JOEM

Volume 45, Number 5, May 2003

499

CME Article #3

Early Workplace Intervention for Employees

With Musculoskeletal-Related Absenteeism: A
Prospective Controlled Intervention Study
Bengt B. Arnetz, MD, PhD
Berit Sjogren
Berit Rydehn
Roland Meisel, BA

Learning Objectives
Specify how the intervention program designed to improve work-related
outcomes in employees with musculoskeletal disorders differs from traditional
case management.
Assess the cost of intervention and its impact on administrative parameters such
as sick days, sick pay, and time of reimbursed rehabilitation.
Compare self-rated outcomes between employees assigned to active intervention and those subject to conventional case management.

Abstract
Sickness absenteeism caused by musculoskeletal disorders (MSDs) is a persistent and
costly occupational health challenge. In a prospective controlled trial, we compared the effects
on sickness absenteeism of a more proactive role for insurance case managers as well as
workplace ergonomic interventions with that of traditional case management. Patients with
physician-diagnosed MSDs were randomized either to the intervention group or the reference
group offered the traditional case management routines. Participants filled out a comprehensive
questionnaire at the initiation of the study and after 6 months. In addition, administrative data
were collected at 0, 6, and 12 months after the initiation of the project. For the entire 12-month
period, the total mean number of sick days for the intervention group was 144.9 (SEM 11.8)
days/person as compared to 197.9 (14.0) days in the reference group (P 0.01). Compared
with the reference group, employees in the intervention group significantly more often received
a complete rehabilitation investigation (84% versus 27%). The time for doing this was reduced
by half (59.4 (5.2) days versus 126.8 (19.2), P .01). The odds ratio for returning to work in
the intervention group was 2.5 (95% confidence interval 1.25.1) as compared with the
reference group. The direct cost savings were USD 1195 per case, yielding a direct
benefit-to-cost ratio of 6.8. It is suggested that the management of MSDs should to a greater
degree focus on early return to work and building on functional capacity and employee ability.
Allowing the case managers a more active role as well as involving an ergonomist in workplace
adaptation meetings might also be beneficial. (J Occup Environ Med. 2003;45:499506)
From the Department of Public Health and Caring Sciences, Section for Social Medicine and CEOS,
Center for Environmental Illness and Stress, Uppsala University, Uppsala, Sweden (Dr. Arnetz);
lgdalsvagen 14, 134 63 Ingaro, Sweden (Mr Sjogren); Skogs Forsakringskassa, 142 81 Skogs,
A
Sweden (Rydehn); and A-rehab, Inc., Brannerigatan 1, 116 38 Stockholm, Sweden(Mr Meisel).
Supported by a grant from the Research Unit of the Stockholm branch of the Swedish National
Health Insurance Plan.
Bengt Arnetz has no commercial interest related to this article.
Address correspondence to: Bengt B. Arnetz, MD, Section for Social Medicine, Department of Public Health
and Caring Sciences, Uppsala University, 751 85 Uppsala, Sweden; E-mail address: bengt.arnetz@pubcare.uu.se.
Copyright by American College of Occupational and Environmental Medicine
DOI: 10.1097/01.jom.0000063628.37065.45

espite much progress as to the cause

and prevention of musculoskeletal
disorders (MSDs), including symptoms from the neck, shoulder, and
upper and lower back, they continue
to be some of the most prevalent and
challenging occupational health
problems in industrialized countries.15 Low back disorders, a major
part of MSDs, affect up to 85% of
the population sometime during their
lifetime.6 It has been estimated that
in an industrialized setting, the lifetime incidence of lost time from
work because of lower back disorders is close to 30%.7 The costs for
MSDs are substantial, including lost
work time and productivity, medical
and rehabilitation services, workers
compensation, in addition to human
suffering.8 MSDs also make up a
disproportional percentage of the
costs of all workers compensation
claims. Thus, workers compensation claims for low back disorders
account for 15% to 25% of all claims
but represent up to 40% of the
costs.2,9 Furthermore, some 12% of
the claims with a disability duration
longer than 3 months account for
almost 90% of the costs.1,10 Webster
and Snook3 reported that MSDs
(musculoskeletal disorders/cumulative trauma disorders) on average
cost up to 10 times as much as that of
other workplace injuries. Two thirds
of the costs for MSDs were attributed to indemnity costs rather than
medical costs.
Based on the fact that MSDs remain one of the most challenging
and costly occupational health disor-

