title: Early intervention for back-injured nurses at a large Canadian tertiary care hospital: an evaluation of the effectiveness and cost benefits of a two-year pilot project. Effectiveness of adjuvant occupational therapy in employees with depression: design of a randomized controlled trial Return to work after a workplace-oriented intervention for patients on sick-leave for burnout - a prospective controlled study The implementation of occupational health guidelines principles for reducing sickness absence due to musculoskeletal disorders. Prevention of recurrent sickness absence among employees with common mental disorders: design of a cluster-randomised controlled trial with cost-benefit and effectiveness evaluation Collaborative care for major depressive disorder in an occupational healthcare setting. Cost effectiveness of a multi-stage return to work program for workers on sick leave due to low back pain, design of a population based controlled trial [ISRCTN60233560] Effectiveness of early part-time sick leave in musculoskeletal disorders Randomised controlled trial of integrated care to reduce disability from chronic low back pain in working and private life Mini-Intervention for Subacute Low Back Pain: A Randomized Controlled Trial Multidisciplinary Collaborative Care for Depressive Disorder in the Occupational Health Setting: design of a randomised controlled trial and cost-effectiveness study The Effects of a Graded Activity Intervention for Low Back Pain in Occupational Health on Sick Leave, Functional Status and Pain: 12-Month Results of a Randomized Controlled Trial A Population‐Based, Randomized Clinical Trial on Back Pain Management Randomized Controlled Trial of Workplace-based Rehabilitation for Work-related Rotator Cuff Disorder The epidemiology of back injuries in nurses at a large Canadian tertiary care hospital: implications for prevention. Economic Evaluation of a Problem Solving Intervention to Prevent Recurrent Sickness Absence in Workers with Common Mental Disorders Cost-Utility Analysis of a Collaborative Care Intervention for Major Depressive Disorder in an Occupational Healthcare Setting Economic evaluation of a workplace intervention for sick-listed employees with distress Substantial sick-leave costs savings due to a graded activity intervention for workers with non-specific sub-acute low back pain Work-focused treatment of common mental disorders and return to work: a comparative outcome study. The Effectiveness of Standard Care, Early Intervention, and Occupational Management in Worker’s Compensation Claims The effect of graded activity on patients with subacute low back pain: a randomized prospective clinical study with an operant-conditioning behavioral approach. Cost-benefit and cost-effectiveness analysis of a disability prevention model for back pain management: a six year follow up study Adjuvant occupational therapy for work-related major depression works: randomized trial including economic evaluation. Graded Activity for Low Back Pain in Occupational Health Care Multimodal cognitive-behavioural treatment for workers with chronic spinal pain: a matched cohort study with an 18-month follow-up A Prospective Study Evaluating Early Rehabilitation in Preventing Back Pain Chronicity in Mine Workers Collaborative care for sick-listed workers with major depressive disorder: a randomised controlled trial from the Netherlands Depression Initiative aimed at return to work and depressive symptoms The Effectiveness of Standard Care, Early Intervention, and Occupational Management in Workers’ Compensation Claims: Part 2 Return to work after early part-time sick leave due to musculoskeletal disorders: a randomized controlled trial. Adjuvant occupational therapy improves long-term depression recovery and return-to-work in good health in sick-listed employees with major depression: results of a randomised controlled trial The secondary prevention of low back pain: a controlled study with follow-up The causality field (extrinsic and intrinsic factors) in industrial subacute low back pain patients. A two-year follow-up on a program theory of return to work intervention. Predictors of time loss after back injury in nurses. Work-related treatment for major depressive disorder and incapacity to work: preliminary findings of a controlled, matched study. A workplace intervention for sick-listed employees with distress: results of a randomised controlled trial Early Intervention Options for Acute Low Back Pain Patients: A Randomized Clinical Trial with One-Year Follow-Up Outcomes Economic Evaluation of a Multi-Stage Return to Work Program for Workers on Sick-Leave Due to Low Back Pain Management of occupational back pain: the Sherbrooke model. Results of a pilot and feasibility study. Mini-Intervention for Subacute Low Back Pain: Two-Year Follow-up and Modifiers of Effectiveness Vocational training integrated into inpatient psychosomatic rehabilitation – short and long-term results from a controlled study Components of Initial and Residual Disability After Back Injury in Nurses Multidisciplinary Rehabilitation for Subacute Low Back Pain: Graded Activity or Workplace Intervention or Both?: A Randomized Controlled Trial Graded activity for workers with low back pain: who benefits most and how does it work? Early Occupational Health Management of Patients with Back Pain: A Randomized Controlled Trial Prevention of recurrent sickness absence in workers with common mental disorders: results of a cluster-randomised controlled trial
abstract: This study evaluated a two-year multidisciplinary early intervention pilot programme for back-injured nurses employed at a large teaching hospital , using a pre- versus post-programme analysis . The purpose was to ascertain whether this programme could reduce the incidence , morbidity , time lost and cost due to  back injuries in the 250 nurses employed on ten targeted high-risk wards . Injuries in the remaining 1395 nurses employed on the other 45 wards were monitored concurrently for comparison . The programme consisted of prompt assessment , treatment and rehabilitation through modified work . Evaluative data were gathered by one research nurse on st and ardized forms at the time of injury , weekly until return to work , and at a six-month follow-up . Time lost and cost data for up to one-year post-injury were derived from workers ' compensation statements . Compared to the two years prior to introduction of the programme , the rates of back injuries and lost-time back injuries decreased by 23 % and 43 % , respectively , on the targeted wards , while these increased on the control wards . Combined expenditure was 32 % lower per injury and 34 % lower per lost-time injury for those in the targeted group who consented to take part in the programme compared to their counterparts on the control wards , as the increased assessment and treatment costs per case attributable to the programme were more than offset by the savings in lower compensation ( wage loss ) costs . This programme thus reduced the incidence and time lost due to back injuries and was cost-beneficial Background Major depressive disorder is among the medical conditions with the highest negative impact on work outcome . However , little is known regarding evidence -based interventions targeting the improvement of work outcomes in depressed employees . In this paper , the design of a r and omized controlled trial is presented in order to evaluate the effectiveness of adjuvant occupational therapy in employees with depression . This occupational intervention is based on an earlier intervention , which was design ed and proven effective by our research group , and is the only intervention to date that specifically targets work outcome in depressed employees . Methods / Design In a two-arm r and omized controlled trial , a total of 117 participants are r and omized to either ' care as usual ' or ' care as usual ' with the addition of occupational therapy . Patients included in the study are employees who are absent from work due to depression for at least 25 % of their contract hours , and who have a possibility of returning to their own or a new job .  