Adding work-focus to multidisciplinary interventions in specialist care
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This thesis examines the effect of a work-focused intervention in specialist care for sick-listed patients with neck or low back pain on return to work (RTW), pain and disability. Neck and back pain is the leading cause of years lived with disability. A high proportion of patients with a chronic course of pain and disability are referred to specialist care. In the search for an effective treatment for pain-related work disability, multidisciplinary rehabilitation programs that focus on reducing the obstacles to return to work (RTW) have been developed. The effect of these interventions in countries with different financial compensation systems and labour markets is unknown. Most studies have been conducted in primary care or occupational settings, and whether these interventions are as effective in specialist care is unknown. Therefore, the main objective of this thesis is to evaluate whether work-focused interventions could reduce the time until RTW compared with multidisciplinary interventions in specialist care. Secondly, we wanted to explore the effect of work-focused interventions on fear-avoidance beliefs regarding work, pain and disability. Thirdly, to evaluate the associations among pain, disability, anxiety, depression and the perception of psychological and social factors at work. We found a median time until RTW of approximately 160 days. Nearly three-quarters of the patients returned to work after 12 months, without any differences between the intervention and control groups. The improvement in pain and disability was similar in the two intervention groups. The work-focused intervention group focused specifically on reducing the barriers to RTW, including fear, but fear avoidance of work decreased similarly in both the work-focused and control groups after the intervention. A clinically relevant change in the fear avoidance of work after the intervention significantly increased the probability of RTW (OR 3.60), and a change in fear avoidance of physical activity increased the likelihood of a clinically important improvement in disability scores (OR 3.65). Of the assessed medical factors, anxiety and depression showed the most association with psychological and social factors at work. The degree of pain and disability at baseline Showed surprisingly low associations with the perceived psychological and social factors at work. Our results support similar effect of multidisciplinary interventions and work-focused intervention in specialist care on RTW, pain and disability outcomes. A reduction in fear avoidance after treatment predicted better outcomes, and may be one of the mechanisms behind improvement in both interventions.