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Int Arch Occup Environ Health (2009) 82:427–434

DOI 10.1007/s00420-008-0346-9

O R I G I N A L A R T I CL E

Outpatient rehabilitation of workers with musculoskeletal


disorders using structured workplace description
Stephan W. Weiler · Kay Peter Foeh · Anke van Mark ·
Rene Touissant · Nina Sonntag · Annette Gaessler ·
Johannes Schulze · Richard Kessel

Received: 6 March 2007 / Accepted: 25 June 2008 / Published online: 9 August 2008
© Springer-Verlag 2008

Abstract descriptions were given to the therapists and individual


Objectives In most industrialized countries musculoskele- return-to-work (rtw) schemes were implemented. Therapy
tal disorders contribute considerably (25%) to illness lasted from 3 to 4 weeks followed by workplace reintegra-
induced work absence. A special interest to reduce worker tion. OV-work-time was calculated from 0 to 6 years before
absences exists in highly specialized industries such as jet and 0 to 3 years after rehabilitation from insurance and
manufacturing, where speciWc knowledge is hard to industrial medical reports.
replace. We investigated the reduction and sustainability in Results A total of 97% of the patients returned to their
sick leave days by a workplace oriented outpatient rehabili- original job at the workplace, usually directly after the
tation program based on structured information exchange rehabilitation. Average sick leave days per year were
between occupational physicians and therapists. reduced from 48.8 § 32.8 days before to
Methods Sick leave days reduction and return-to-work- 34.2 § 37.3 days after the rehabilitation. The therapy
ratios were analysed for 79 male blue collar workers with interrupted an increase in sick leave days over the years
musculoskeletal disease, who voluntarily participated in an stabilizing absence at a low level for at least 2 years.
outpatient rehabilitation treatment between 2002 and 2005. Duration of illness related work absence was the only sig-
During rehabilitation therapy standardized workplace niWcant predictor for sick leave reduction (P < 0.05).
Other common risk factors for musculoskeletal diseases
like smoking or body mass index did not signiWcantly
inXuence the therapeutic eVect.
Conclusions Our results support evidence that informa-
All authors have contributed substantially to this article and thereby tion exchange for workplace description and rehabilitation
fulWlling the criteria of authorship.
therapist may help to reduce sick leave days and achieve
S. W. Weiler (&) · A. van Mark · R. Kessel very high rtw-ratio. However it is important to observe the
Institute of Occupational Medicine, University of Luebeck, eVects of this shared information for longer intervals.
Ratzeburger Allee 160, 23538 Luebeck, Germany
e-mail: info.contact@uni-luebeck.de Keywords Musculoskeletal disease · Airplane assembly ·
K. P. Foeh · N. Sonntag · A. Gaessler Outpatient vocational rehabilitation
Airbus Deutschland GmbH, Medical Services Hamburg NDAM,
Hamburg, Germany
Introduction
R. Touissant
Department for Orthopaedics,
Medica Hospital Leipzig, Leipzig, Germany Musculoskeletal disorders account for a large part of work
disability in most industrialized countries (Franche et al.
J. Schulze
2005). These disorders are responsible for 25% of illness-
OYce of the Dean, Faculty of Medicine,
Johann Wolfgang Goethe-University Frankfurt/Main, induced workplace absence in Germany and 30% in the
60590 Frankfurt/Main, Germany USA (RKI 2006; BLS 2006), and are the second most