The occupational intervention consists of six individual sessions , eight group sessions and a work-place visit over a 16-week period . By increasing exposure to the working environment , and by stimulating communication between employer and employee , the occupational intervention aims to enhance self-efficacy and the acquisition of more adaptive coping strategies . Assessment s take place at baseline , and at 6 , 12 , and 18-month follow-ups . Primary outcome measure is work participation ( hours of absenteeism and time until work resumption ) . Secondary outcome measures are work functioning , symptomatology , health-related quality of life , and neurocognitive functioning . In addition , cost-effectiveness is evaluated from a societal perspective . Finally , mechanisms of change ( intermediate outcomes ) and potential patient-treatment matching variables are investigated . Discussion This study hopes to provide valuable knowledge regarding an intervention to treat depression , one of the most common and debilitating diseases of our time . If our intervention is proven ( cost- ) effective , the personal , economic , and health benefits for both patients and employers are far-reaching . Trial registration Background In the present study the effect of a workplace-oriented intervention for persons on long-term sick leave for clinical burnout , aim ed at facilitating return to work ( RTW ) by job-person match through patient-supervisor communication , was evaluated . We hypothesised that the intervention group would show a more successful RTW than a control group . Methods In a prospect i ve controlled study , subjects were identified by the regional social insurance office 2 - 6 months after the first day on sick leave . The intervention group ( n = 74 ) was compared to a  control group who had declined participation , being matched by length of sick leave ( n = 74 ) . The RTW was followed up , using sick-listing register data , until 1.5 years after the time of intervention . Results There was a linear increase of RTW in the intervention group during the 1.5-year follow-up period , and 89 % of subjects had returned to work to some extent at the end of the follow-up period . The increase in RTW in the control group came to a halt after six months , and only 73 % had returned to work to some extent at the end of the 1.5-year follow-up . Conclusions We conclude that the present study demonstrated an improvement of long-term RTW after a workplace-oriented intervention for patients on long-term sick leave due to burnout . Trial registration Current Controlled Trials NCT01039168 BACKGROUND Occupational health guidelines recommend a biopsychosocial approach to manage  sickness absence due to musculoskeletal disorders ( MSDs ) , with a primary focus on early intervention through provision of a supportive network . AIMS To investigate the implementation of a guidelines -based intervention ( early contact of absentees ; addressing psychosocial obstacles ; offering temporary modified work ; communicating among the players ) , and to determine whether this is effective for reducing return-to-work times and duration of future absence . METHODS A non-r and omized controlled trial was conducted within a UK company . Occupational health nurses at two experimental sites ( 1,435 workers ) were trained to deliver the intervention to workers taking absence due to MSDs ( low back and upper limb disorders ) , while usual care was delivered at three control sites ( 1,483 workers ) .  Company-recorded absence data were collected over a 12-month follow-up period . RESULTS The implementation of the experimental intervention was impeded by unforeseen organizational obstacles at one site ( policies , procedures and individual approaches ) which had a detrimental effect on uptake and delivery . At the site where the intervention was delivered per protocol , absence was significantly less compared with controls ; 6.5 and 10.8 days , respectively . However , the duration of future absence was not significantly different ( 13.0 and 25.1 days , respectively ) . CONCLUSIONS An early intervention addressing psychosocial obstacles to recovery can be effective for reducing absence due to MSDs . Successful implementation , where the key players are onside and organizational obstacles are overcome , is difficult to achieve Background Common mental disorders , such as depression , anxiety disorder , and adjustment disorder , have emerged as a major public and occupational health problem in many countries . These disorders can have severe consequences such as absenteeism and work disability . Different interventions have been developed to improve the return-to-work of employees with common mental disorders , but still a large proportion of employees experiences health and work problems after their return-to-work . For this reason , the SHARP-at work intervention is developed to prevent a relapse of sickness absence among employees who have returned to work after a period of sickness absence because of common mental disorders . We aim to evaluate the effectiveness , cost-benefit and process of the intervention compared to care as usual . Methods / Design The study is design ed as a cluster-r and omised controlled trial with r and omisation at the level of the occupational physician . Employees who have returned to work after a period of sickness absence because of a common mental disorder are included in the study . Employees in the intervention group will receive the SHARP-at work intervention . The intervention focusses on active guidance of employees by occupational physicians  during the first weeks of work after sickness absence . Employees in the control group  will receive care as usual . Outcomes will be assessed at baseline and at 3 , 6 , and 12 months follow-up . The primary outcome is cumulative recurrent sickness absence days . Secondary outcome measures are mental health , work functioning , and coping . Adherence to the protocol , communication between stakeholders , and satisfaction with the treatment are the process measures assessed in both study groups . Cost-benefit is calculated from a societal perspective . Finally , prognostic factors for a relapse of sickness absence are investigated . Discussion This study goes beyond return-to-work by focussing on the prevention of recurrent sickness absence . The study incorporates not only outcomes on sickness absence and mental health but also on health-related work functioning . The results of this study can contribute to a further development of practice guidelines and the promotion of sustainable work participation . Trial registration R and omised controlled trial to evaluate the effectiveness of collaborative care in a Dutch occupational healthcare setting : 126 workers on sick leave with major depressive disorder were r and omised to usual care ( n = 61 ) or collaborative care ( n = 65 ) . After 3 months , collaborative care was more effective on the primary outcome measure of treatment response ( i.e. reduction in symptoms of ≥50 % ) on the Patient Health Question naire-9 ( PHQ-9 ) . However , the groups did not differ on the PHQ-9 as a continuous outcome measure . Implication s of these results are discussed Background To describe the design of a population based r and omized controlled trial ( RCT ) , including a cost-effectiveness analysis , comparing participative ergonomics interventions between 2–8 weeks of sick leave and Grade d Activity after 8 weeks of sick leave with usual care , in occupational back pain management . Methods Design : An RCT and cost-effectiveness evaluation in employees sick-listed for a period of 2 to 6 weeks due to low back pain . Interventions used are 1 . Communication between general practitioner and occupational physician plus Participative Ergonomics protocol performed by an ergonomist . 