Early intervention for musculoskeletal disorders among the working population

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Luis Rodriguez-Rodriguez, Lydia Abasolo, Leticia Leon, Juan A. Jover, Rheumatology Department, Hospital Clínico San Carlos, Madrid, Spain

Introduction

This article concerns early intervention where work is compromised by or aggravates a musculoskeletal problem. The sooner a musculoskeletal problem is managed, the less likely it is that it will lead to long-term work loss. Early healthcare intervention consists of: rapid referral; diagnosis and clinical management by musculoskeletal specialists in the first week of work disability; patient education; early mobilisation; recommendations for physical activity; and support for returning to work. The main focus of the article is on how health care systems can provide early intervention, in cooperation with other services, to support the worker to continue in employment. Early intervention in the workplace and the role of the employer is also discussed.

What are musculoskeletal disorders

Musculoskeletal disorders (MSDs) include a broad spectrum of high prevalence conditions in the general population, such as joint diseases, connective tissue diseases, back problems, soft-tissue rheumatisms, osteoarthritis and osteoporosis. MSDs affect all age groups[1], causing a major impact on the quality of life, for both the patients and their relatives. When they are caused or made worse by work, they are referred to as work-related MSDs.

The burden of musculoskeletal disorders

These conditions constitute the main cause of physical disability in most global regions[2]. Moreover, disability related to musculoskeletal disorders is a growing issue, as it has increased by 23% between 1990 and 2017[3]. As far as the socioeconomic impact of musculoskeletal disorders is concerned, it is equivalent to or exceeds cardiovascular disorders or cancer[4].

Regarding the workplace, every year, millions of European workers in all types of jobs and employment sectors are affected by MSDs through their work. Based on data from the 2015 European Survey on Working Conditions[5]5, 43% of workers reported back pain, 42% reported neck and upper limbs muscular pain, and 29% lower limbs pain. MSDs are one of the most important causes of work absence, and early retirement: they cause almost 50 percent of all absences from work lasting at least three days in the EU and 60 percent of permanent work incapacity[6], amounting to more than 500 million sick days per year in Europe.

While it is not easy to calculate the true economic impact of for MSDs, a 2015 analysis estimated that the total costs of work-related MSDs were in the region of €240 billion or up to 2% of Gross National Product (GNP). MSDs are, according to this analysis, responsible for 40–50% of the costs of all work-related health issues[7].

What is early intervention

Early intervention is about ensuring the timing of any intervention is early enough to support the reversibility of the disability associated with any MSD, with the goal of restoring function and preventing long-term disability. Timing is critical to ensuring reversibility: there is no rule, but evidence shows that the longer the initial intervention is delayed, the more likely it is that the problem and associated disability are irreversible.

Early intervention can take different forms, depending on where the individual is located along the continuum between health and disease or between ability and disability. Different strategies can be implemented in order to prevent the progression of disease/disability. These include: preventing the apparition of a disease; tackling a condition head on during its early stages in order to halt its progression; or intervening when a condition is completely developed in order to minimize its consequences and revert or at least minimise its functional impact (i.e. disability). In this regard, early intervention can be considered as a form of prevention as it can ensure that symptoms are discovered, treated and have only minimal impact on an individual’s life, or in this case, in their work ability.

The importance of early intervention

The identification of proven interventions to prevent disability is an important public health challenge[8][9][10][11][12]. As chronic conditions become more prevalent, due to demographic changes, more sustainable healthcare is needed to reduce the burden on health and welfare systems, reduce absenteeism and allow an older working population to remain active in employment.

In recent decades, there has been an expansion of medical and surgical management techniques for MSDs that provide the ability to reduce pain and suffering and the years of life lived with disability burden[13], which are more effective if the intervention is early. Early intervention for MSDs is therefore a means to more effectively use public resources through simultaneously reducing expenditure, relieving pressure on key services and improving the outcomes and experience of system users[14], especially where it involves cooperation between health and welfare systems. Early intervention therefore needs to be a more prominent feature of sustainable healthcare

General principles of early intervention

The key principles for early intervention include:

  • Early access to healthcare (early case identification of someone with a disabling MSD and referral);
  • Diagnostic and therapeutic management by specialists in MSDs;
  • Outcomes focused on function and participation, especially in work;
  • Rapid triage to the appropriate level of care, which may involve:
    • Patient education
    • Early mobilisation, and recommendations for physical activity
    • Pharmacological support
    • Surgical treatment
    • Physiotherapy
  • Incorporation of a planned return to work;

Prerequisites and success factors for early intervention

To be successful early intervention is dependent upon appropriate resources, a health system that offers timely access to pertinent care and has the necessary capacity and competence.

