WORK A Journal of Prevention,
Assessment & Rehabilitation
Work 7 (1996) 183-189
An attempt to work rehabilitation after long sick-leave Inger Nilsson* , Lena von Buxhoeveden Department of Orthopaedics, Malmo University Hospital, S-205 02 Malmo, Sweden Received 7 May 1996; accepted 30 May 1996
Because of the increasing frequency of sick-leave in Sweden the General Health Insurance has directed funds for active rehabilitation by studying the possibilities for long-time sick-leave patients to go back to work. In the present study 38 subjects were randomized to an intervention group and a control group and followed for 3 years. In the intervention group, individual rehabilitation programs were provided and the patients were encouraged to actively deal with and improve their working situation. Also, they were influenced to accept activity and an active life style with a goal in life as an important and valuable concept. There was an obvious tendency of those in the intervention group to return to work more readily, however, the difference between the groups was not statistically significant. Keywords: Work rehabilitation; Sick leave; Health insurance; Employment
1. Introduction Injuries caused by physical load is not a new concept. The complaints have, however, changed with the industrial evolution - earlier when the jobs were heavy with lifting and carrying, back symptoms were more common, particularly low back pain. Lifts and similar machinery were constructed to deal with this problem; also many working stages have been automatized. Today, a large portion of industrial work is process monitoring and computer work which do no require physical strength (SBU-report 1991) but appear to cause other types of load complaints so that
* Corresponding author. Occupational Therapy Department, Department of Orthopaedics, Malmo University Hospital, S-205 02 Malmo, Sweden.
the symptoms have moved from the low back to shoulders and neck (Arbetarskyddsniimnden, 1989). In Sweden, in the 1950s, absence from work because of neck symptoms was 1% and on an average duration of 5 days. In 1987, 4% were neck complaints and the average duration of absence was 67 days. Low back pain constituted in 1970 1% of the absence but in 1987 8% (RiksfOrsiikringsverket 1987; RiksfOrsiikringsverket informerar 1988; SBU-rapport 1991). Also, in studies from other countries, back pain is common but as a cause of absence from work less common in the USA, England and Canada as compared with Sweden (National Center for Health Statistics 1981); in Sweden absence of long duration because of back pain is higher than in other countries (SUitis and Ruusmen, 1991).
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There is so far no explanation of these variations (SBU-rapport, 1991) but the compensation system has been blamed. Feuerstein (1991) proposed that patients with long-standing, non-specific pain should be rehabilitated as soon as possible to avoid a future pain behaviour pattern. The problem is not entirely a medical one (Polatin et al., 1989). The physicians have the medical knowledge and capacity of examining patients and offer physiotherapy or surgical treatment but it is also necessary to recognize the ergonomical relationships and the relationship between the individual, environment and life situation. Guidelines for all ergonomic and occupational medicine work should be to adjust the work environment to man. However, some environments and some occupations require that man is adjusted to the environment. In order to be able to recognize - early - risk groups for work-related symptoms it is important to find which risk factors that interfere with the working environment; age, gender, heredity, ethnic background, anthropometric variables, muscle strength and health. Such factors may also be important for the pathogenesis of disease and symptoms (Hagberg, 1988). Time and resources have already been invested in preventive work. It is also necessary to apply a rehabilitation attitude in co-operation with those involved in the process. The Health Insurance in Sweden has the duty, as decided by the government, to supervise co-operation between rehabilitation resources and the patient; the health care system, employer and other possible agencies that may be involved in rehabilitation (Almkvist and Olsson, 1988). In order to achieve this, grants have been made available for several rehabilitation and treatment projects in Sweden, many of which are financed by the government insurance system. The Malmo project - 'Job rehabilitation for patients with locomotor complaints' - was commenced in May, 1991. This is an attempt to describe how we are working and the model we have used. The objective was to study the effect of a composite program of occupational therapy and social counselling on the rehabilitation of individuals with a long duration sick-leave. In particular
the following problems should be addressed: pattern of sick-leave absence after intervention; and well-being versus pain and tension. 2. Subjects and methods Patients with a long duration of sick-leave were referred from the Health Insurance. They were randomly divided into two groups, each consisting of, 19 individuals. Both groups had the same conventional treatment; in addition the intervention group was subjected to the medical rehabilitation program. The time of sick-leave did not differ significantly between the intervention group (md = 267,62-776) and the control group (md = 313, 80-737). Inclusion criteria were: work related locomotor symptoms; sick-leave, from 6 weeks to 2 years; and age between 18 and 55 years. The outcome of the randomization process is presented in Table 1. There were no statistically significant differences between the two groups. Table 1 The characteristics for the intervention and control groups Characteristic
n = 19
n = 19
Nationality Scandinavian European Other Work-situation Unemployed Factory Cleaning Hospital employee Household Community program
5 13 1
8 5 3 2 1 0
8 3 4 2 0 2
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The following staff were involved in the program: occupational therapist, social worker, occupational therapist assistant and secretary. This may be accepted as a minimum for the conduction of the program assuming that a physiotherapist, a psychiatrist or other physicians are available for consultation. A co-operation between the occupational therapists and the social workers has been established in the Department since the early 1980s (Nilsson, 1985/86). The working evaluation/training begins with an interview and a presentation of the individual rehabilitation plan. The patients are also required to fill an inquiry form to describe their working conditions, family economy, education, drugs and their future expectations. Also, the patients describe how they experience pain, tension and well-being with a visual analogue scale (VAS) (Gift, 1989; Wewers and Lowe, 1990). In the Occupational Therapy Department the patient will be tested in various activities as a part of a functional analysis of the individual working capacity. The following activities are available: easy carpentry, sewing, office work, simple assembling work in wood materials, paperback folding, weaving, house-keeping, wicker-work, silver-work, printing with a small printing press, leather-work and engraving machinery. The following variables were evaluated: Punctuality: ability to be on time for work and after breaks. Attending: number of days attending for training. Pattern of movement and working positions: working patterns and positions, need for improvement of technical aids such as furniture. Quality: attention to detail and accuracy. Quantity: working tempo. Instructions: capacity of following oral or written instructions. Staying power: capacity of a sustained effort. Interest: capacity to become interested in an activity. Communication: capacity to establish contact with other patients and personnel. Initiative: the capacity of independent finishing and expanding of a project.
