Early Intervention for Disability Management
Nelofar Kureshi , clinical researcher and case manager,
Rupert Case Management Inc.
In a synthesis of disability management studies, Frank et al (1998) determined that medical management in the first 3-4 weeks after the onset of pain should be focused on guideline-based care by primary providers. In the subacute phase (3-12 weeks), case management including comprehensive case review, physiotherapy, and ergonomic work adjustment can potentially reduce time lost from work by 35-50%. Evidence indicates that employers who offer modified duties without delay, can reduce time lost due to back pain injury and reduce the incidence of new back-pain claims as well.
Gatchel et al (2003) evaluated the clinical effectiveness of employing an early intervention program with high-risk ALBP (acute lower back pain) patients in order to prevent the development of chronic disability at a 1-year follow-up. The study also evaluated the relative cost savings of such an early intervention program. The early intervention program involved an interdisciplinary team approach consisting of four major components—psychology, physical therapy, occupational therapy, and case management.
The high-risk ALBP subjects who received early functional intervention (the HR-I group) displayed statistically significant fewer indices of chronic pain disability on a wide range of work, healthcare utilization, medication use and self-reported pain variables, compared to the high-risk ALBP subjects in the non-intervention (the HR-NI group). The HR-I group was much more likely to have returned to work (odds ratio 4.55) and less likely to be taking narcotic analgesics and psychotropic medication (odds ratio 0.44 and 0.24 respectively).
The overall cost per patient for the 1-year follow up was significantly higher for the HR-NI group.
A study investigated the effect of the timing of physical intervention by comparing two research-based models of care for acute low back pain: assess/advise/treat” and “assess/advise/wait” (Wand et al, 2004). The intervention consisted of biopsychosocial education, manual therapy, and exercise. The study concluded that a short-term active intervention program was more effective than advice on staying active, leading to more rapid improvement in function, mood, quality of life, and general health. In the long term, disability and pain were not significantly different between the two groups.
Hagen et al (2000) conducted a controlled randomized clinical trial to investigate the effect of a light mobilization program on the duration of sick leave for patients with subacute low back pain. The intervention in this trial was a light mobilization program and the control group received primary health care. At the 3-month follow-up assessment, 51.9% of the patients in the intervention group had returned to full-duty work, as compared with 35.9% in the control group. Patients in the intervention group also had fewer days of sickness compensation than the patients in the control group. The authors concluded that patients with subacute LBP returned to work sooner if they were offered examination, information, reassurance, and encouragement to engage in physical activity when compared with conventional primary health care.
A population based randomised clinical trial was undertaken to assess a comprehensive model of management of back pain (Sherbrooke model) aimed at returning workers with subacute back pain to their regular job (Loisel et al., 1997). This model consists of the combination of a clinical rehabilitation intervention and an occupational intervention that included an ergonomic component. Absent workers were placed in one of four treatment groups: usual care, clinical intervention, occupational intervention, and full intervention (a combination of the last two). After a one year follow up, the Sherbrooke model returned subjects to their regular work 2.4 times quicker than subjects who received usual care.
Loisel et al (2002) tested the long term cost-benefit and cost-effectiveness of the Sherbrooke model of management of subacute occupational back pain. In the analysis, “the cost-benefit analysis was performed by using outcomes expressed in monetary terms. The cost-effectiveness analysis was performed by using the outcome of number of fully compensated days because of back pain.” The Sherbrooke model arm led to a saving of $18,585 per worker at a 6 year follow-up. The authors deduced that a fully integrated disability prevention model for occupational back pain appeared to be cost beneficial for the workers’ compensation board and to save more days on benefits than usual care or other interventions.
Early intervention programs provide many benefits to all stakeholders, including the client, employer, and healthcare provider. Pre-disability services minimize the cost of prolonged illness and absenteeism, promote early return to work with transitional duties if necessary, reduce disability costs, and increase employee confidence.
The authors of Disability Prevention (Loisel et al., 2001) suggest a conceptual model for disability management that integrates the healthcare, workplace, compensation, and personal systems. The new disability paradigm means adopting a rehabilitation approach that addresses the physical, cognitive and affective characteristics of the worker.
Secondly, the paradigm should account for interdisciplinary and interorganizational teams. Finally, the rehabilitation approach should document return to work opportunities and barriers and the communication with the compensation system (Loisel et al., 2001).
Frank, J., Sinclair, S., Hogg-Johnson, S., Shannon, H., Bombardier, C., Beaton, D., & Cole, D. (1998). Preventing disability from work-related low-back pain. New evidence gives new hope–if we can just get all the players onside. Canadian Medical Association Journal, 158(12), 1625-1631.
Gatchel, R. J., Polatin, P. B., Noe, C., Gardea, M., Pulliam, C., & Thompson, J. (2003). Treatment-and cost-effectiveness of early intervention for acute low-back pain patients: a one-year prospective study. Journal of occupational rehabilitation, 13(1), 1-9.
Wand, B. M., Bird, C., McAuley, J. H., Dore, C. J., MacDowell, M., & De Souza, L. H. (2004). Early intervention for the management of acute low back pain: a single-blind randomized controlled trial of biopsychosocial education, manual therapy, and exercise. Spine, 29(21), 2350-2356.
Hagen, E. M., Eriksen, H. R., & Ursin, H. (2000). Does early intervention with a light mobilization program reduce long-term sick leave for low back pain?. Spine, 25(15), 1973-1976.
Loisel, P., Abenhaim, L., Durand, P., Esdaile, J. M., Suissa, S., Gosselin, L., & Lemaire, J. (1997). A population-based, randomized clinical trial on back pain management. Spine, 22(24), 2911-2918.
Loisel, P., Lemaire, J., Poitras, S., Durand, M. J., Champagne, F., Stock, S., … & Tremblay, C. (2002). Cost-benefit and cost-effectiveness analysis of a disability prevention model for back pain management: a six year follow up study. Occupational and Environmental Medicine, 59(12), 807-815.
Loisel, P., Durand, M. J., Berthelette, D., Vézina, N., Baril, R., Gagnon, D., & Tremblay, C. (2001). Disability Prevention. Disease Mana