Multidisciplinary intervention versus brief intervention in specialist healthcare. Attempting to improve outcomes for patients on sick leave with musculoskeletal pain
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Background: Musculoskeletal pain (MSK), such as low back pain (LBP), neck pain and widespread pain, is among the most common health problems in industrial countries. Subsequently, MSK is associated with substantial healthcare utilization and a leading cause of sick leave and work disability. The impact on individuals, families and working life is substantial and the societal costs are huge. Most patients have MSK with few or no objective findings. Psychosocial factors are of the most important predictors for long-term disability from MSK and subsequently different multidisciplinary treatment models (MDIs) have evolved over recent last decades. As part of this PhD project, a multidisciplinary intervention (MI) was developed, primarily aimed at a quicker return to work (RTW) for MSK patients. The MI involved a particular focus on work and psychosocial factors in addition to the somatic complaints and included strengthened patient education (PE) and communication in treatment. The MI was tested against the more established brief intervention (BI), which is mainly focused on musculoskeletal complaints. Aims: The main purpose was to clarify whether MI can improve RTW rates within two years over BI in patients on sick leave due to MSK. Secondly, we aimed at identifying predictors for sustainable RTW (s-RTW) and compared patient health, functional ability and coping between groups during 12 months of follow-up. Methods: A randomized controlled trial (RCT) was performed with MI and BI as equally sized intervention groups. Patients were referred to specialist healthcare by their general practitioners (GPs) and on sick leave for a maximum of 12 months with MSK. BI is based on the non-injury model (NIM), a non-directive communication and PE approach, and involves a physician and a physiotherapist in the treatment team. Patients in the BI group met twice at the outpatient clinic: at baseline and at the twoweek follow-up stage. The MI was more comprehensive, involved the use of a novel educational communication tool, and focused particularly on psychosocial and workrelated factors. The MI was administered by a physician, a social worker and a physiotherapist on the treatment team, and the patients met three times in the outpatient clinic, at baseline, after two weeks and after three months. Data on work participation and sickness benefits were derived from the social insurance register, providing 100% response rate on follow-up data. Questionnaires to identify demographic and clinical variables were filled out by both groups at baseline, and at the three and 12-month follow-ups. Results: Out of 534 patients referred by GPs, 284 patients (mean age=41.3 years, 53.9% women) were included and randomized to MI (n=141) and BI (n=143). The mean duration of sickness absence at baseline was 147 days. The treatment drop-out rate was low in both groups (MI: n=7, BI: n=15), indicating that both methods were feasible in a clinical setting. The results showed that MI hastened the RTW process through increased use of partial sick leave (PSL) in the first seven months of the study. At 12 months, there were no differences between groups in terms of either full RTW (f-RTW) (45%: both groups) or partial RTW (p-RTW) (MI=14%, BI=10%). The corresponding numbers at 24 months were: f-RTW: MI=43%, BI=37%, p-RTW: MI=13%, BI=6%. The MI predicted s-RTW, defined as increased work participation, compared to the baseline, for three consecutive months, at the three-month follow-up (OR=2.4), and the subgroup of patients who reported to have low support at work benefitted more from MI than BI. The belief that work was the cause of the pain predicted s-RTW at three months irrespective of the intervention. Anxiety/depression and duration of sick leave at baseline were risk factors for an s-RTW. Secondly, the MI hastened improvements in some of the clinical outcomes: anxiety, depression, somatization and physical functioning. Levels of pain and subjective health complaints (SHCs) followed the same course in the two groups. The MI group used fewer healthcare services in terms of consulting a GP, at both the three and 12-month follow-ups, as well as reported significantly better perceived coping, physical fitness and satisfaction with treatment than the BI group at 12 months. Conclusion: An MI with a particular focus on work, psychosocial factors, PE and communication in therapy could speed up the RTW process and the process of improving from mental health complaints and physical functioning among workers on sick leave with MSK, compared to the effects of a BI. Patients receiving MI are more satisfied with treatment, report improved physical fitness and being able to cope with health complaints, and make lesser use of healthcare services, which could also confirm improved coping. Earlier reconnection with working life could be important, as the length of sick leave is a risk factor for RTW. The reported sense of improved coping in the MI group could be associated with a successful earlier reconnection with work or to faster improvements in clinical outcomes. It may also relate to the strengthened educational process and patient involvement in the MI, which can improve patient adherence to treatment and thereby improve a sense of coping. However, results so far do not advocate recommending MI before BI to patients on long-term sick leave with MSK, as effect sizes in this study are small to modest and BI performs equally well in the long run for most outcomes. Results should be further improved and cost-benefit analyses should be part of future studies. The identification of subgroups of patients who might benefit more from comprehensive treatment is another future challenge.
Has partsPaper I: Brendbekken, R., Eriksen, H. R., Grasdal, A., Harris, A., Hagen, E. M. & Tangen, T. Return to work in patients with chronic musculoskeletal pain: multidisciplinary intervention versus brief intervention: a randomized clinical trial. J. Occup. Rehabil. 2017; 27: 82-91. The article is available at: https://hdl.handle.net/1956/19077
Paper II: Brendbekken, R., Vaktskjold, A., Harris, A. & Tangen, T. Predictors of return to work in patients on sick leave with chronic musculoskeletal pain. J. of Rehab. Med. 2018; 50:193- 199. The article is available at: https://hdl.handle.net/1956/18175
Paper III: Brendbekken, R., Harris, A., Ursin, H., Eriksen, H. R., & Tangen, T. Multidisciplinary intervention in patients with musculoskeletal pain: a randomized clinical trial. Int. J. Behav. Med. 2016; 23:1-11. The article is available at: https://hdl.handle.net/1956/10741