Systematic Review of Workplace Rehabilitation Interventions for Work- Related Low Back Pain

1. Systematic Review of Workplace Rehabilitation Interventions for Work- Related Low Back Pain Dr Renee Williams, Professor Muriel Westmorland, Chia-Yu Lin, Gloria Schmuck & Marg Creen School of Rehabilitation Science McMaster University Hamilton Ontario, Canada

2. Objectives To review literature on effectiveness of workplace-based rehabilitation interventions for injured workers with work-related low back pain (LBP) - focused on secondary prevention interventions To determine quality of articles using quality guidelines (MacDermid, 2004) & levels of evidence (Centre for Evidence Based Medicine 2001)

3. Background – Why LBP? LBP is major challenge to employers, employees & service providers ( Tulder et al 1995; Wadell 1987) Reviews have examined effectiveness of workplace interventions for LBP (van Tulder et al, 2000; Heymans et al, 2004) Inconclusive - methodological problems (sample sizes, inadequate descriptions of interventions) Did not distinguish between clinical vs workplace & primary vs secondary prevention (Tveito et al, 200; Volinn, 1999)

4. Methods 2 academics, 1 experienced clinician, 1 Disability Management consultant & 1 kinesiologist Inclusion Criteria Intervention was carried out at workplace Participants had work-related LBP Intervention involved secondary prevention Study design was prospective or cross-sectional Study published in English

5. Search Strategy MEDLINE, CINAHL (Cumulative Index to Nursing & Allied Health Literature), EMBASE (Excerpta Medica Database) & AMED (Allied & Complementary Medicine) Jan 1982 to Apr 2005 Search Terms back pain; return to work; disabled persons; job accommodation; rehabilitation; occupational health services; workplace

6. Search Strategy . . . 1,224 abstracts - 198 full text articles identified 54 articles randomly allocated to 2 pairs reviewers 15 articles/10 studies met eligibility criteria Reasons For Exclusion Intervention was not workplace based Participants did not sustain work-related LBP Article was case study not primary research Intervention was primary prevention & not secondary prevention

7. Review by Team 2 pairs reviewers evaluated articles using Quality guidelines (MacDermid, 2004) 24 specific research design elements 2 = best score (high quality); 1 = acceptable (fair quality); 0 = poor (low quality or unmet criteria) Total possible score = 48 Levels of evidence (Centre for Evidence Based Medicine, 2001) were assigned

8. Levels of Evidence (Centre for EBM, 2001) 1a = Systematic review of RCT studies 1b = individual RCT 2a = Systematic review of cohort studies 2b = Individual cohort study 3a = Systematic review of case control studies 3b = Individual case control study 4 = Case series 5 = Expert opinion

9. Results (15 articles) 4 RCTs Karjalainen et al, 2004; 2003; Alexandre et al, 2001; Loisel et al, 1997 7 Cohort Studies With Control Groups Anema et al, 2004; Durand & Loisel, 2001; Cooper et al 1998; Grayzel et al, 1997; Yassi et al, 1995; Cooper et al, 1996; Linton, 1991 4 Cohort Studies Without Control Groups Anema et al, 2003; Bakhtiar et al, 2002; Jellema et al 2002; Cooper et al, 1997

10. Quality Ratings

11. Quality Ratings . . .

12. Categories Early RTW/modified work Clinical interventions with occupational interventions Ergonomics including exercises & lumbar supports Exercise & workplace visit Supervisor involvement for return to work

13. 1. Early RTW/Modified Work 2 yr study in Canadian hospital (Yassi et al, 1995; Cooper et al, 1998; 1997; 1996) 60 nurses with LBP (intervention group) & 158 nurses (control) Intervention = assessment, treatment & modified work Findings - rates of back injury & lost-time injuries decreased by 23% (intervention) & increased by 44% (control) & decreases in pain & disability

14. 2. Clinical Interventions With Occupational Interventions Loisel et al (1997) - 130 employees from 31 workplaces Randomized to: usual care clinical/rehab intervention occupational intervention combination of 2 & 3 Findings - full intervention group returned to work 2.4 times faster than usual care

15. 2. Clinical interventions With Occupational Interventions . . . As part of Loisel study, Durand & Loisel (2001) examined therapeutic return to work (TRW) with 28 employees & 99 (control) Findings - at 2 yr follow up, 93% in TRW working & had less pain but control group was not randomly selected

16. 3. Ergonomics Including Exercises & Lumbar Supports Anema et al (2003) evaluated participatory ergonomics (n = 35) Findings – satisfied with program but no control group & small sample size Anema et al (2004) examined ergonomic supports for 1631 employees (Netherlands, Denmark, Sweden, Germany, Israel & USA) Findings – ergonomics was effective on rate of RTW

17. 3. Ergonomics Including Exercises & Lumbar Supports . . . Bakhtiar et al, (2002) examined ergonomics & exercises in 15 milk vendors & 15 goldsmiths Findings - 13/15 & 14/15 recovered but description of intervention/results limited Alexandre et al, (2001) evaluated exercise & education in 27 nursing aids & 29 (control) Findings - reduction in pain but retrospective study

18. 3. Ergonomics Including Exercises & Lumbar Supports Jellema et al, (2002) studied lumbar supports in 59 home care workers Findings – disability decreased but no control group & psychometric properties of survey tool were not tested

19. 4. Exercise & Workplace Visit Karjalainen et al, (2004; 2003) Randomized to: group 1 (n = 56) Mini intervention (light mobilization & graded activity group 2 (n = 51) Mini intervention & worksite visit group 3 (n= 57) Usual care Findings - average sick days group 1 = 19; group 2 = 28 & group 3 = 41 At 2 yrs decreased pain sustained & workplace visit (group 2) did not add to its effectiveness

20. 4. Exercises & Workplace Visit . . . Grayzel et al (1997) - compared in-house PT (n = 10) to outside PT (n = 120) Findings - lost days reduced in intervention group was 28 versus 57 in controls but small sample size

21. 5. Supervisor Involvement for RTW Linton (1991) examined education about back & neck injuries - 22 supervisors vs 14 control supervisors Findings - Intervention group rated knowledge higher, contacted sick employees more often, felt they initiated more ergonomic improvements but sampling bias & male supervisors

22. Summary 15 articles - 8 medium (32) to very high (48) Key Messages Clinical interventions with occupational interventions are effective in RTW & reducing pain & disability Early RTW/modified work is effective in reducing rates & disability Exercises & ergonomic interventions are important

23. Limitations Quality guidelines –psychometric properties? Some outcome measures discussed in articles were unknown Selection bias of articles

24. Conclusions More quality studies on workplace rehabilitation interventions for LBP are necessary to promote early & safe return to work & to reduce number of lost-time injuries

25. Questions