2 . Grade d Activity based on cognitive behavioural principles by a physiotherapist . 3 . Usual care , provided by an occupational physician according to the Dutch guidelines for the occupational health management of workers with low back pain . The primary outcome measure is return to work . Secondary outcome measures are pain intensity , functional status and general improvement . Intermediate variables are kinesiophobia and pain coping . The cost-effectiveness analysis includes the direct and indirect costs due to low back pain . The outcome measures are assessed before r and omization ( after 2–6 weeks on sick leave ) and 12 weeks , 26 weeks and 52 weeks after first day of sick leave . Discussion The combination of these interventions has been subject of earlier research in Canada . The results of the current RCT will : 1 . crossvali date the Canadian findings in an different sociocultural environment ; 2 . add to the cost-effectiveness on treatment options for workers in the sub acute phase of low back pain . Results might lead to alterations of existing (inter)national guidelines Background The importance of staying active instead of bed rest has been acknowledged in the management of musculoskeletal disorders ( MSDs ) . This emphasizes the potential benefits of adjusting work to fit the employee 's remaining work ability . Despite part-time sick leave being an official option in many countries , its effectiveness has not been studied yet . We have design ed a r and omized controlled study to assess the health effects of early part-time sick leave compared to conventional full-day sick leave . Our hypothesis is that if work time is temporarily reduced and work load adjusted at the early stages of disability , employees with MSDs will have less disability days and faster return to regular work duties than employees on a conventional sick leave . Methods / Design The study population will consist of 600 employees , who seek medical advice from an occupational physician due to musculoskeletal pain . The inclusion requires that they have not been on a sick leave for longer than 14 days prior to the visit . Based on the physician 's judgement , the severity of the symptoms must indicate a need for conventional sick leave , but the employee is considered to be able to work part-time without any additional risk . Half of the employees are r and omly allocated to part-time sick leave group and their work time is reduced by 40–60 % , whereas in the control group work load is totally eliminated with conventional sick leave . The main outcomes are the number of days from the initial visit to return to regular work activities , and the total number of sick leave days during 12 and 24 months of follow-up . The costs and benefits as well as the feasibility of early part-time sick leave will also be evaluated . Conclusion This is the first r and omised trial to our knowledge on the effectiveness of early part-time sick leave compared to conventional full-time sick leave in the management of MSDs . The data collection continues until 2011 , but preliminary results on the feasibility of part-time sick leave will be available already in 2008 . The increased knowledge will assist in better decision making process regarding the management of disability related to MSDs . Trial Registration International St and ard R and omised Controlled Trial Number Register , register number IS RCT Objective To evaluate the effectiveness of an integrated care programme , combining a patient directed and a workplace directed intervention , for patients with chronic low back pain . Design Population based r and omised controlled trial . Setting Primary care ( 10 physiotherapy practice s , one occupational health service , one occupational therapy practice ) and secondary care ( five hospitals ) . Participants 134 adults aged 18 - 65 sick listed for at least 12 weeks owing to low back pain . Intervention Patients were r and omly assigned to usual care ( n=68 ) or integrated care ( n=66 ) . Integrated care consisted of a workplace intervention based on participatory ergonomics , involving a supervisor , and a grade d activity programme based on cognitive behavioural principles . Main outcome measures The primary outcome was the duration of time off work ( work disability ) due to low back pain until full sustainable return to work . Secondary outcome measures were intensity of pain and functional status . Results The median duration until sustainable return to work was 88 days in the integrated care group compared with 208 days in the usual care group ( P=0.003 ) . Integrated care was effective on return to work ( hazard ratio 1.9 , 95 % confidence interval 1.2 to 2.8 , P=0.004 ) . After 12 months , patients in the integrated care group improved significantly more on functional status compared with patients in the usual care group ( P=0.01 ) . Improvement of pain between the groups did not differ significantly . Conclusion The integrated care programme substantially reduced disability due to chronic low back pain in private and working life . Trial registration Current Controlled Trials IS RCT N28478651 Study Design . R and omized controlled trial . Objectives . To investigate the effectiveness and costs of a mini-intervention , provided in addition to the usual care , and the incremental effect of a work site visit for patients with subacute disabling low back pain . Summary of Background Data . There is lack of data on cost-effectiveness of brief interventions for patients with prolonged low back pain . Methods . A total of 164 patients with subacute low back pain were r and omized to a  mini-intervention group ( A ) , a work site visit group ( B ) , or a usual care group ( C ) . Groups A ( n = 56 ) and B ( n = 51 ) underwent one assessment by a physician plus a physiotherapist . Group B received a work site visit in addition . Group C served as controls ( n = 57 ) and was treated in municipal primary health care . All patients received a leaflet on back pain . Pain , disability , specific and generic health-related quality of life , satisfaction with care , days on sick leave , and use and costs of health care consumption were measured at 3- , 6- , and 12-month follow-ups . Results . During follow-up , fewer subjects had daily pain in Groups A and B than in Group C ( Group A vs. Group C , P = 0.002 ; Group B vs. Group C , P = 0.030 ) . In Group A , pain was less bothersome ( Group A vs. Group C , P = 0.032 ) and interfered less with daily life ( Group A vs. Group C , P = 0.040 ) than among controls . Average days on sick leave were 19 in Group A , 28 in Group B , and 41 in Group C ( Group A vs. Group C , P = 0.019 ) . Treatment satisfaction was better in the intervention groups than among the controls , and costs were lowest in the mini-intervention group . Conclusions . Mini-intervention reduced daily back pain symptoms and sickness absence , improved adaptation to pain and patient satisfaction among patients with subacute low back pain , without increasing health care costs . A work site visit did not increase effectiveness Background Major depressive disorder ( MDD ) has major consequences for both patients and society , particularly in terms of needlessly long sick leave and reduced functioning . Although evidence -based treatments for MDD are available , they show disappointing results when implemented in daily practice . A focus on work is also lacking in the treatment of depressive disorder as well as communication of general practitioners ( GPs ) and other health care professionals with occupational physicians ( OPs ) . The OP may play a more important role in the recovery of patients with MDD . Purpose of the present study is to tackle these obstacles by applying a collaborative care model , which has proven to be effective in the USA , with a focus on return to work ( RTW ) . From a societal perspective , the (cost)effectiveness of this collaborative care treatment , as a way of transmural care , will be evaluated in depressed patients on sick leave in the occupational health setting . Methods / Design A r and omised controlled trial in which the treatment of MDD in the occupational health setting will be evaluated in the Netherl and s. A transmural collaborative care model , including Problem Solving Treatment ( PST ) , a workplace intervention , antidepressant medication and manual guided self-help will be compared with care as usual ( CAU ) .  126 Patients with MDD on sick leave between 4 and 12 weeks will be included in the study .  Care in the intervention group will be provided by a multidisciplinary team of a trained OP-care manager and a consultant psychiatrist . The treatment is separated from the sickness certification . Data will be collected by means of question naires at baseline and at 3 , 6 , 9 and 12 months after baseline . Primary outcome measure is reduction of depressive symptoms , secondary outcome measure is time to RTW , tertiary outcome measure is the cost effectiveness . Discussion The high burden of MDD and the high level of sickness absence among people with MDD contribute to the relevance of this study . The intervention is an innovative approach , with trained OPs in a new role as care managers in the treatment of MDD . If this intervention proves to be cost-effective , implementation will be very relevant for individual patients as well as for society . Trial registration IS RCT Introduction : Behaviorally oriented grade d activity interventions have been suggested for sick-listed workers with low back pain on return to work , but have not been extensively evaluated . Methods : One hundred and thirty-four workers were r and omly assigned to either a grade d activity intervention ( n = 67 ) or usual care ( n = 67 ) and followed-up for 12 months . Results : The grade d activity group returned back to work faster with a median of 54 days compared to 67 days in the usual care group . The grade d activity intervention was more effective after approximately 50 days post-r and omization ( HRR = 1.9 , CI = 1.2–3.1 , p = 0.01 ) . Differences between the groups in number of recurrent episodes , total number of days of sick leave due to low back pain , and total number of days of sick leave due to all diagnoses , were in favor of the grade d activity group , although not statistically significant . No effects of the grade d activity intervention were found for functional status or pain . Conclusion : Grade d activity intervention is a valuable strategy to enhance short-term return to work outcomes Study Design . Population ‐based r and omized clinical trial . Objectives . To develop and test a model of management of subacute back pain , to prevent prolonged disability . Summary of Background Data . The present management of back pain seems inadequate , and development of innovative models has been urged . Methods . A model for the treatment of subacute work‐related back pain has been developed and evaluated in a population ‐based r and omized clinical trial . Workers ( n = 130 ) from eligible workplaces in the Sherbrooke area ( N = 31 ) , who had been absent from work for more than 4 weeks for back pain , were r and omized , based on their workplace , in one of four treatment groups : usual care , clinical intervention , occupational intervention , and full intervention ( a combination of the last two ) . The duration of absence from regular work and from any work was evaluated using survival analysis . Functional status and pain were compared at study entry and after 1 year of follow‐up . Results . The full intervention group returned to regular work 2.41 times faster than the usual care intervention group ( 95 % confidence interval 1.19‐4.89 ; P = 0.01 ) . The specific effect of the occupational intervention accounted for the most important part of this result , with a rate ratio of return to regular work of 1.91 ( 95 % confidence interval = 1.18‐3.10 ; P < 0.01 ) . Pain and disability scales demonstrated either a statistically significant reduction or a trend toward reduction in the three intervention groups , compared with the trend in the usual care intervention group . Conclusions . Close association of occupational intervention with clinical care is of primary importance in impeding progression toward chronicity of low back pain Introduction Return to work following an occupational injury is a multifactoral process although many traditional clinic-based rehabilitation programs do not appreciate the importance of workplace factors . A r and omized controlled trial was conducted to investigate the effect of workplace-based rehabilitation program on the return to work outcome of work-related rotator cuff disorder , which is based on the therapeutic use of actual work facilities and work environment . Methods A total of 103 workers were recruited and r and omly assigned into Clinic-based Work Hardening ( CWH ) or Workplace-based Work Hardening ( WWH ) groups . The CWH group were given traditional generic work hardening training while WWH group received workplace-based work hardening training with rehabilitative principles of athletic rotator cuff pathology , biomechanics and specific job activities . Results After four weeks , a higher return to work rate was obtained in WWH group compared to CWH group ( 71.4 % vs. 37 % , p < 0.01 ) . A statistically significant difference ( p < 0.05 ) was also noted in lowering of self-reported shoulder problems and functional work capabilities in the WWH group versus the CWH group . Conclusion Workplace-based rehabilitation program appeared to be more effective in facilitating the return to work process of the injured worker as assessed immediately following intervention . In particular this approached was associated with many of the psychosocial workplace factors related to separation from the work routine . The influence of peer group and /or employer could be minimized . This initial attempt with rotator cuff injuries appears promising however long-term outcome needs to be determined Two years of prospect i ve data on 416 back injuries were gathered at a 1100-bed acute and tertiary care hospital to assist target prevention efforts . The rate of injury among 1645 nurses was found to be highest for those working on orthopaedic , medicine , neurology , spinal and surgery wards , indicating priorities for prevention . In fact , 51 % of the orthopaedic nurses sustained at least one back injury during the two-year period . Gender did not significantly affect the risk of back injury ; however , injuries were slightly more common in nurses with less seniority and younger nurses were found to be at significantly increased risk of back injury . Almost 63 % of the back injuries which occurred in nurses working 8 h shifts on the high-risk wards occurred during the first two hours of the shift . Lifting and transferring