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Intervention for Employees with MSD-Related Absenteeism

ders, numerous prevention and interventions strategies have been advanced to decrease the burden on
individuals, health care organizations, and corporations. Ergonomic
improvements, fitness training, multidisciplinary biopsychosocial rehabilitation, and back school-type programs have been the most common
interventions.1114 Melhorn et al.2
reported substantial financial savings
from an intervention program designed to integrate a traditional occupational medicine clinic practice
with a disease-specific individual
risk assessment strategy for assigning risk and guiding interventions.
However, in more rigorously controlled intervention studies, most of
the initially encouraging findings do
not hold up with the possible exception for cognitive behavioral-based
interventions, preplacement risk assessment, and early physical therapy.2,12,14 Effectively reducing the
prevalence of MSDs, improving disease management, and decreasing
time off from work would result in
substantial savings by reducing
costs, increasing productivity, and
enhancing employees quality of life.
The purpose of the present prospective controlled study was to assess the possible beneficial effects
from early medical, rehabilitation
and vocational interventions on employee absenteeism and well-being.
The focus of the program was to
facilitate return to work and limit
extended absenteeism, since the
longer a person is absent the higher
the cost for MSDs at the same time
as the likelihood for ever returning to
work is reduced substantially.1
The hypothesis tested in the current study was that employees with
MSDs subject to early workplacebased interventions, focusing on ergonomic improvement and adaptation of workplace conditions, would
have less disability days and return
to work faster than those employees
with MSDs who were offered more
traditional disease and disability
management.

Materials and Methods

Administrative Setting
In Sweden, all employees are part
of the Swedish National Health Insurance plan. In case of sickness or
disability, employees receive financial reimbursement that is proportional to their salaries up to a ceiling
cap. In addition to the reimbursement
paid by the state, employers might
contribute complimentary sick-leave
pay. It is also possible to have additional private insurance. Most typically, however, the sick-leave pay
from the Swedish National Health
Insurance plan is the major source of
income during sick-leave for most
low- to medium-income employees
in Sweden.
Employers are required by law to
conduct an investigation as to suitable rehabilitation measures when an
employee has been out on sick leave
4 weeks or longer. The result of this
rehabilitation investigation should be
forwarded to the local branch office
of the Swedish National Insurance
Agency Fo rsa kringskassan (FK)
within 8 weeks of the employees
first sick-day. Under the ideal situation, based on the investigation, the
local branch office develops a plan
for the rehabilitation in collaboration
with the employee, employer, and
other necessary resources, such as
physicians, physical and occupational therapists. The role of FK is
thus one of ensuring that the insured
employee actually receives the rehabilitation deemed necessary. Each
branch office has a full or part-time
physician at their disposal. However,
firmly regulated in theory and law, in
reality only a minority of employers
actually conduct a rehabilitation investigation and then typically much
later than the 8 weeks stipulated by
law. It is a common phenomenon
that both employers as well as claims
adjustors at FK await the medical
investigation and diagnosis before
initiating the rehabilitation process.
Thus, an employee out sick because
of MSDs is not offered rehabilitation
and vocational services until months

Arnetz et al

have passed since the initiation of the

sick-leave process. Furthermore, a
large proportion, in some nonpublished studies as many as two out of
every three patients, does not receive
any adequate rehabilitation whatsoever.