For successful rehabilitation to work, early intervention requires closer integration of health and social care. To achieve the clinical, societal and economic benefits of early intervention, it will be key that all stakeholders (clinicians, policymakers, employers and workers) coordinate their efforts.

Strategies and programmes for early intervention

Effective strategies have been developed to address in a timely way the impact of musculoskeletal conditions, mostly in inflammatory diseases with high risk of disability and decreased life expectancy. For example, early intervention is being universally applied and integrated in health care for patients with rheumatoid arthritis using the opportunity window in the early phases of the disease, and its success demonstrated[15][16].

Different early intervention programmes have been developed with differing aims:

  • to prevent the development of MSDs (acting when workers start developing early warnings of those conditions, such as fatigue and/or discomfort)
  • to prevent the development of MSD-related disability (when the MSDs appear, but before a sickness absence is required), or
  • to enhancing the return-to-work after a sickness absence (when the worker develops sickness absence).

Healthcare interventions

Workers with MSDs are a clear target for early health care intervention due to the presence of a window of opportunity during the early phases of most of these conditions, which is usually associated with good response to different forms of therapies at their onset. There is growing evidence that, if remaining in work is regarded as a clinical (or treatment) outcome and that if workers are given early access to treatments and therapies, this can help to improve their functional capacity and work ability.

Effectiveness of healthcare interventions

Various studies have shown the benefits of healthcare interventions carried out in different stages of disease:

Rogerson et al[17] tested the efficacy of physical therapy and cognitive behavioural therapy in subjects with early onset low back pain. Compared with the usual care, workers in the healthcare interventions programme experienced fewer sickness absence days in the following year, and a greater gain in quality of life. Furthermore, the healthcare interventions were proven cost-effective.

Gatchel et al[18] also carried out an early intervention in workers with early onset low back pain and high risk of chronification, consisting in physical activity and education. A higher percentage of workers participating in the early intervention programme were able to maintain employability, had lower pain and disability levels, and lower healthcare utilization.

Squires et al[19] carried out a cost-utility analysis of different workplace interventions and healthcare interventions, in sick-listed workers of less than 6 months of duration (including both workplace modifications, physical activity and education). Again, any of these early interventions was cost-effective compared with usual care.

The ‘Madrid’ early intervention study

Jover et al[20] carried out a voluntary, randomized, controlled intervention study in the early 2000s, showing the efficacy of an early intervention programme compared to the normal care practice. All workers from three health public districts of Madrid (Spain) with a temporary work disability initiation form related to an MSD during the study period (1998–2001) were included (n=13 077). As soon as the workers had a completed sick leave form their primary care physician, they were allocated either to a control or intervention group in a randomised way. The control group received standard primary care management, with referral to specialized care if needed. The intervention group received a specific care programme, ‘The early intervention programme’. It was delivered during regular visits by the patient to the rheumatology outpatient clinics of the participating centres, with the aim of the first visit taking place within the initial week of sick leave (median lag time 5 days).

The programme integrated different standard clinical processes, which are usually provided by different agents in different scenarios, at a single contact point with the health system, which was the rheumatologist. It consisted of a protocolized clinical management made for specific disease syndromes, including education, self-care stretching exercises, ergonomic training, pharmacologic and non-pharmacological treatment, and timing of diagnostic tests based on three growing levels of complexity in a stepwise manner. The use of these protocols did not replace the clinical criteria of the physician, but helped to integrate those therapies which have proven to be the most satisfactory in the past and provided the material that the patients need in terms of self-care.

This early intervention programme, showed a clear efficacy, improving patients’ short (39% decrease of the days off work or relative efficacy of the programme) and long-term

functionality (50% reduction in the number of patients who end up with a permanent work disability). The programme had its highest impact in the early stages of treatment, and always within the first 2 months, which can be seen in figure 1, reinforcing the importance of early intervention.

Figure 1: Failure curves showing the rate to resolution of disability episodes during the whole follow-up of the ‘Madrid’ study, by groups.