patients with assistance were the two most common mechanisms for back injury ( 22.6 % and 23.3 % , respectively ) . In total , injured nurses attributed 52.3 % of their injuries to inadequate training ; inadequate staffing was given as the primary reason for 13.8 % of the injuries . The results suggest that training in the indications for and use of  mechanical devices for lifting/transferring patients requires intensification , and a ' warm-up ' period should also be considered in the face of injuries occurring early in the shift if work activities can not be evenly planned Objectives Workers with common mental disorders ( CMDs ) frequently experience recurrent sickness absence  but scientifically evaluated interventions to prevent recurrences are lacking . The objectives of this study are to evaluate the cost-effectiveness and cost-benefit of a problem solving intervention aim ed at preventing recurrent sickness absence in workers with CMDs compared to care as usual  . Methods An economic evaluation was conducted alongside a cluster-r and omised controlled trial with 12 months follow-up . Treatment providers were r and omised to either a 2-day training in the SHARP-at work intervention , i.e. a problem solving intervention , or care as usual . Effect outcomes were the incidence of recurrent sickness absence and time to recurrent sickness absence . Self-reported health care utilisation was measured by question naires . A cost-effectiveness analysis ( CEA ) from the societal perspective and a cost-benefit analysis ( CBA ) from the employer ’s perspective were conducted . Results The CEA showed that the SHARP-at  work intervention was more effective but also more expensive than care as usual . The CBA revealed that employer ’s occupational health care costs were significantly higher in the intervention group compared to care as usual . Overall , the SHARP-at work intervention showed no economic benefit compared to care as usual . Conclusions As implementation of the SHARP-at work intervention might require additional investments , health care policy makers need to decide if these investments are worthwhile considering the results that can be accomplished in reducing recurrent sickness absence Purpose Major depression is associated with high levels of absence and reduced productivity . Therefore the costs to society are high . The aim of this study was to evaluate the cost-utility of collaborative care for major depressive disorder ( MDD ) compared to care as usual in an occupational healthcare setting . A societal perspective was taken . Methods In this r and omised controlled trial , 126 sick-listed workers with MDD were included ( 65 collaborative care ,  61 care as usual )  . Baseline measurements and follow up measures ( 3 , 6 , 9 and 12 months ) were assessed by question naire . We applied the Trimbos/iMTA question naire for costs associated with psychiatric illness , the SF-HQL and the EQ-5D respectively measuring the health care utilization , production losses and general health related quality of life . Results The average annual healthcare costs in the collaborative care group were € 3,874 ( 95 % CI € 2,778–€5,718 ) compared to € 4,583 ( 95 % CI € 3,108–€6,794 ) in the care as usual group . The average quality of life years ( QALY ’s ) gained were lower in the collaborative care group , 0.05 QALY . The majority of the ICERS ( 69 % ) indicate that collaborative care  is less costly but also less effective  than care as usual . Including the productivity costs did not change this result . Conclusions The cost-utility analysis showed that collaborative care generated reduced costs and a reduction in effects compared to care as usual and was therefore not a cost-effective intervention Objectives To evaluate the cost effectiveness , cost utility and cost benefit of a workplace intervention compared with usual care for sick-listed employees with distress . Methods An economic evaluation was conducted alongside a r and omised controlled trial . Employees with distress and who were sick-listed for 2–8 weeks were r and omised to a workplace intervention ( n=73 ) or to usual care ( n=72 ) . The workplace intervention is a stepwise process involving the sick-listed employee and their supervisor , aim ed at formulating a consensus-based plan for return to work ( RTW ) . The effect outcomes were lasting RTW and quality -adjusted life years ( QALYs ) . Healthcare utilisation was measured over 12 months . Cost effectiveness analyses ( CEA ) and cost utility analyses ( CUA ) were conducted from the societal perspective and cost benefit analyses ( CBA ) from the employer perspective . Bootstrapping techniques were used to estimate cost and effect differences , related CIs , and cost effectiveness and cost utility ratios . Cost effectiveness planes were presented and subgroup analyses were performed . Results CEA and CUA revealed no statistically significant differences in lasting RTW , QALYs or costs . The CBA indicated a statistically significant higher cost of occupational health services in the workplace intervention group . The workplace intervention was not cost effective according to the CEA , CUA and CBA . Conclusions Widespread implementation of the workplace intervention for sick-listed employees with distress is not recommended because there was no economic benefit compared with usual care . Future trials should confirm if the workplace intervention is cost effective for the subgroup employees who intended to return to work despite symptoms . This trial has been registered at the Dutch National Trial Register IS RCT N92307123 The objective of this study is to compare the costs and benefits of a grade d activity ( GA ) intervention to usual care ( UC ) for sick-listed workers with non-specific low back pain ( LBP ) . The study is a single-blind , r and omized controlled trial with 3-year follow-up . A total of 134 ( 126 men and 8 women ) predominantly blue-collar workers , sick-listed due to LBP were recruited and r and omly assigned to either GA ( N = 67 ; mean age 39 ± 9 years ) or to UC ( N = 67 ; mean age 37 ± 8 years ) . The main outcome measures were the costs of health care utilization during the first follow-up year and the costs of productivity loss during the second and the third follow-up year . At the end of the first follow-up year an average investment for the GA intervention of € 475 per worker , only € 83 more than health care utilization costs in UC group , yielded an average savings of at least € 999 ( 95 % CI : −1,073 ; 3,115 ) due to a reduction in productivity loss . The potential cumulative savings were an average of € 1,661 ( 95 % CI : −4,154 ; 6,913 ) per worker over a 3-year follow-up period . It may be concluded that the GA intervention for non-specific LBP is a cost-beneficial return-to-work intervention The aim of this study was to compare the effectiveness of two individual-level psychotherapy interventions : ( a ) treatment as usual consisting of cognitive-behavioral therapy ( CBT ) and ( b ) work-focused CBT ( W-CBT ) that integrated work aspects early into the treatment . Both interventions were carried out by psychotherapists with employees on sick leave because of common mental disorders ( depression , anxiety , or adjustment disorder ) . In a quasi-experimental design , 12-month follow-up data of 168 employees were collected . The  CBT group consisted of 79 clients , the W-CBT group of 89 . Outcome measures were duration until return to work ( RTW ) , mental health problems , and costs to the employer . We found significant effects on duration until RTW in favor of the W-CBT group : full RTW occurred 65 days earlier . Partial RTW occurred 12 days earlier . A significant