Participants
Potential study participants were
selected from the rooster of all sickleave cases at the two local branches
of FK in Skogs and Handen, respectively, approximately 20 km (1.25
miles) south of the city of Stockholm. The inclusion criteria included
cases of both gender diagnosed with
a first or recurrent MSD. Prior history of MSDs did not disqualify a
person from inclusion as long as she
or he had recovered sufficiently to
return to work during the interim
period. Statistical power analysis indicated a need for at least 60 subjects
in the intervention and reference
groups, respectively, to achieve an
beta of 0.05 and a power of 0.95,
with a two-tailed P value of 0.05 to
detect a 20% difference on the major
outcome factors of interests; which
were days out sick at 6 and 12
months, respectively.
A total of 137 potential participants were selected at random from
the total pool of eligible subjects.
Every other subject was allocated to
either the intervention or reference
group, respectively, based on the
scheduled time of their visit to the
local insurance branch office. That
is, subjects baseline conditions were
assessed as they entered the study,
which occurred over a period of
time. The allocation to the control or
reference group, respectively, was
concealed for the employees at the
local insurance branch offices as
well as to the scientist responsible
for data analysis. It was not possible
to conceal group allocations to participating employees with MSDs, nor
the insurance branch managers or the
ergonomist that were part of the team
visiting the employers together with
the employee with MSD-related
sickness absenteeism.

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501

TABLE 1
Characteristics of the Study Population Divided into the Intervention and
Reference Groups, Respectively (absolute number (%) unless otherwise stated)
Variable*
Mean Age in years (S.D.)
Gender male/female
Profession
Blue collar, little education
Blue collar, skilled
White collar, 12 years ed.
Mid-level white collar
Skilled white collar with 12
years ed./manager
Mean working hours (SD)
Sick leave pay/day (SD) $
Diagnostic classification based on
the sick-leave certificate
Neck and shoulder
Back
Joint disorders/rheumatic
Other musculoskeletal symp

Intervention group
(n 65)

Reference group
(n 72)

42.7 (10.1)
31/41 (40/60)

42.1 (10.4)
26/39 (43.1/56.9)

54 (83.1)
6 (9.2)
2 (3.1)
3 (4.6)
0 ()

48 (66.6)
9 (12.5)
11 (15.3)
2 (2.8)
2 (2.8)

37.0 (6.8)
59.2 (13.7)

37.5 (11.3)
61.8 (19.3)

18 (27.7)
29 (44.6)
4 (6.2)
14 (21.5)

15 (20.8)
24 (33.3)
4 (5.6)
29 (40.3)

* There were no significant differences in the variables between the two study groups.

Characteristics of the study participants are depicted in Table 1. There

were no systematic and statistically
significant differences in background
characteristics between the intervention and reference groups, respectively.

Study Variables and

Data Collection
At the initiation of the study, a
number of relevant variables were
included to assess the effects of the
program. Table 2 depicts variables
included as well as means by which
data were collected. In addition to
those listed in Table 2, questions
were included concerning the participants view of vocational training,
changes in work tasks as a consequence of their MSD as well as
possible introduction of ergonomic
equipment in the workplace and
whether they believed such changes
would impact favorable on their
MSD. The participants also rated
how they thought being out on sickleave might impact them personally,
for example financially, accumulation of work, decreased social status,
and feelings of not being wanted.
Musculoskeletal symptoms were
rated on a four-point graded scale

indicating the intensity of MSD

symptoms, ranging from 1, not at all,
to 4, intense symptoms (pain all the
time). A revised and shortened form
of the Standardized Nordic Questionnaire for the analysis of musculoskeletal symptoms was used, including a depiction of the body
viewed from behind marked with
named section of the body, to which
specific MSD questions were referring.15
At the 6-month follow-up, participants were also asked to rate how
they perceived the role and commitment of the following in the rehabilitation process: employer, FK, and
representatives of the health care
system. Finally, questions were
asked pertaining to reasons why they
chose to return to work when that
had been the case. Choices offered
included: own free will; pressure
from one or more of the following:
family, employer, FK, colleagues at
work; request from the personal physician; or financial reasons.
Most of the questions and scales
used have previously been validated
in prior studies.16,17 Typically, responses were given using four- or
five-point-graded Likert-type ordinate-response scales. Self-rated

health was assessed using the standard question how one would rate
ones health with a five-point response scale ranging from very good
to very poor.18
The cost benefit analysis of the
intervention program used only direct costs. Thus, the decreased cost
for sick eave in the intervention
group was related to the direct costs
of the intervention including the addition of an occupational therapist/
ergonomist in the program, costs
generated by vocational and occupational training as well as ergonomic
improvements and purchasing of
tools. This is a conservative cost
benefit calculation since it does not
include indirect cost savings, such as
improved productivity and need for
less substitutes at work.2 The additional cost applying the present program design involving an occupational therapist/ergonomist was
450.000 Skr (USD 75,000).