Concentration: capacity to maintain an effort and finish a job. Pain: painful pattern of movement and the patient's attitude to this.
These variables were on the basis of the individual rehabilitation program. The patient is required to arrive to the Occupational Therapy Department every day and to spend, in the beginning 2 h and, later 4 h. The training continues for at least, 6 weeks and can be extended in co-operation with the Health Insurance and the patient's physician. The duration and content of the training is individual. During the training period we tried to evaluate and improve the patient's health physically, psychologically and socially. We attempted to help the patient to find the problems, plan for the future and begin to undertake necessary changes and assume more responsibility for his/her situation. Since the daily social circumstances may indeed cause unhealth and prevent improvement, a social investigation is essential. A site visit to the patient's place of employment was undertaken to establish the possibilities of changes in working position, training in the real environment or possible transfer to some other work with the same employer. In conjunction with this site visit contact was established with the health insurance assistant handling the patient, the employer, the foreman, the union, the environment protection representative and the company health care representative in order to simplify return to work. After the evaluation/training a report was presented with suggestions concerning the patient's functional capacity and activity and his/her social situation. This evaluation report was presented to the Health Insurance, to the physician in charge of the patient and to the patient and was the basis for further activities and decision by the Health Insurance. 3. Results Many of our patients have been on sick-leave for a long time. Despite of the fact that we had a two year upper limit, some patients had, indeed,
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been on sick-leave even longer but with interruptions for other measures such as education, parenthood leave, employment trials and tests in government sponsored jobs. Last un-interrupted time of sick-leave for intervention and control groups. Sick-leave before referral
Intervention group (n = 19)
Control group (n = 19)
From 1 day to 6 months,
From 6 months to 12 months,
> 12 months,
Before referral to rehabilitation in the Orthopaedic Department Occupation Therapy section we found that the period of un-interrupted sickleave for the intervention group was, 267 days
(median range) and for the control group, 313 days (median range). This indicates that the individuals can be on sick-leave for a long time before physicians and Health Insurance refer to rehabilitation. When the evaluation of working capacity in the Occupational Therapy section is concluded, a suggestion for further procedures is presented to the Health Insurance. The procedures may be: go back to work, go back to modified work with technical aids, change work, further training, unemployment, sick-pension or continued sick-leave if medical work-out is incomplete. After 12 months we found that out of the 19 patients in the intervention group our suggestions have been followed by the Health Insurance in eight cases, the patients should go back in some form of work or training without economic support from the Health Insurance. In the control group, six individuals had had some change in their economic or work situation since they no
subjects not working
18 16 14 12
6 4 2
Fig. 1. Rate of return to work with and without intelVention.
