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Early Intervention with Low Back Injured Workers Who are at Risk for Work Disability
RS2002/03-012
Final Report Date: May 2008
| Principal Investigator: | Izabela Schultz (UBC) |
| Co-Investigators: | Gregory Meloche (WorkSafeBC), Kenneth Prkachin (University of Northern British Columbia) |
For more information about this project, please contact Dr. Izabela Schultz.
Issue
Although most individuals recover from low back pain in a short period of time, some cases are lengthy, resulting in significant disability and high compensation costs. Research has identified a number of risk factors for low back pain related disability, and early interventions (EI) can be designed to target these risk factors. In this project, a randomized controlled trial was conducted to evaluate the effectiveness of an EI intervention within a workers’ compensation setting, for high and moderate risk workers with a back injury, who have been off work for 4–10 weeks. The key outcomes evaluated were return to work (RTW) rates, health care costs and work days lost. This project builds on an earlier pilot study that showed that EI can reduce time loss outcomes in a workers’ compensation setting.
Key findings
- Due to changes in WorkSafeBC’s approach to case management for workers with musculoskeletal injuries (including low back pain) in the sub-acute stage, the control group received an alternate form of EI, as opposed to the conventional case management approach anticipated when the study was designed.
- At three months, participants with moderate risk of disability had better RTW outcomes in the control group than in the intervention group.
- At six months, participants with high risk of disability had better RTW outcomes in the EI intervention group than in the control group.
- High risk workers appear to benefit more from the EI approach used in the intervention group (which was more intensive), while moderate risk workers benefit more from the EI approach used in the control group (which was less intensive and more flexible).
- There were no statistically significant differences between the EI intervention group and the control group with respect to health care costs or work days lost.
Objectives
- To evaluate the effectiveness of proactive, interdisciplinary EI within a workers’ compensation interdisciplinary case management setting
- To evaluate EI for sub-acute back-injured workers at elevated risk for protracted work disability
- To evaluate the recovery and RTW outcomes
- To provide EI improvement recommendations
Methods
This was a randomized controlled study, to compare conventional workers’ compensation case management with interdisciplinary, multimodal, clinical, occupational and case management-based early intervention for back injured workers at two different levels of risk for disability: moderate and high.
The design of the EI intervention incorporated components from evidence-informed RTW guidelines and studies. This included: case management-based secondary disability prevention; multidisciplinary, multimodal intervention combining clinical, occupational and case management approaches; ongoing, timely communication among stakeholders; an early workplace visit involving stakeholders which focused on medically-indicated, productive job accommodations; motivational interviewing, negotiation and RTW coaching by an occupational health trained nurse to reduce fears of re-injury and other negative expectations held by the workers, and; joint development and implementation of a cost effective recovery and RTW plan, in conjunction with the worker and multi-disciplinary case management team.
Participants were selected from workers’ compensation (WorkSafeBC) Service Delivery Locations (SDLs) in large, urban centres in B.C.
Workers with non-specific back injury claims 4–10 weeks post injury were sent a letter from the research team inviting their voluntary participation, together with the consent forms and the Risk for Disability Questionnaire. The information obtained from the questionnaire, including the workers’ risk for disability level, was kept confidential.
Consenting injured workers who qualified for the study were randomly assigned to either the EI intervention group or the control group. The control group received case management in the usual manner of the B.C. workers’ compensation system, while the EI intervention group received the EI intervention.
The main outcome measures were RTW at 3, 6, and 12 months for the EI intervention and control groups. Duration of disability, compensation costs, and days lost were also measured at 6 and 12 months, using workers’ compensation administration databases.
Results
- There were 63 participants in the study: 29 in the EI intervention group and 34 in the control group.
- The EI Intervention group received about twice as many interventions (i.e., nurse advisor involvements, workplace visits or assessments, case management involvements, communications between WorkSafeBC’s medical advisor and the workers primary physician, etc.) than the control group.
- RTW rates for all participants were: 66% at 3 months, 71% at 6 months, and 79% at 12 months.
- At three months, the RTW rate for moderate risk participants was higher in the control group than in the intervention group, although this difference was not statistically significant.
- At six months, the RTW rate for high risk participants was higher in the EI intervention group than in the control group or in the control group of the previous pilot study.
- There were no statistically significant differences between the EI intervention group and the control group with respect to disability and health care costs or work days lost.
Conclusions
Due to the new early intervention approach implemented in the B.C. workers’ compensation system for injured workers with musculoskeletal injuries in the sub-acute stage, the researchers advise that this study is best seen as a comparison between a more intensive, less flexible EI (the study-based EI intervention) and a more flexible, less intensive EI (the EI received by the control group).
The better three month RTW rate for moderate risk participants in the control group suggests that moderate risk workers are unlikely to benefit from the more intensive approach of the EI intervention (which is designed to target high risk workers). The finding that the six month RTW for high risk workers was better in the EI intervention group suggests that high risk workers benefited from the more intensive approach.
The researchers conclude that workers at high risk of low back pain related disability require a goal-oriented, individualized and intensive interdisciplinary intervention involving ongoing monitoring-type intervention after the initial return to work, and recommend system-wide screening efforts to identify high risk workers for early intervention.
Future directions
The researchers identify considerations for future studies in this area, particularly the need to ensure that no significant changes will take place in control groups that are part of the workers’ compensation delivery system. A longer data collection period is also recommended, to allow enough time to recruit sufficient numbers of participants (smaller than anticipated samples sizes created some challenges for this project).
Future studies may also benefit from monitoring longer term RTW outcomes, capturing recurring patterns of disability rather than singular RTW events, and including a measure of job accommodations provided in the course of RTW as part of the outcome evaluation process in interventions. It may also be beneficial to provide interventions on an as-needed basis after the formal EI is finished. It is also recommended that EI studies aimed at workers with high risk of disability not include workers at moderate risk, as they are unlikely to benefit from it.