Non-Industry funded
Sponsor:
The Danish Working Environment Research Fund
Conflicts:
None disclosed
Was the allocation sequence adequately generated?
Was allocation adequately concealed?
Blinding Treatment Providers: Was knowledge of the allocated interventions adequately prevented?
Blinding Outcome Assessors: Was knowledge of the allocated interventions adequately prevented?
Blinding Patients: Was knowledge of the allocated interventions adequately prevented?
Was loss to follow-up (missing outcome data) infrequent?
Are reports of the study free of suggestion of selective outcome reporting?
Were outcomes objective, patient-important and assessed in a manner to limit bias (ie. duplicate assessors, Independent assessors)?
Was the sample size sufficiently large to assure a balance of prognosis and sufficiently large number of outcome events?
Was investigator expertise/experience with both treatment and control techniques likely the same (ie.were criteria for surgeon participation/expertise provided)?
Yes = 1
Uncertain = 0.5
Not Relevant = 0
No = 0
The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.
2/4
Randomization
3/4
Outcome Measurements
2/4
Inclusion / Exclusion
4/4
Therapy Description
4/4
Statistics
Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.
Why was this study needed now?
A previous study examining the effects of a brief intervention and multidisciplinary intervention on sick leave due to low back pain revealed that return to work rate, disability, and pain were not significantly different at the 1 year follow-up. The results did disclose that the patients who had autonomous and secure work were able to return to work more quickly after a brief intervention, whereas the patients who did not have autonomous and secure work were able to return to work more quickly after a multidisciplinary intervention. In order to determine the sustainability of return to work, this study assessed duration until return to work, number of weeks on sick leave, and return to work status among low back pain patients who received a brief intervention or multidisciplinary intervention.
What was the principal research question?
Does a brief intervention or multidisciplinary intervention result in improved sustainability of return to work among patients with low back pain through reduced duration until return to work, decreased number of weeks on sick leave, and improved return to work status, 2 years after treatment?
Study Characteristics
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Population:
351 patients between the ages of 16 and 60 years on sick leave for 3 to 16 weeks due to low back pain.
Intervention:
Brief hospital-based intervention (described in previous study) (Mean age: 41.9 (31.5 to 52.3) years) (n=175).
Comparison:
Multidisciplinary intervention (described in previous study) (Mean age: 42.1 (31.6 to 52.6) years) (n=176).
Outcomes:
The outcomes assessed were return to work (duration until the first 4 week period without sick leave compensation or receiving no benefits in the 52nd and 104th week after inclusion), number of weeks on sick leave, partial or full sick leave, modified job or training, and labor market exclusion.
Methods:
RCT: prospective.
Time:
104 weeks (outcomes assessed at weeks 52 and 104).
What were the important findings?
- During the first year, 76.0% of patients from the brief intervention group and 72.2% of patients from the multidisciplinary group returned to work for longer than 4 weeks (p=0.20). The percentage of patients that returned to work for longer than 4 weeks during the second year was slightly higher, with 80.0% of patients from the brief intervention group and 77.3% of patients from the multidisciplinary group achieving return to work abilities (p=0.22).
- The patients in the brief intervention group required 14 sick leave weeks whereas the patients in the multidisciplinary group required 20 sick leave weeks during the first year, which was found to be clinically significant (p=0.018). The difference was no longer significant by the second year as the patients in the brief intervention group required 0 sick leave weeks and the patients in the multidisciplinary group required 1 sick leave week (p=0.29).
- Return to work status between the patients in the brief group and the patients in the multidisciplinary group was found to be not significantly different at the 52 week follow up (65.7% and 61.4%, respectively; p=0.43) and the 104 week follow-up (61.1% and 58.0%, respectively; p=0.54).
- From the brief intervention group, 5.7% of patients required a modified job or training and 3.4% of patients were excluded from the labour market, and from the multidisciplinary intervention group, 9.1% of patients required a modified job or training and 0.6% of patients were excluded from the labour market, during the first year. The percentage of patients that required a modified job, job training, or were excluded from the labour market increased by the 2 year follow-up (modified job or job training: 12% and 12.5%, respectively; labour market exclusion: 6.3% and 5.7%, respectively).
- Work related autonomy and security significantly affected the effects of the brief and multidisciplinary interventions at both the 1 year (p=0.006) and 2 year (p=0.017) follow-ups. The brief intervention appeared to be more effective among the patients that had more work security and autonomy and the multidisciplinary intervention appeared to be more effective among the patients that had less work security and autonomy.
What should I remember most?
The data suggests that the brief intervention is more effective among patients that are autonomous and have job security and the multidisciplinary intervention is more effective among the patients that are not autonomous and do not have job security. The brief intervention results in significantly less short term sick leave weeks than the multidisciplinary intervention, but the difference was no longer significant by the 2 year follow-up. There were no significant differences in the other sustainability outcomes between the brief intervention and multidisciplinary intervention.
How will this affect the care of my patients?
The study suggests that the brief intervention and multidisciplinary intervention may not result in differences in low back pain sustainability but the workplace autonomy and security may influence the effects interventions on the return to work rates. Further research using larger sample sizes is required to confirm the external validity of the findings.
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