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428 Int Arch Occup Environ Health (2009) 82:427–434

common reasons for physician consultations as well as Methods


early retirement (Osborne et al. 2007). This emphasizes the
importance of interventions to reduce such eVects. Study population
The prevalence of musculoskeletal pain increases with
age with a maximum in the Wfth and sixth decade, but is rel- The study was performed by the Institute of Occupational
evant in younger persons too (Bigos et al. 1986; Punnett Medicine, University of Luebeck, in cooperation with Air-
et al. 2004; Schmidt and Kohlmann 2005). In general bus Deutschland GmbH, Hamburg, Germany, and diVerent
women are more aVected by pain disorders including mus- social insurance companies. The study sample consisted of
culoskeletal pain (Andersson 1981; Punnett et al. 2004; 79 male aircraft workers age 25–56 years, with a mean of
Schierhout et al. 1995), probably due to increased pain rec- 40.4 § 8.0 years. A total of 42 worked as mechanics, 23 as
ognition, pain processing or memoralization (RKI 2006). In painters, 14 workers had diverse occupations. Most of the
addition iatrogenic factors have been discussed as contrib- patients suVered from back pain (n = 53, 67%), 9 patients
uting factors like gender-speciWc physician–patient interac- (11%) from shoulder pain, 11 patients suVered from diverse
tion (Burton et al. 1989) to account for the otherwise knee illnesses (14%). Miscellaneous pain localisations were
unexplained gender preference. Other known risk factors present in six patients (8%). Onset of complaints was given
are repetitive work strain as well as psychosocial factors by 65 patients and was widely variable with 37 to
like eVort/reward imbalance, high work demands, stress 5,514 days before rehabilitation started (mean of
and dissatisfaction (Anema et al. 2004; Hoogendoorn et al. 730 § 1,101 days). For 14 patients onset data were missing
2002; Nahit et al. 2003; Punnett et al. 2004; Pincus et al. or not reproducibly documented, with extremely diVerent
2002). onset dates given in the records.
Occupational risk factors for the onset and recurrence of Body mass index (BMI) ranged from 19.6 to 39.4 kg/m2
musculoskeletal complaints are reported for many indus- with a mean of 26.6 § 3.9 kg/m2 (median 25.8), other risk
trial sectors, e. g. healthcare, forestry, manufacturing and factors for musculoskeletal diseases are summarized in
food processing (Punnett et al. 2004; Häkkinen et al. 2001) Table 1.
and consist of work related strains like heavy loadings
(Frost et al. 2002), awkward postures (Hoogendoorn et al. Outpatient rehabilitation program
2002; Andersson 1981; Svensson and Andersson 1989;
Bernard 1997), vibrations (Andersson 1981; Boshuizen The evaluated program is the most intensive element of a
et al. 1992; Fredriksson et al. 2002; Bernard 1997) and con- stepwise intervention program to reduce sick leave due to
tinuous standing (Svensson and Andersson 1989; Andersen musculoskeletal disorders at airbus industries (Table 2).
et al. 2007). After becoming chronic musculosceletal disor- Eligible for this pre- post-intervention study were workers
ders remain a challenge both in diagnosis and treatment meeting grade IV criteria and volunteering for participation
(Koes et al. 2006; Walker-Bone and Cooper 2005); thus, in a vocational outpatient rehabilitation between 2002 and
ergonomic optimisation of working conditions is a prime 2005.
factor to decrease musculosceletal diseases within the limi- Following a written informed consent and clinical inves-
tations of workplace demands. tigation by occupational physicians the rehabilitation pro-
This study was conducted to investigate the eVect of gram was proposed if grading as “work ability at risk” was
workplace oriented outpatient rehabilitation program based conWrmed. If therapy was approved by health insurance a
on structured information exchange between occupational structured occupational information sheet was given to the
physicians and rehabilitation therapists on the duration of therapists. Those information included a standardized
sick leave. workplace description, ergonomic data sheet and photo
In one German aircraft plant internal health reports
stated excessive rates of sick leave due to musculoskele- Table 1 Risk factors for musculoskeletal disorders in the study popu-
tal complaints among airplane assembly workers and lation 79 German aircraft plant workers
varnishers. Improvements in ergonomics were planned No. % RKI 2006
and implemented when possible to avoid strenuous pos- (n = 79) (%)
tures; however, physiological conditions could not
always be met due to the special product geometry of air- Smoking 42 53 40
planes. Adipositas (BMI >30 kg/m2) 13 16 20
It is hypothesised that even exchange of critical infor- Psychosocial burden (on record) 33 42 No data
mation between the stakeholders in disability manage- Performing regular sport activities 14 18 41
ment, e.g. workers and supervisors, can reduce sick leave For comparison, data from the total German Population are given as re-
times. ported by the Robert Koch Institute ( 2006)