Intervention Program
Participants on sick leave that had
been randomized to the intervention
group were asked within 1 week to
visit the local branch of FK for an
interview together with the FK case
manager for rehabilitation and an
occupational therapist/ergonomist.
At the time of the interview, potential participants were asked about
their interest to participate in the
project both in writing and verbally.
The purpose with the interview was
to get a better view of the employees own preferences and degree of
internal control over the rehabilitation process, their view of their current health status, work, and social
situation.
All potential participants received
a brief project description. They
were told that they were randomly
selected for the inclusion in a study
aimed at possible enhancing the
FKs management of the rehabilitation process and facilitate the persons own rehabilitation. They were
told that they had not been asked to
show up at the FK office from strict
administrative control purposes. The

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Intervention for Employees with MSD-Related Absenteeism

Arnetz et al

TABLE 2
Study Variables and Means by Which Data Were Collected
Variable Name

Description

Source

Medical diagnosis
Days to rehab investigation
Days to rehab plan
Days to rehabilitation
Rehab costs
Vocation service costs
6-month sick days
12-month sick days
Age, gender, and work hours
SRH

Medical diagnosis on MD certificate

Days from first sick day until rehabilitation investigation arrived from employer
Days from first sick day until FKs rehab plan
Days from first sick day until start of rehabilitation
Type and costs for purchase of rehab services
Costs for purchasing of vocational equipment
Cumulative number of sick days at 6 months
Cumulative number of sick days at 12 months
Age, gender, and working hours of participant
Self-rated health using a five-graded response scale

FK*
FK
FK
FK
FK
FK
FK
FK
FK/Q
Q

* FK, Local branch of the National Health Insurance Agency; Q, Questionnaire; SRH, self-rated health.

interviewers were bound by law to

keep all information confidential. All
persons asked whether they wanted
to be part of the study or not, volunteered to participate.
The interview focused on the persons social and occupational situation, education, ongoing or previous
rehabilitation experiences, professional career, their current employer,
working hours, travel time to and
from work as well as traveling arrangement to and from work, work
habits, work postures, and physical
work load, ergonomic equipment at
work, and psychosocial work characteristics. Functional capacity, work
demands, work capacity and work
duties that a person could perform
despite their current MSDs, as well
as how their health impacted on their
life in general were also discussed.
The interview was concluded by
questions concerning possible adaptation at work to confirm to the
persons current capacity. The possibility of vocational training was also
aired at this time.
Approximately 1 week later, the
employee, the FK case manager, the
occupational therapist/ergonomist,
and the employer met at the employees workplace. The workplace was
assessed from an ergonomic point of
view, physical and psychosocial
stressors were assessed by the ergonomist while the employee performed
his/her regular work tasks. When
appropriate, ergonomic improvements were introduced. Participants

that were deemed to benefit from

vocational training were given a personal training schedule to follow.
The training schedule included information on type of training and work
tasks adapted to the employees capacity, time allotted for each training
session, weeks of training, and a
schedule for the successive increase
in workload. The ergonomist instructed the participant once or,
when necessary, more times directly
at work. Participants were also encouraged to fill-out a semistructured
personal diary about their experience
of the training. They were all told not
to perform at their maximum capacity and stop whenever they experienced pain. The participants were
instructed that the diary should cover
the following topics: date, time,
work duties, for example, office
tasks, work postures, breaks, tasks
related to feelings of discomfort and
pain, and work tasks found to be fun
and stimulating as well as tiring and
boring. At the time of the workplace
visit, psychosocial issues were also
commonly addressed. For example,
it was not uncommon that the FK/
ergonomist team had to act as conflict resolution coaches.
The employer was encouraged to
complete a rehabilitation investigation and, when deemed necessary,
also offered support from the FK
case manager in completing the investigation. One of the goals with the
intervention was to increase the percentage of employees that were sub-