decrease in mental health problems was equally present in both conditions . The average financial advantage for the employer of an employee in the W-CBT group was estimated at $ 5,275 U.S. dollars compared with the CBT group . These results show that through focusing more and earlier on work-related aspects and RTW , functional recovery in work can be substantially speeded up within a regular psychotherapeutic setting . This result was achieved without negative side effects on psychological complaints over the course of 1 year . Integrating work-related aspects into CBT is , therefore , a fruitful approach with benefits for employees and employers alike Study Design . A retrospective and prospect i ve cohort . Objectives . To compare the effectiveness of occupational intervention , early intervention , and st and ard care in the management of Worker ’s Compensation injury cl aims . Summary of Background Data . The current management of occupational back pain and work-related upper extremity disorders with either st and ard care or early intervention appears to be ineffective . Methods . A retrospective cohort compared injury cl aim incidence , duration ,  and costs  between one company with access to st and ard care and another similar company with access to early intervention .  A prospect i ve cohort looked at the effect of one company changing from  st and ard care to occupational management  in comparison with the control group with early intervention .  Survival analysis was used to attempt to explain differences in injury cl aim duration . Results . St and ard care result ed in lower injury cl aim incidence , duration , and costs than early intervention , whereas occupational management result ed in lower injury cl aim incidence , duration , and costs than st and ard care . The covariates of physical therapist involvement , chiropractor involvement , injury severity , and relationship between Worker ’s Compensation and the employer were associated with delayed time to cl aim closure in the company with access to early intervention with the most important covariate being physical therapist involvement ( hazard rate ratio 19.88 , 95 % confidence interval 7.95–39.77 ) . Only the covariate of injury severity was associated with delayed time to cl aim closure in the company with access to occupational management ( hazard rate ratio 1.67 , 95 % confidence interval 1.05–27.20 ) . Conclusions . It is recommended that an occupational management approach , in comparison with st and ard care or early intervention , be considered for management of occupational injuries The aim of this study was to determine whether grade d activity restored occupational function in industrial blue-collar workers who were sick-listed for 8 weeks because of subacute , nonspecific , mechanical low back pain ( LBP ) . Patients with LBP , who had been examined by an orthopedic surgeon and a social worker , were r and omly assigned to either an activity group ( n = 51 ) or a control group ( n = 52 ) . Patients with defined orthopedic , medical , or psychiatric diagnoses were excluded before r and omization . The grade d activity program consisted of four parts : ( 1 ) measurements of functional capacity ; ( 2 ) a work-place visit ; ( 3 ) back school education ; and ( 4 ) an individual , submaximal , gradually increased exercise program , with an operant-conditioning behavioral approach , based on the results of the tests and the dem and s of the patient 's work . Records of the amount of sick leave taken over a 3-year period ( ie , the 1-year periods before , during , and after intervention ) were obtained from each patient 's Social Insurance Office . The patients in the activity group returned to work significantly earlier than did the patients in the control group . The median number of physical therapist appointments before return to work was 5 , and the average number of appointments was 10.7 ( SD = 12.3 ) . The average duration of sick leave attributable to LBP during the second follow-up year was 12.1 weeks ( SD = 18.4 ) in the activity group and 19.6 weeks ( SD = 20.7 ) in the control group . Four patients in the control group and 1 patient in the activity group received permanent disability pensions . The grade d activity program made the patients occupationally functional again , as measured by return to work and significantly reduced long-term sick leave Aims : To test the long term cost-benefit and cost-effectiveness of the Sherbrooke model of management of subacute occupational back pain , combining an occupational and a clinical rehabilitation intervention . Methods : A r and omised trial design with four arms was used : st and ard care , occupational arm , clinical arm , and Sherbrooke model arm ( combined occupational and clinical interventions ) . From the Quebec WCB perspective , a cost-benefit ( amount of consequence of disease costs saved ) and cost-effectiveness analysis ( amount of dollars spent for each saved day on full benefits ) were calculated for each experimental arm of the study , compared to st and ard care . Results : At the mean follow up of 6.4 years , all experimental study arms showed a trend towards cost benefit and cost effectiveness . These results were owing to a small number of very costly cases . The largest number of days saved from benefits was in the Sherbrooke model arm . Conclusions : 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 partial interventions . A limited number of cases were responsible for most of the long term disability costs , in accordance with occupational back pain epidemiology . However , further studies with larger sample s will be necessary to confirm these results BACKGROUND Major depression has far-reaching consequences for work functioning and absenteeism . In most cases depression is treated by medication and clinical management . The addition of occupational therapy ( OT ) might improve outcome . We determined the cost-effectiveness of the addition of OT to treatment as usual ( TAU ) . METHOD Sixty-two adults with major depression and a mean absenteeism of 242 days were r and omized to TAU ( out-patient psychiatric treatment ) or TAU+OT [ 6 months , including ( i ) diagnostic phase with occupational history and work reintegration plan , and ( ii ) therapeutic phase with individual sessions and group sessions ] . Main outcome domains were depression , work resumption , work stress and costs . Assessment s were at baseline and at 3 , 6 , 12 and 42 months . RESULTS The addition of OT to TAU : ( i ) did not improve depression outcome , ( ii ) result ed in a reduction in work-loss days during the first 18 months , ( iii ) did not increase work stress , and ( iv ) had a 75.5 % probability of being more cost-effective than TAU alone . CONCLUSION Addition of OT to good clinical practice does not improve depression outcome , improves productivity without increasing work stress and is superior to TAU in terms of cost-effectiveness Context Low back pain causes frequent disability and lost productive time . Contribution This r and omized trial compared a behavioral-oriented grade d activity program with usual care in 134 Dutch airline company workers who had missed work because of persistent low back pain .  