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Int Arch Occup Environ Health (2009) 82:427–434 429

Table 2 Structured intervention programme at Airbus


Grade Actually Work ability/cumulative Back pain characteristics Intervention
on sick sick leave (past 2 years)
leave

I No Not at risk/average Slight Behavioural therapy/preventive


back school program
II No Not at risk/<6 weeks Ongoing or recurrent Exercise therapy, 10 £ 4 h
during 5 weeks
III Yes At risk/<6 weeks Ongoing or recurrent Return to work program, medical
therapy, 15–20 £ 4 h during
3–4 weeks
IV Yes High risk/>6 weeks Chronic Outpatient rehabilitation, multiprofessional
team, 15–20 £ 4 h during 3–4 weeks,
if needed: graded work

documentation of the workplace in addition to the usual Patient history of clinical data coding was done in retro-
patient history and clinical Wndings at study inclusion. spect blinded to job or sick leave status. This was used to
Throughout the rehabilitation speciWc contacts were named evaluate the eVect strength on sick leave changes (pre vs.
at all cooperating institutions. post-treatment, patients vs. controls), duration of complaints
Outpatient rehabilitation lasted from 3 to 4 weeks with (onset to rehabilitation), age, body-mass-index as well as the
daily treatment of approximately 4–6 h per day. After the dichotomized factors smoking habits, regular sports,
Wrst 8 days of treatment the most reasonable way of work- recorded psychosocial burden as independent risk factors.
place reintegration was evaluated (Fig. 1), and occupational We evaluated the relative strength of each factor by mul-
physicians were informed accordingly. Regularly multidis- tiple linear regression retaining all variables with a signiW-
ciplinary team conferences were held with therapists and cant eVect for the F statistic. For statistical data analysis
Airbus health professionals to achieve optimal rehabilita- single missing values were substituted by variable mean
tion results and overcome communication diYculties. values to allow multiple linear regression analysis. Analysis
For all patients annual sick leave days were calculated was conducted with SPSS 15.0 (SPSS Inc, Chicago, USA).
by the appropriate health insurance fund. Sick leave data We consider data in boxplots as outliers if they do not Wt
were available for Airbus employees up to 5 years before within 1.5–3 box-lengths from the 75th percentile or 25th
treatment and up to 3 years following treatment. percentile, extreme values are cases with the values more

Fig. 1 Flowchart of the outpa-


tient rehabilitation and return to
work After the 8th day of treat-
ment a “return to work” (rtw)
decision was made and all study
participants were scheduled
according to the Xow chart

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430 Int Arch Occup Environ Health (2009) 82:427–434

than 3 box-lengths from the 75th percentile or 25th percen- reports. The most common suggestion for ongoing treat-
tile. SigniWcance level was deWned as P = 0.05. ment was “training by the patient itself” (75/79) without
The study was approved by the Ethics Committee of the further speciWcation.
Luebeck University (Germany) and informed consent had
been obtained from all subjects. Sick leave duration

