Rationale for the scheme
There is good evidence that an early intervention approach to the management of musculoskeletal disorders can prevent work loss in those who are symptomatic and reduce the time to return to work for those who absent from work [24–26]. There is also increasing evidence that early intervention approaches, particularly those that address return to work can be cost effective for employers, health purchasers and providers of wage replacement benefits [27–30].
Numerous systematic and narrative reviews have concluded that early treatment for musculoskeletal pain problems can reduce work-loss and improve the patient's chances of rehabilitation and sustained retention in work . The evidence that physical therapy interventions alone are effective in returning people to work is equivocal . One previous study demonstrated early referral to physiotherapy was more effective than usual care . However, the provision of appropriate workplace assessments and the incorporation of recommendations from such an assessment by way of modified duties may help the worker return to work sooner [12, 34, 35].
Providing active rehabilitation, rather than simply the provision of symptomatic relief (analgesia and manual therapies), is an effective way of speeding up return to work and reducing work loss in the longer term . The aim of the current intervention was to provide symptomatic relief where required, but to focus on active rehabilitation to assist the person to return to work. The basic elements of an active rehabilitation programme include; advice on activity management including work, graded physical exercise, and early resumption of avoided or ceased activities using a cognitive behavioural approach . Numerous reviews of the literature [35, 36, 38–40] have indicated that this is the most effective and cost-effective way to help workers with musculoskeletal pain problems from a variety of diagnoses. Guidance and recommendations from NICE relating to the management of long-term sickness absence and incapacity reflect such evidence .
Uptake rates for this service were lower than expected, with around half of the anticipated number of service users contacting OHPP. However, the vast majority of people contacting the service were referred for face-to-face treatment. Uptake for the workplace assessments, however, was also lower than expected. Approximately 2-3% of the employees at participating organisations contacted the service over the 8 month period when the evaluation was being conducted. The vast majority of people with acute musculoskeletal pain (approximately 98%) spontaneously recover relatively quickly [32, 38], and therefore the rate of contact with the OHPP service may reflect this. This may have meant that those with more minor or self-limiting complaints did not require the telephone advice to the extent that had been anticipated. Indeed, the average pain duration of participants in this study was 56 months indicating that they had persistent problems.
The Welsh Backs initiative, promoting awareness of recommendations for the self-management of musculoskeletal pain for both members of the public and health professionals, had been taking place around the time that this service was introduced and therefore this may also have influenced the way in which the OHPP service was used. It is also possible that telephone advice alone could have been sufficient for some of the service users referred for face to face contact. The lack of referrals for workplace assessments could have been due to a number of reasons, such as the availability of OH services in the participating workplaces and possibly reluctance on the part of the clinicians and service users to take the management of what they perceived to be a clinical problem in to a workplace setting. It is possible that further education and training would be required to increase uptake of this component of the service.
In summary, these findings suggested that in terms of adoption and implementation of the service, the face-to-face hospital based contact was most successful, with little demand for telephone advice alone or workplace assessments. The reasons for this would need further investigation if the service were to be rolled out.
Change in outcomes and cost-effectiveness
As this was a cohort study and no control group was included, it is not possible to conclude to what extent to which changes observed were due to spontaneous recovery as opposed to being a result of the intervention. Nonetheless, statistically significant improvements were observed in all the outcomes shown in Table 2 between the baseline and follow up assessments. Current health status had the strongest association with work-related variables and association was stronger for work performance than for absence, which was similar to findings from a previous study conducted by some of the authors [42, 43], and highlights the importance of managing MS pain effectively.
Furthermore, cost-effectiveness analyses indicate that this service could potentially be provided at an acceptable cost for the level of benefit yielded. The analysis indicated that the service would continue to be cost-effective until the cost per user increased by 160%. Furthermore, it would be anticipated that once such a service becomes established and the uptake increases the cost per case would reduce.
It should be noted that the wider societal effects associated with reduced sickness benefits costs, reduced costs to employers attributed to improved production and reduced absence rates were not included in the current analysis. Sickness absence and presenteeism in particular are associated with significant economic costs [3, 4]. However, we did examine associations with work performance and absence at follow up and end of treatment within the cohort using multivariate regression analysis. This indicated that physical health status was particularly important in understanding impaired work capacity at follow up. Current physical health status (independently of baseline physical health) had the strongest association with work performance and absence at 3 month follow up, confirming the importance of timely and effective management of musculoskeletal pain in reducing its burden.
First and foremost, it must be stressed that this evaluation employed a pragmatic cohort design and was not based on a Randomised Controlled Trial (RCT). This means that it is not possible to state that the benefits seen were due to the intervention employed (the OHPPP scheme). Nonetheless, a cohort design is a pragmatic approach to initial evaluation of clinical practice, and this study indicate that there was change in the relevant variables in the expected direction and that it could potentially be cost-effective. This suggests that further investigation using an RCT is warranted
Despite regular and on-going marketing of the scheme, the level of engagement by employers and service users was considerably less than had been anticipated when the scheme was being established. This had an impact on participant numbers resulting in the extension of the recruitment period from 12 weeks to 7 months. Furthermore, many service users failed to return follow-up questionnaires. These issues are important in terms of the representativeness of the sample and ability to generalise from the findings and improving engagement and minimising attrition are important issues for further trials of such interventions.