These results were accompanied by higher patient satisfaction and decreased health care utilization (40% decreases in direct costs). An economic analysis (of both direct and indirect costs), showed that for each dollar invested, a benefit of $11 was crreated. Extrapolating this to the whole working population the savings in lost productivity would be around 0.5% of GDP. Furthermore, this type of programme provides positive results in both the immediate and long-term. A complementary early intervention study using cognitive therapy further improved the functional results of the patients[21].

Overall, the healthcare intervention showed, with a reasonable degree of confidence, that targeted, multidisciplinary, work-focused, and consensual early intervention that is clinically led, but involves employers and individual workers, can deliver superior and cost-effective return to work and related outcomes compared to ‘standard’.

Examples of programmes and pilot programmes

Despite the evidence regarding the health, and economic benefits associated with early intervention programmes, there remain few programmes incorporating it. Some examples of programmes and pilot schemes that do exist or have taken place follow.

Fit2Work[22]: This Austrian initiative is a cross-institutional, coordinated multidisciplinary early-intervention programme providing services to help employees to maintain their work ability following physical or mental health issues. The programme, developed as a result of Austria’s work and health law, can be accessed by individuals or companies. It also supports workers who have left employment or lost their job because of health problems, helping them to reintegrate into their workplace or the labour market. Fit2work assists companies and individuals using tools such as work ability assessment questionnaires, provision of counselling sessions or vocational rehabilitation services. Working with the company, a case manager is appointed and a plan is developed. Fit2work organises and combines the services of a number of partner organisations in order to find a solution that fits the needs of the person(s) concerned.

The main success factors are the early-intervention and the integrated approach. The early interventions have received particularly positive feedback, as they allow for the rehabilitation process to start as soon as a problem appears and before it develops into a chronic or long-term condition. Findings from an early intervention can also support prevention, by helping the company concerned to identify common health problems among it’s employees. Prior to Fit2work, the rehabilitation process began only when there was already a case for an invalidity pension.

Cases from the programme show that, other than working hours, companies report few incurred costs. The programme is largely funded by government institutions and insurance providers.

Early intervention programme in musculoskeletal disorders [Programa de Intervención Temprana en Enfermedades Musculosesqueléticas (Programa IT-ME)]: This early intervention programme has been carried out in the Madrid Community (Spain) in three health areas since March 2019, covering around half a million active workers. The programme offers workers a clinical management of the MSD causing sickness absence, and it is carried out by trained rheumatologists, following educational and clinical protocols of proven efficacy[23]. Workers are contacted within the first days on their sickness absence and offered an appointment in the closest participating centre. More than 90% of workers are attended within the first week of sick leave. The programme is funded by the National Institute of Social Security, in the context of a general agreement between this Institution and the regional health system. During 2019, the programme attended more than 3,000 sickness absence episodes, covering more than 25% of the sickness absence episodes related to MSDs. A similar programme is running in another autonomous community in Spain (Castilla y León).

Leeds ‘Early Intervention Clinic’. An earlier intervention pilot project was based in Leeds Community Healthcare NHS Trust[24] in the UK. It was designed to enable quick referrals from primary care, allowing patients signed off work with a musculoskeletal problem to access a specialist within five days and make an early return to work. The clinic was based on a previous model from Spain. Patients issued with a ‘fit note’ by their family doctor were referred for a 30 minute consultation within five days of the ‘fit note' being issued[25].

Early intervention in the workplace

Early intervention programmes can include workplace interventions to provide accommodations or adaptations to facilitate continued working. Accommodations may involve changes in the workplace or equipment (such as changes in the furniture or the materials needed to perform the work), work design, organisation, and working relationships (such as changes in schedules or tasks, training in task performance, and altered working relationships with supervisors and co-workers), working conditions (such as changes in the financial and contractual arrangement), work environment (such as those concerning noise, lighting, or vibration), and/or occupational (case) management with active stakeholder involvement of (at least) the worker and the employer.

Workplace interventions involve the worker, the supervisor or employer, and professionals in occupational health. In addition, other stakeholders can be involved, such as the insurer or trade union representatives. These measures are in line with the report “Pathways for the reintegration of workers recovering from injury and illness into quality employment”, issued and adopted in June 2018 by the European Parliament Committee on Employment and Social Affairs[26][27].

This report sets out measures that the European Commission and Member States should address to retain and reintegrate workers into the workplace who suffer from chronic conditions or injuries. In addition to the personal improvements in quality of life and mental health, the report also stresses the economic benefits, such as reducing costs for companies and making pensions and social security systems more sustainable for future generations. It calls for: improvement in how sickness absences are managed; workplaces to be made more adaptable to chronic conditions and disabilities by modifying tasks, equipment, and working time; raising awareness of and addressing potential psychological barriers to return to work (such as stress or stigma); developing and implement systematic monitoring and support for those affected by psychosocial risks (such as depression or burnout); and the use evidence-based policy to support return-to-work approaches.