Rehabilitation reduced the mean sick leave per year from


Results 48.8 § 32.8 days to 34.2 § 37.3 days (Student’s t test,
P = 0.002). A statistically signiWcant increase in sick leave
Workplace simulation during rehabilitation duration before rehabilitation was eVectively interrupted
(Fig. 3; Jonkheere-Terpstra-Test, P < 0.001). There seemed
Using the workplace description provided before rehabilita- to be no rebound in sick leave days up to 3 years after reha-
tion it was possible to simulate realistic workplace conditions bilitation (Jonkheere-Terpstra-Test, P = 0.341), but the
during rehabilitation treatment by using standard equipment sample size for long term observation post-treatment was
within the rehabilitation centre (Fig. 2). As can be seen from small (30/79 2 years, 7/79 > 2 years). Persons with higher
the Wgure ergonomic improvements of the workplace were sick leave duration before rehabilitation were more likely to
not the primary therapeutic focus—usually all conditions get a graded work rtw schedule (average sick leave in
were optimized if possible before rehabilitation took place. Group A 39.9 days/year, Groups B/C 63.3 days/year, Pt
By supervision it was possible to identify unilateral postures, Test = 0.03). After rehabilitation all groups had about the
to train eVective work strategies and to help the patients to same number of sick leave days with 36.4 and 39.0 days/
regain self-conWdence in their ability to work and tolerate year (Pt Test = 0.449).
limited pain by addressing pain beliefs and fear.
Outcome predictors
Return to work
Although there were signiWcant bivariate correlations
All patients except two successfully returned to their prior between sick leave days as outcome parameter and some
workplace. A sum of 49 of 79 Study participants (Group A) commonly known risk factors and predictors for musculo-
returned directly after the therapy without further voca- skeletal diseases (Table 3), the multiple linear regression
tional elements, 23 of 79 participants (Group B) were rein- analysis revealed only mean pre-treatment sick leave dura-
tegrated by the classical stepwise work scheme, 7 of 79 tion as predictor for good therapeutic success, i.e. a large
participants (Group C) needed an individualized reintegra- reduction of sick leave (Table 3). Reduction of sick leave
tion procedure usually including graded workload. Due to days per year is equal to 0.644 £ sick leave pre-treatment
the low numbers Groups B and C were combined for statis- (days/year) + 16.83, accounting for 25.3% of the variance
tical analysis. in sick leave days (R = 0.513, R-square 0.263, adjusted R-
A total of 90% of the patients had an “improved” state of square 0.253, SE 35.62). A rtw by a graded schedule also
health after rehabilitation according to the treatment had a high correlation with the number of sick leave days

Fig. 2 Comparison of work-


place and simulation during
therapy

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Int Arch Occup Environ Health (2009) 82:427–434 431

Fig. 3 Sick leave before (R¡)


and after (R+) rehabilitation.
Patients were grouped for the
time diVerence in years between
symptom onset and the calendar
year in which rehabilitation took
place. The data for the treatment
year were split into the interval
before (R ¡ 0) and after (R + 0)
rehabilitation and normalized for
a whole year. Boxes and whis-
kers represent quartiles,
O = Outlier, Asterisk = Extreme
values

Table 3 Correlations between outcome and potential risk indicators for musculoskeletal disease
Sick leave Sick leave Changes
change before in sick
(days/year) rehabilitation leave (%)

Sick leave change (days/year) 1.000 ¡0.520** ¡0.767**


0.000 0.000
Sick leave pre-rehabilitation (days/year) ¡0.520** 1.000 0.068
0.000 0.551
Age (years) 0.014 ¡0.089 ¡0.048
0.902 0.436 0.674
2
BMI (kg/m ) ¡0.048 ¡0.011 0.212
0.680 0.926 0.068
Smoking habit(0 = non smoker, 1 = smoker) ¡0.221* 0.359** ¡0.055
0.050 0.001 0.629
Psychosocial burden (0 = absent, 1 = present) ¡0.113 0.187 0.033
0.323 0.099 0.771
Regular physical activity (0 = no, 1 = yes) ¡0.198 ¡0.070 0.213
0.081 0.541 0.059
Duration of complaints before rehabilitation (years) ¡0.133 ¡0.101 0.119
0.291 0.422 0.344
Graded work rtw schedule (0 = no, 1 = yes) 0.254* ¡0.379** ¡0.097
0.024 0.001 0.393
EVects of known risk factors for musculoskeletal disease were analysed by multiple regression; results are given as bivariate nonparametric
correlation coeYcients (rho) for a two tailed analysis
* SigniWcant at the 0.05 level
** SigniWcant at the 0.01 level