ject to a rehabilitation investigation

as well as to markedly decrease the
time both for the rehabilitation investigation and the subsequent rehabilitation plan developed by case managers at FK.
Only rarely was one intervention
sufficient to improve a persons
working conditions and capacity. In
most cases a combination of rather
limited changes were instituted. For
example, in the case of a municipal
park attendant with low back pain,
the work organization was changed,
tools were ergonomically improved,
and vocational training instituted. In
another case of a postal worker the
working methods were changed, ergonomic tools instituted, work tasks
were changed, vocational training
initiated, and she was referred to the
occupational health clinic.

Reference Group
The reference group received the
same information about the study
and questionnaires as did the intervention group. However, they were
not part of the semistructured interview nor were there any worksite
visits and improvement offered to
this group.

Summary of Differences
Between the Intervention and
Reference Groups
To summarize, the differences between the intervention and the reference groups were first of all the

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503

TABLE 3
Mean Sick Days during 0 6 Months, 6 12 Months, and the Entire 12-Month
Study Period by Intervention and Reference Group, Respectively, as Well as
Total Reimbursement from the National Health Insurance Plan During the
Study Period
Variable
Sick days 0 6 months
Sick days 6 12 months
Sick days 0 12 months
Total reimbursement from the
health insurance system/Skr
(USD equivalents)

Intervention
Group

Reference
Group

P Between
Groups

110 (6,5)
95.8 (13.1)
144.9 (11.8)
57,564 (4524)

131.1 (5.9)
150.3 (8.8)
197.9 (14.0)
73,178 (5805)

0.05
0.01
0.01
0.05

9,600 (754)

12,196 (970)

Mean (S.E.M.) days and Swedish Crowns, skr, respectively/person.

focus and speed of initiating workplace-based rehabilitation and accommodation efforts. Traditionally,
all rehabilitation and vocational initiatives are held back until the medical work-up and diagnosis are completed. In the present study, the focus
was on functional capacity and using
the remaining capacity of a person.
Early and parallel measures were
therefore encouraged. The objective
was to bring back the person as soon
as possible to work and adapt the
workplace to suit a persons current
capacity. The employees physicians
were asked for advice whenever necessary to ensure the parallel process
was not impairing the employees
recovery process and health.
For the intervention group, a semistructured assessment model was
used to review an employees current
psychosocial and physical work situation. At the same time, the visits
offered an opportunity for primary
preventive actions, because employers in many cases were offered advice beneficial also to other employees. In the model used in the current
study, the case managers at FK extended his/her work duties to also
include the role of a central integrator of the patients rehabilitation process, which entailed medical workups, medical rehabilitation and
vocational training.
The study was approved by the
Huddinge University Hospitals ethics committee (case number 367/95).
All participation was voluntary and

employees could withdraw at any

time without any consequences for
their own relationship with the FK,
medical and vocational rehabilitation.

Statistics
The intervention and reference
groups were compared using unpaired Students t tests for continuous variables and 2 for discrete
variables. Logistic regression analyses were used for more complex
modeling. Statistical significance
was set at a two-sided P 0.05.

Results
Results Based on Administrative
Data from the National Health
Insurance Administration
In the intervention group, employers of 55 of a total of 65 employees
submitted rehabilitation investigations as compared with 20 of 72 in
the reference group (P 0.05). The
time for employers in the intervention group to complete their rehabilitation investigation was 59.4 days
(S.E.M. 5.2) as compared to 126.8
days (19.2), P 0.01, in the reference group. The number of days
from initial sick leave to that the FK
had established a rehabilitation plan
was on average 49.4 days (2.5) in the
intervention group as compared with
183.5 (19.1) days in the reference
group (P 0.0001).
Work-oriented vocational rehabilitation was deemed appropriate for