Grade d activity consisted of biweekly 1-hour exercise sessions with physiotherapists who emphasized operant-conditioning principles . Over 6 months of follow-up , participants in the grade d activity program missed 58 days of work , while participants receiving usual care missed 87 days . Implication s A behavioral-oriented grade d activity program returned participants with low back pain to work more often than did usual care . The Editors Nonspecific low back pain is an uncomfortable medical condition that causes frequent disability and absence from work . Most episodes of low back pain resolve fairly quickly and cause only short periods of absence from work . However , some workers with low back pain miss work for several days to weeks and are at risk for more permanent disability ( 1 ) . To reduce the individual and socioeconomic burden related to this absenteeism , we need effective intervention strategies in occupational health care setting s that promote safe and rapid return to work . One promising and often-advocated intervention strategy for workers with prolonged nonspecific low back pain is active rehabilitation that is directed toward return to normal activity and work ( 2 ) . Examples are grade d activity interventions that include physical exercise , application of operant-conditioning behavioral principals , and promotion of improved functioning and safe return to work even if pain persists ( 3 - 6 ) . In a r and omized , controlled trial , Lindstrm and colleagues ( 3 , 4 ) found that a grade d activity intervention reduced absence from work more than did traditional care in Swedish workers employed in the automobile industry . We investigate , in a second r and omized , controlled trial , whether absence from work because of low back pain is reduced more with grade d activity intervention than with traditional care in an occupational health care setting in the Netherl and s. Methods Study Design and Sample The study was a single-blind , r and omized , controlled trial in an occupational health services center ( KLM Health , Safety and Environment ) at Schiphol Airport , Amsterdam , the Netherl and s. The center provides occupational health services for all employees of a major Dutch airline ( KLM Royal Dutch Airlines ) . The source sample ( n = 20 000 ) consisted of workers who were employed in the following organizational units of the airline : baggage and aircraft turnaround services , passenger services , engineering and maintenance , cargo , and cabin and cockpit . Workers who were listed as absent from work because of low back pain were invited for a consultation with the occupational physician . Those who were thought to be eligible for inclusion were referred to the research assistant , who judged whether they met the inclusion criteria : full or partial absence from work because of nonspecific low back pain and low back pain symptoms with a minimum duration of 4 weeks in succession . The exclusion criteria were low back pain with radiation below the knee with signs of nerve-root compression ( 7 ) ; cardiovascular contraindications for physical activity , as checked according to the Physical Activities Readiness Question naire ( 8 , 9 ) ; any conflict between worker and employer with legal involvement ; or pregnancy . Workers who met the inclusion criteria were informed of the purpose and procedures of the study and were enrolled after giving informed consent . The Medical Ethical Committee of the VU University Medical Center , Amsterdam , the Netherl and s , approved the study . Treatment Allocation The participants were assigned to grade d activity or usual care on the basis of block r and omization , after prestratification for the organizational unit in the workplace from which they were recruited ( the 5 organizational units listed earlier ) and for the severity of pain symptoms ( scored on a scale of 0 to 10 ; severity scores were < 6 or 6 points ) . This result ed in a total of 10 strata . R and omized , permuted blocks of 4 allocations were generated for each stratum through a computer-generated r and om-sequence table . Opaque , sequentially numbered , sealed envelopes were prepared for each stratum by a research er who was not involved in enrolling the participants or assigning them to their groups . The envelopes contained a sheet of paper that indicated 1 of the 2 interventions . Participants learned their group assignments after a research assistant completed the baseline measurements and delivered the sealed envelopes . Blinding The research assistants who collected the data were blinded to the treatment allocation . All participants were repeatedly asked not to reveal any information about their treatment allocation . The participants and treatment providers were not blinded to treatment allocation . Interventions In the Dutch occupational health care system , occupational physicians guide disabled workers who are absent from work through their disability period . These occupational physicians are employed by occupational health services that are paid for by the companies . The occupational physicians adhere to back pain management strategies that consist of advising workers on ergonomics , prevention , and return-to-work schedules and advising and communicating with other stakeholders ( such as health care providers and representatives of the workplace ) . Disabled workers who participated in the present study were assigned to either grade d activity or usual care within the context of the Dutch occupational health care setting . Grade d Activity The intervention group received the usual guidance from the occupational physician about work-related problems and barriers to return to work as well as the grade d activity intervention supervised by a physiotherapist .  Three physiotherapists who worked in a private practice at Schiphol Airport provided the treatment according to the grade d activity protocol . Two of those physiotherapists were also trained as manual therapists , and 1 was also a human movement scientist . Before the study , the physiotherapists had been specifically trained to treat patients with low back pain according to behavioral principles . A research physiotherapist who was experienced in treating patients with chronic pain in rehabilitation centers instructed the physiotherapists in three 2-hour sessions and practice d patienttherapist interactions with them through role-play . Before the study , the physiotherapists treated several patients according to the grade d activity protocol to gain more experience . The physiotherapists made audiotapes of the intervention sessions before and during the study period . The contents of these audiotapes were assessed and discussed with the research physiotherapist in 3 additional meetings . Furthermore , the physiotherapists summarized the treatment after each session , and research ers used these summaries to review the sessions . The same physiotherapist treated participants each time , except for temporary st and -in sessions that were supervised by colleagues because of holidays or other reasons . Specific therapists were not systematic ally selected to treat specific participants ; selection was based on pragmatic reasons , such as the time available in the work schedules of the physiotherapists or the days of treatment preferred by the participants . Table 1 presents the concept and content of the grade d activity intervention . The intervention consisted of 1-hour exercise sessions that participants attended twice per week until they returned completely to regular work or until the maximum therapy duration of 3 months was reached . At the start of the intervention , the physiotherapist inquired about the participant 's medical history and completed a brief physical examination consisting of flexion , extension , and lateroflexion of the lumbar spine and a brief screening for nerve-root pain ( 10 ) . The purpose of the physical examination was to confirm the diagnosis of benign , nonspecific low back pain and to reduce participants ' fears about any presumed underlying disease . The participants were reassured that despite the annoying pain , nothing was seriously wrong with their backs . Subsequently , the physiotherapist and participant decided on a set of general exercises and individually tailored exercises . Both types of exercises had to be performed during each session . The general exercises were aerobic exercises , such as cycling or rowing , and strengthening exercises for large muscle groups , and most were carried out in a gym while using exercise equipment . The strengthening exercises were a floor abdominal sit-up exercise , a dynamic back extension exercise , a leg-press exercise , a latissimus pull-down exercise , and st and ing up from a low chair .  