Pre-requisites for early intervention in the workplace

Employers need to think about how they can work more effectively with both their workers and healthcare professionals in order to support workers with a musculoskeletal condition to stay in and return to work. Early intervention at the workplace is central to a good outcome for both the worker and the employer. Employers therefore need to take a proactive approach to reduce risks that may result in musculoskeletal problems, but also to support workers who have musculoskeletal problems, whether they are short-term or long-term conditions, to enable them to remain working. A three-pronged approach is needed in the workplace through: preventive action; encouraging early intervention for any musculoskeletal problem and making reasonable adjustments to work; and accommodating effective rehabilitation and return to work plans and supporting workers to self-manage their condition[28].

Early identification of physical capability problems of workers and determining suitable reasonable adjustments to the work to allow continued working is dependent on effective communication and open dialogue between workers and their managers[29]. Employers need to be proactive in any return to work process and responsive to recommendations from healthcare professionals[28].

Reasonable accommodations can be as simple as a new chair, an ergonomic mouse, temporary or permanent adjustment to working hours, or short breaks so the worker can do some stretching exercises.

Advice and support available to employers and workers to support early intervention and rehabilitation will depend on the European Member State’s rehabilitation system.

An example of early intervention as part of a prevention approach in a workplace

Female workers in a small Danish kindergarten were suffering from many work-related MSD complaints. To prevent the loss of older, experienced workers, the kindergarten implemented an intervention that included individual advice from an occupational therapist, early access to physiotherapy at a reduced cost and ergonomic improvements in employees’ work. The benefits of this were more sustainable working conditions, a reduction in MSDs and the retention of experience in the workplace. Success factors included support from trade unions and external experts and the diversity of the measures undertaken. While the measures were tailored to the kindergarten, the approach is transferable to other businesses[30].

Early intervention with the complexity of work disability systems

Early intervention programmes for MSDs take place within the complexities of systems involved in work disability. Work disability is an extremely complex problem, which involves the healthcare system, the productive system, and the social security system[31][32][33]. The first is the public health domain, including the individual and the organisation of the health care system. The second is the work context of the individual, usually including occupational health services. Finally, there is the social security environment that regulates economic compensation for those sick workers unable to work. These three actors generally coexist in a relatively independent manner, but coincide during time the worker is incapable of performing his or her work and leading to an episode of temporary work disability. The evolution of the worker’s disability and the eventual development of the same into a permanent work disability will depend on the joint response the worker obtains for this health problem. This convergence requires a multi-pronged approach to work disability, corresponding to the different stakeholders involved in the prevention, treatment and social support of sick workers[34][35].

Conclusions

Return to work needs to be a coordinated effort aimed at job retention and preventing early exit from the workforce, encompassing all procedures and interventions intended to protect and promote the health and work ability of workers and to facilitate the reintegration into the workplace of anyone experiencing a reduction in work capacity due to injury or illness[36]. Early health care intervention is a crucial part of this and has been shown to be effective for work disability of a musculoskeletal origin.

Early intervention programmes are designed to provide delivery of the right care at the right time, avoiding multiple contacts and expenses. Their organisation, and sustainability contributes to the sustainability of the health and social care systems by reducing the cost associated to disability, and by opening the door to cross-budgeting of the two more important pillars of the welfare system. They enable the health system to align its objectives with the priorities of the individual, to provide a specific person-centred response to recent disability in active workers. They contribute to unifying different perspectives, by means of the common goal of achieving a quick return to work for workers with health issues. Such programmes work in a similar way to other successful programmes directed to more serious diseases (e.g. suspected malignancy, chest pain, early arthritis) that ‘unlock’ the gateways between different levels and health professionals, increasing the equity of the system for those suffering from the oxymoron: “non-serious, disabling diseases”.

The individual benefits will be reflected in terms of better health outcomes in the population: a decreased prevalence of moderate and severe acute and chronic disability in the active population. The health system will be more efficient, with patients obtaining better health results at lower costs. In the workplace, early intervention interventions will be able to reduce sickness absence, supporting their effectiveness’ on health outcomes.

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Contributors

Palmer