27 of a total of 65 employees in the

intervention group as compared to 15
of 72 in the reference group (P
0.05). The time between the initial
sickness episode and the initiation of
work-related vocational rehabilitation was a mean of 88.1 (11.7) days
for the intervention group and 190.7
(22.7) days for the reference group
(P 0.001). The cost for the purchasing of externally supplied rehabilitation services was an average of
35,800 (USD 6000, n 12) Skr
(SEM 7176 Skr; USD 1200) in the
intervention group as compared to
16,821 (USD 2800, n 7) Skr (2016
Skr; USD 340) for the reference
group (P 0.05).
The total mean number of sick
days during the first and second half
of the study, as well as for the entire
study period, is depicted in Table 3.
For all three assessment period, the
number of sick days were significantly less in the intervention group
as compared with the reference
group.
The likelihood (odds ratio) that a
person in the intervention group
would be off sick leave after the
initial 6 months, as compared with
the reference group, was 1.9; 95%
C.I. 1.0; 3.6, P 0.06). At the end of
the 12-month follow-up period, the
equivalent odds ratio was 2.5; 1.2;
5.1, P 0.01).
There was no significant difference in the number of reimbursed
rehabilitation days between the two
groups during the first 6 months
(mean 40.0 days; SEM 5.3, P for
groups 0.7; n 22 for the intervention and 7 for the reference
group), neither during the subsequent
6- to 12-month period (43.3 days;
SEM 9.6, P 0.9; n 7 for both
groups). During the entire 12 months
period the mean days of paid rehabilitation was 50.4 days (6.1) with no
significant differences between
groups (P 0.8). During the entire
12 month period 23 subjects in the
intervention group as compared to 12
in the reference group received paid
rehabilitation days (P 0.05).

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Intervention for Employees with MSD-Related Absenteeism

The mean sick pay was 364 Skr

(USD 60) (SEM 8.8 Skr; USD 1.50)/
person. Table 3 shows that the total
reimbursement from the national
health insurance system was significantly lower for the intervention as
compared to the reference group.
The total reimbursement paid out
to the intervention group during the
12-month study period was
3,741,000 (USD 623,500: SEM
294,100 Skr/49,000 USD) Skr as
compared to 5,268,900 (USD
878,200; 418,000 Skr/USD 70,000,
P 0.01) for the reference group.
The direct cost of the intervention
was approximately 550,000 Skr
(USD 91,700) or 8,500 Skr (1,410)
per person for a total saving of
972,900 Skr (USD 162,150) or 7,164
Skr (USD 1,195) per case. The benefit-to-cost ratio being 6.8.

Results from the

Questionnaire Data
At baseline, the intervention and
reference groups were comparable
on most of the variables included in
the questionnaire. The one exception
was that participants in the intervention group to a larger degree believed
that they could influence things so
they would be able to go back to
work (P 0.001). However, regardless of groups, most participants
stated that they could not influence
things at all that would make it possible to go back to work (42%).
Twenty-eight percent responded that
they might be able to influence
things. Twenty percent stated that
they to a certain degree could influence when they would be able to go
back to work, and 10% answered that
they could do it to a large extent
(13% in the intervention as compared to 7% in the reference group).
At the 6-month follow-up, 65% of
the respondents reported that some
kind of initiatives had been taken to
facilitate their return to work (P for
groups NS).
At the follow-up those that had
returned to work stated that they at
that time had felt: completed healthy

(5%), just about completely recovered (26%), neither sick nor healthy
(34%), and still ill (35%). When the
responses were collapsed comparing
those that responded that they felt
healthy or just about completely recovered to all other responses, 22%
in the intervention group as compared to 9% in the reference group
responded that they had recovered by
the time they returned to work (P
0.05). Nineteen percent of all respondents believed that their rehabilitation in their long run would definitely favor their health (p between
groups NS). Thirty-six percent
believed the rehabilitation might
possible have some effects on their
long-term health whereas 28% and
17%, respectively, answered they
were doubtful or did not think that it
would have any impact (p between
groups NS).
The major reasons for returning to
work was foremost the participants
own free will (listed by 82% of the
respondents); however, pressure
from the employer (40%) as well as
economic reasons (36%) were also
listed as reasons.
Participants in the intervention
group rated that the role of the FK to
be significantly more supportive and
important during their rehabilitation
process than did the reference group
(88% versus 62% rated the FKs role
as favorable, P 0.05). The employers role in the rehabilitation process
was ranked favorable by 38% of the
respondents with no differences between groups. The role of the health
care sector in the rehabilitation process was ranked favorable by 84% of
the respondents (p between groups
NS).
A final question concerned the
participants ranking of their health
at the end of the 6-month follow-up
period. On the question, How
would you rate your health to day?
7.4% answered very good; 28.7%
fairly good; 28.7% reasonable;
17.0% rather poor, and 18.1% very
poor. There were no significant differences between groups, even when
those responding that their health