I. Nilsson. L. von Buxhoeveden / Work 7 (1996) 183-189
longer received compensation form the Health Insurance. The rehabilitating measures suggested from the Orthopaedic Occupational Therapy Department speeded up the decision process more in the intervention group than what was observed in the control group (Fig. 1). These changes occurred soon after the subjects had concluded their 6-week rehabilitation period. In the intervention group there was an improvement up to 2 years. At a later date individuals returned to sick-leave and one who had tried to return to work did not manage and two subjects returned to sick-leave after studies. In the control group the major change occurred after 12 months. Even in this group there was a tendency that subjects after a short intermission returned to sick-leave, possibly due to the inability to manage the job they had been provided. This occurred in four individuals. In the intervention group those who had returned to work or to training and terminated their period of sick-leave usually did not return to compensation suggesting that our proposal and the Health Insurance rehabilitation plan had been possible to complete in co-operation with the patient. The rehabilitation is planned with the Health Insurance officer and the insured. The occupational therapist in the Orthopaedic Department will provide suggestions which the Health Insurance has no obligation to follow but usually does in due time. If changes occur we are usually not informed and there is no long-term follow-up. A governmental suggestion includes that the Health Insurance shall plan rehabilitation in cooperation with the insured person during the sick-leave period. The Health Insurance will decide if there is any working capacity left, not necessarily in the present occupation but in any form of occupation. The employer has a responsibility to contribute to the rehabilitation of the individual by providing a new work. 4. Discussion Many patients with back pain or an injury will get well with or without the aid of drugs, physical
therapy or surgery but some develop with time obvious impairment of their function in daily life in their homes, at work or in leisure time (SBUrapport 1991). The objective of rehabilitation work and the rehabilitation knowledge is to detect early - risks of incapacity and to act accordingly. The rehabilitation work includes co-operation between patient and Health Care and co-operation with agencies outside the Health Care Delivery System (Almkvist and Olsson, 1988). The earlier the planning and rehabilitation are introduced the more likely is success with small means. The later the process is begun, the greater the risk of secondary somatic, psycho-social and social complications and the rehabilitation will cost more, need more time and have less chances of success. A similar tendency has been experienced in studies in the USA - psycho-social factors are important for the success of rehabilitation (Niemeyer et al., 1994). Because of the government decision in 1990 to invest in early and co-ordinated rehabilitation (Almkvist and Olsson, 1988), we have in the Orthopaedic Occupational Therapy Department received resources to conduct the present study for a period of 4 years. After that time it should be decided if the program should be included in the regular rehabilitation activity and on the expense of the Health Insurance. At the same time other rehabilitation projects started in the city in Malmo so the total availability of rehabilitation increased. This, naturally, interfered with our study and decreased the possibility of finding a difference between the intervention and control groups. Since we had no opportunity to interfer with the control group, these subjects may have participated in other programs. We cannot conclude whether our program is better or worse than others. The result was just that, 1/3 of the intervention group changed their situation and did not received further economic compensation from the Health Insurance. The insurance agency found the gain for society sufficiently good to maintain our program. Our main goal has been to change the situation of the subjects involved by improving their self-
I. Nilsson, L. von Buxhoeveden / Work 7 (1996) 183-189
esteem and bringing them back to work-life or an active life in family, culture and society. When the work-training started the patient received an interview form and made an estimate of pain, degree of tension and their well-being. From this data it became apparent that the sick-leave period was not always due to physical injury. The subjects could have many complex social problems such as poor economy because of long sickleave, unemployment, drug misuse and family problems which became obvious during the 6week program. The data concerning the patient's pain, tension and well-being, measured on a VAS, did not show differences between the groups, possibly since the methods are too imprecise. Most interference and control groups are immigrants. They often have limitations in their selection of jobs because of poor education and lacking knowledge of Swedish leading them to the more heavy labour on the market. However, some good results were achieved among the immigrants who otherwise are believed to be more difficult to rehabilitate. One explanation may be that it may be difficult to communicate with these patients and that they have had no time or possibility for other types of rehabilitation or physician contacts. In the Orthopaedic Occupational Therapy section we have had the time and ability to find individual solutions for rehabilitation on the conditions of the patient who takes part in the planning. The experience of Swedish-born patients is that they have more social problems, housing problems, unemployment and drug and alcohol use than the immigrants. The time of rehabilitation may be longer which is not a severe obstacle since we can accomplish individual planning for each and one. Most patients have, after a long period of sickleave, a poor self-esteem; they feel useless, know nothing, they have forgotten everything, are not appreciated and are incapable of sustaining an effort. Using the activities in the Orthopaedic Occupational Therapy section a psycho-social process could be initiated which will break isolation and improve self-confidence. Some problems must be solved before rehabilitation is possible,
to some extent the social worker and the occupational therapist may give assistance. The occupational therapist has an important duty in motivating patients to go back to work. It is important that we understand the patients' problem and are able to add motivation for activity and the improved quality of life. It is important to teach the patients how man works, biologically and anatomically, and the importance of accepting physical loads even with pain. The occupational therapist and the social worker will attempt to prove for the patient that pain will decrease with physical exercise and that this will not jeopardize their health. This was obvious in a VAS-study, pain did not change, the degree of tension was difficult to depace and to evaluate but an improved well-being was the most obvious finding. The patients feel better when they do not sit back home in solitude but rather go out, see other people and establish social contacts. If this happens most patients can stand pain and tension to a certain degree. 5. Conclusion
In summary, more subjects are needed, intervention and control subjects, to study significant differences in sick-leave, pain, tension and wellbeing. Is it ethically possible to exclude some from rehabilitation? This may be one objection to a large control study. During the first year of the study we only had the follow-up data from Health Insurance on both groups. We soon found that continued individual follow-up was of great value. A direct result of the project was that individual follow-up became a new routine. Acknowledgements
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