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432 Int Arch Occup Environ Health (2009) 82:427–434

Table 4 Excluded variables in the multiple linear regression model for risk factor inXuence on sick leave days
Excluded variable Beta In t Sig. Partial
correlation

Graded work rtw schedule (0 = no, 1 = yes) 0.024 0.226 0.822 0.026
Age (years) 0.033 0.336 0.738 0.039
BMI (kg/m2) ¡0.082 ¡0.832 0.408 ¡0.095
Smoking habits (0 = non smoker, 1 = smoker) ¡0.064 ¡0.609 0.544 ¡0.070
Psychosocial burden (0 = absent, 1 = present) ¡0.005 ¡0.049 0.961 ¡0.006
Regular physical activity (0 = no, 1 = yes) ¡0.179 ¡1.858 0.067 ¡0.208
Duration of complaints before rehabilitation (years) 0.174 1.805 0.075 0.203
Sick leave days change before and after intervention (mean days per year) were set as dependent variable, with risk factors as independent variable
tested for inXuence. Sick leave change pre/post-treatment (mean days/year), predictor in the model: sick leave pre-treatment

before intervention indicating that this pattern of work changes (optimized communication, workplace customiza-
return applied mostly for severely handicapped workers. tion of rehabilitation procedures) could easily be evaluated
All other factors tested including physical activity and for other workplace situations as well as the eVect strength
duration of complaints showed no signiWcant correlation to over longer time periods.
the sick leave days change (Table 4). Another advantage over conventional rehabilitation
schedules was the increasing interest of the therapists in
occupational aspects concerning functional limitations and
Discussion work demands.
Limitations of our study are the small sample size, the
There is strong evidence that duration of work disability is lack of a control group and the low number of persons
signiWcantly reduced by contact between healthcare pro- observed for 2 or more years after therapy. Most data were
vider and workplace, although the available evidence for collected by insurances or industrial medical services for
the sustainability of these eVects is limited (Bendix et al. routine purposes and had to be recoded for statistical analy-
1998; Franche et al. 2005; Steenstra et al. 2006). We have sis; this resulted in only a few parameters with complete
investigated the inXuence of optimized rehabilitation and reliable documentation. Therefore, some factors
schedules focused on speciWc work burden and optimal reported to be relevant had to be omitted from the statistical
communication between employer and healthcare provider; analysis, e.g. history of pain, individual (pain or work)
our data suggest a major reduction of sick leave days for at beliefs, behavioural changes, functional limitations, extent
least 2 years after rehabilitation and the disruption of a of physical activity, psychosocial stressors. Also, some
trend of increasing sick leave days over the years before clinical as well as radiological Wndings were not considered
intervention. The presence of this increase indicates the as relevant factors (Bigos et al. 1992; Boos et al. 2000;
necessity to improve the work ability in workers with back Savage et al. 1997; van Tulder 1997 and Waddell and
complaints. Burton 2001).
The sick leave reduction shown here exceeds the eVects Other known risk factors for the incidence of musculo-
of non-invasive therapy regimen in musculoskeletal dis- skeletal diseases are age, sex, body mass index (Bernard
eases (van Tulder et al. 2006; Weiler et al. 2006; Heymans 1997) or smoking (Cassou et al. 2002); however, the pre-
et al. 2007); in addition, we had a 97% return-to-work ratio dictive value of these factors was low in our cohort. In
1 year post-treatment, whereas Anema et al. (2004) and patient records from both occupational and family physi-
Heymans et al. (2007) reported a 70–75% rtw rate as nor- cians most patient history and physical examination data
mal. Our results suggest that sick leave duration before are incompletely documented, especially for healthy work-
rehabilitation is more predictive than the reintegration ers; thereby these data usually are of poor quality. In Ger-
model with or without graded work, but this result may be many occupational medical examination is voluntary as
biased by the fact that workers with high sick leave prefera- long as no speciWc health threat exists, even if work-related
bly got a graded work rtw-schedule. related complaints are common and well known.
The changes implemented in this rehabilitation proce- From our data average sick leave days should be
dure are rather simple and consist of detailed workplace regarded as predictors for the necessity of rehabilitation
descriptions handed out to the therapists. A brief report procedures; and are more likely to be reduced signiWcant
after 8 days of treatment enabled the possibility of early the higher the initial number of sick leave days was. Both
workside rtw-action; therefore the eVectivity of these political opinion and insurance companies emphasize fac-