Arnetz et al

were very good and fairly good were

compared with all others.

Discussion
In the current investigation, a
1-year prospective controlled study
of the impact on MSDs-related sickness absenteeism of early workplacebased rehabilitation and adaptations
was carried out. The case managers
at the local National Health Insurance Agency (FK) played a much
more active role in integrating the
needs of the employee with available
resources. In addition, an occupational therapist/ergonomist was
added to the intervention. An important part of the intervention was to
accelerate the completion of the employers rehabilitation investigation
and the FK rehabilitation plan. Furthermore, an early and timely meeting at the employees workplace involving the employee, employer, the
FK case manager and the occupational therapist/ergonomist was a
central part of the intervention. The
idea was, in addition to cutting the
time from injury to rehabilitation and
return to work initiatives, to focus
more on functional capacity, rather
than focusing on what the employee
could not do.
Days out sick were significantly
shorter and the likelihood to return to
work was 50% higher in the intervention group as compared to the
reference group. The intervention
program was associated with significant savings. At baseline, the intervention and reference groups were
comparable on a wide range of measures, such as age, gender, income,
schooling, job functions, present, and
passed histories of MSDs. The selection of participants was randomized
as far as possible as was the allocation to the reference and intervention
groups, respectively. The study results are therefore likely to be representative for employees with MSDsrelated sick-leave.
Even though it is stipulated by law
that the employers should conduct a
rehabilitation investigation within 4
weeks when an employee has been

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Volume 45, Number 5, May 2003

out on sick leave for 4 weeks or

longer, in reality this is rarely the
case. In this study only 27% of the
employers conducted a rehabilitation
investigation in the reference group.
However, in the intervention group
as many as 85% of the employers
were able to complete their rehabilitation investigation. The FK case
manager and ergonomist played a
facilitating role in assisting the employers in completing the investigation. The rehabilitation investigation
in the intervention group was also
completed significantly faster. Thus,
the early intervention strategy enabled significantly more employers
to complete the investigation within
the time stipulated by law. In addition, the FK completed their rehabilitation plan significantly faster for
the intervention as compared to the
reference groups. Active rehabilitation, vocational training and ergonomic workplace improvement were
also introduced to a greater degree
and significantly earlier for the intervention group. The cost for purchasing external rehabilitation services
was twice as high for the 12 participants in the intervention group that
received this as compared with seven
in the reference group. Up-front investment to rehabilitate an employee
might cost more in the short-term but,
as shown in the present study, might
actually preserve substantial amount of
resources in the long-term.
The intervention strategy resulted
in an earlier and more comprehensive rehabilitation where the employees were encouraged at an early
stage to meet with the employers
and, together with the FK case manager and ergonomist, decide on necessary steps to enable their return to
work. The employees physicians
were involved to ensure that the persons health was not threatened by
the early return strategy. The close
collaboration between the FK, the
employer and the health care system
ensured that rehabilitation services
could be initiated already during the
time that medical work-ups were
planned or ongoing. Not only does

this save time, it also decreases the

risks for passivity and secondary sick
gains among the employee out on
sick leave.
A range of factors can influence
the duration of MSD-related sickness
absence, including existence of radiating pain, functional disability,
work-related characteristics, and personal characteristics, as well as comorbidity, that is, patients suffering
from more than one ailment.19 23 In
the current study, we were able to
control for the possible effects of a
range of relevant factors that might
impact on the return to work rate,
such as physical and psychosocial
work characteristics, comorbidity of
the musculoskeletal system, selfrated health, gender, and socioeconomics. There were no systematic
differences between the intervention
and reference groups with regard to
such factors. Therefore, we believe
the beneficial effects of our program
are attributed to the program per se.
It appears that the effects of our
program increase with time. Thus,
the odds ratio that a person would be
back at work in the intervention
group was 1.9 (P 0.06) at the
6-month follow up. At 12-month follow up, the odds ratio had increased
to 2.5 (P 0.01).
The benefit-to-cost ratio, based on
direct benefits and costs only, was
calculated to be 6.8, representing
cost savings of 7,200 Skr (USD
1,195) per case. This is within the
range reported by other researchers
concerning the benefit-to-cost ratio
for general health prevention. Melhorn et al.2 calculated a direct benefit-to-cost ratio of 34 for a comprehensive individual risk assessment
program aimed at decreasing MSDs.
Because the indirect cost is estimated
to be 3 to 14 times the direct costs,
using Melhorn et al. estimation of
8.5, the benefit-to-cost ratio in the
current study would be 58, with a
total saving of 60,950 Skr (USD
10,158) per case.
The responses to the 6-month follow-up questionnaire revealed that
participants in the intervention group

505

were significantly more favorable in

their view of the National Health
Insurance Agency as compared with
the control group. There were, however, no differences as to how favorable they rated the role of the health
care system (high) or the role and
commitment of their employer (lowto-medium). This suggests that an
active approach by the case manager
not only might result in a more favorable outcome based solely on
sickness absentee rates but also improve the rapport between the insurance organization and the insured
employee. The role and commitment
of the employer was rated rather low
with no significant differences between groups. These findings indicate a need to study the role and the
attitude of the employer and its possible impact on an employees likelihoood to return to work or not.
Only about one in five participants
felt healthy and recovered when they
returned to work. However, twice as
many in the intervention as compared to the reference group, felt
healthy and recovered when they returned to work. One important question is whether returning to work
before feeling healthy and recovered
impacts on long-term sick leave and
the MSDs prognosis.
The rating of the participants overall health revealed that only 35% rated
their health as very good or fairly
good. This compares unfavorable to
the general public where approximately 80% rate their health as very or
fairly good.18 Because self-rated
health is related to long-term wellbeing and longevity, there is a need to
further study possible associations between a history of MSDs and longterm health. There was no significant
difference in the current study between
self-rated health in the intervention and
reference groups, respectively.
We applied a rather broad program. Further research is needed to
identify what specific components of
the program are the most beneficial.
Basically, we introduced three factors: 1) early rehabilitation and return to work focus; 2) a closer col-

506

Intervention for Employees with MSD-Related Absenteeism

laboration among the employee,

employer, and the case manager at
the insurance agency; and 3) the
introduction of an ergonomist/
occupational therapist that participated in workplace-based rehabilitation and adaptation meetings.

Conclusion
MSDs account for a significant
proportion of work-related absenteeism. MSDs also make up a disproportional amount of direct and indirect cost for work-related
absenteeism. Early workplace-based
interventions resulted in a significant
reduction in sickness absentee and
costs. A key ingredient in the intervention was the creation of a more
proactive role for the case manager
at the insurance agency as well as the
introduction of an ergonomist who
participated in meetings with the employee and the employer. The rehabilitation investigation and the rehabilitation plans were completed to a
larger degree and significantly faster
for employees in the intervention
group. By applying the experience
and skills of the case manager as
well as the ergonomist to individual
workplaces knowledge sharing is enhanced to the benefit of both employers and employees at the same
time as the benefit-to-cost ratio is
very attractive. It is suggested that
future strategies to bring back employees with MSDs should be based
on the activity theory, focusing less
on what the employee can not do and
more what he or she, with appropriate interventions, can do at his/her
current place of work.

Acknowledgment
Mr Roland Meisel is an owner of A-Rehab,
Inc., the ergonomic firm used for the interventions.

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