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Int Arch Occup Environ Health (2009) 82:427–434 433

tual data, suggesting that data from self report question- 3–4 months. Occup Environ Med 61:289–294. doi:10.1136/
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Bendix AE, Bendix T, Haestrup C, Busch E (1998) A prospective, ran-
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ation (van der Giezen et al. 2000). doi:10.1007/s005860050040
Known barriers to work return for patients with muscu- Bernard BP (ed) (1997) Musculoskeletal disorders and workplace fac-
tors: a critical review of epidemiologic evidence for work-related
loskeletal diseases not addressed in this study are chronic musculoskeletal disorders of the neck, upper extremity, and low
pain (Straaton et al. 1998; Buchner et al. 2007), psychoso- back. National Instiute for Occupational Safety and Health. http:/
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Pincus et al. (2008). They ought to focus on factors possi- bour Nonfatal Occupational Injuries and Illnesses Requiring Days
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Boos N, Semmer N, Elfering A, Schade V, Gal I, Zanetti M et al (2000)
administered instruments have the same sensitivity to pre- Natural history of individuals with asymptomatic disc abnormal-
dict further sick leave as longer ones (Lindberg et al. 2008); ities in magnetic resonance imaging. Spine 25:1484–1492.
however our results indicate that questions for preceding doi:10.1097/00007632-200006150-00006
sick leave should be included. Boshuizen HC, Bongers PM, Hulshof CTJ (1992) Self-reported back
pain in fork-lift truck and freight-container tractor drivers ex-
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Conclusions Buchner M, Neubauer E, Zahlten-Hinguranage A, Schiltenwolf M
(2007) The inXuence of the grade of chronicity on the outcome of
multidisciplinary therapy for chronic low back pain. Spine
Our data support the notion that occupational physicians 32:3060–3066
should improve contacts both to the workplace and the Burton AK, Tillotson KM, Troup JDG (1989) Prediction of low-back
medical provider; improving communication and individu- trouble frequency in a working population. Spine 14:939–946.
alizing the rehabilitation leads to sustainable reduction of doi:10.1097/00007632-198909000-00005
Cassou B, Derriennic F, Monfort C, Norton J, Touranchet A (2002)
sick leave time and a very high rate of successful workplace Chronic neck and shoulder pain, age, and working conditions:
reintegration. The concept has been useful for rehabilitation longitudinal results from a large random sample in France. Occup
purposes in this study, possibly because relevant pain Environ Med 59:537–544. doi:10.1136/oem.59.8.537
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Institute for Work and Health (IWH) Workplace-Based RTW
Acknowledgments We acknowledge the support by the “Techniker Intervention Literature Review Research Team: workplace-based
Krankenkasse” (TK) and the German pension insurance (“Deutsche return-to-work interventions: a systematic review of the quantita-
Rentenversicherung Nord”) in sick leave days calculations and Wnanc- tive literature. J Occup Rehabil 15:607–631. doi:10.1007/s10926-
ing of the rehabilitation treatment, respectively. 005-8038-8
Fredriksson K, Alfredsson L, Ahlberg G, Josephson M, Kilbom Å,
ConXict of interest statement None. Wigaeus Hjelm E et al (2002) Work environment and neck and
shoulder pain: the inXuence of exposure time. Results from a pop-
ulation based case-control study. Occup Environ Med 59:182–
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