Participants in the grade d activity group had to perform not only these general exercises but also individually tailored exercises , which imitated physical tasks at work or difficult and painful activities of daily living . For example , a participant who reported back problems while lifting and moving suitcases from a luggage wagon into an airplane might be given an exercise to practice lifting and moving a suitcase with a certain number of repetitions . During the first 3 sessions , the maximal performance ( for example , the maximum number of repetitions ) was assessed for each exercise separately , and the average score for each exercise over the 3 sessions was used as a baseline value for specifying a gradually progressive exercise scheme . Subsequently , the participant was asked to propose a date for full return to regular work , which would consequently be the end point of the physical exercise program . Before returning to full regular work , participants could return to work with modified hours and duties . Advised by the physiotherapist , the participant & NA ; An outpatient multimodal cognitive‐behavioural treatment program ( MMCBT ) for chronic spinal pain was evaluated during an 18‐month follow‐up period . The treatment included a 1‐day course for the patients ’ work supervisors . The aim of the study was to evaluate the long‐term effect of the treatment program as well as the effect of a work supervisor‐training program on the patients ’ return to work . The design was a matched cohort study with four repeated measures . Two groups of subjects suffering from non‐specific spinal pain ( treatment group n=67 , no treatment control group n=29 ) were assessed with regard to pain intensity , sick‐leave , pain coping ability and behavioural changes at work and in personal life . Recordings on supervisors attending the course and changes of supervisory behaviour were also obtained . The results show a significant between group difference in pain intensity and perceived pain coping ability at work , favouring the MMCBT group . Further , the MMCBT intervention enhances self‐reported behavioural changes in areas within the subjects ’ own control . There is not sufficient statistical support to accept the assumption of MMCBT being superior in reducing sick‐leave , either with or without the education of supervisors . Even when supervisors changed their behaviour as reported by the patient , no significant effect was found on patients ’ return to work . In conclusion , the MMCBT do not seem to be effective in reducing sick‐leave compared to no treatment , but the MMCBT program is superior in decreasing pain intensity , enhancing self‐reported behavioural changes in personal life and improving pain coping ability at work Study Design . This was a prospect i ve study . Objectives . To evaluate the results of education and early rehabilitation in the prevention of  back pain chronicity  in coal mine workers . Summary of Background Data . A new mine was established in central Queensl and , Australia . Preventing chronicity is important in the treatment of back pain in the industrial setting , because back pain is often refractory to treatment . Back pain patients also constitute the majority of compensation cl aims . Methods . A back pain program was instituted that comprised work force education , early injury reporting , first aid at the mine , and changing workplace psychosocial perceptions . Management employees were actively involved . The time off work , number of cl aims per hundred workers , and costs per cl aim were compared with another mine in the area . Results . The median time to return to work was 10 days . In the study group the number of cl aims and costs per cl aim were significantly less ( P < 0.01 ) as compared to the control group . Conclusions . This was an easy to institute , inexpensive back pain program , which succeeded in preventing back pain chronicity in the studied group of mine workers , with no worker being off work for more than 60 days Objectives Major depressive disorder ( MDD ) is associated with absenteeism . In this study , the effectiveness of collaborative care , with a focus on return to work ( RTW ) , was evaluated in its effect on depressive symptoms and the duration until RTW in sick-listed workers with MDD in the occupational health setting . Methods In this r and omised controlled trial , 126 sick-listed workers with MDD were r and omised to usual care  ( N=61 ) or  collaborative care  ( N=65 ) . Collaborative care was applied by the occupational physician care manager , supported by a web-based tracking system and a consultant psychiatrist . Primary outcome measure was time to response . Secondary outcome measures were time to remission , depressive symptoms as continuous measure and the duration until full RTW . Results Collaborative care participants had a shorter time to response , with a difference of 2.8 months . However , no difference was found on time to remission or depressive symptoms as continuous measure . With a mean of 190 days in the collaborative care group , and 210 days in the usual care group , the groups did not differ significantly from each other in the duration until full RTW . Adherence to the collaborative care intervention was low . Conclusions These results do not justify a widespread implementation of collaborative care in occupational healthcare , as it was operationalised in this study . However , since the study might have been underpowered for RTW and because treatment integrity was low , further research , with larger sample sizes , is needed to develop the best fitting ( collaborative care ) model for addressing RTW in depressed sick-listed workers . Trial registration : IS RCT Study Design . A prospect i ve cohort . Objectives . To compare the effectiveness of st and ard care , early intervention treatment , and occupational management in the management of Workers ’ Compensation injury cl aims . Summary of Background Data . The current management of occupational back pain and work-related upper extremity disorders with either st and ard care or early intervention treatment appears to be ineffective . Methods . A prospect i ve cohort looked at the effect of one company with access to st and ard care ( primary care ) changing to occupational management ( worksite encouragement to resume activity and work as soon as safely possible ) and then to early intervention treatment ( offsite work hardening ) . This information was then compared with the control company with access to early intervention treatment , which later changed to a combined occupational management/early intervention treatment approach .  Survival analysis was used to attempt to explain differences in time to injury cl aim closure . Results . Occupational management result ed in lower injury cl aim incidence , duration , and costs than early intervention treatment . Only the covariate of enhanced physical therapist ( work hardening ) involvement ( 2001 hazard rate ratio 17.41 , 95 % confidence interval 3.72–41.51 and 2002 hazard rate ratio 6.22 , 95 % confidence interval 2.51–15.40 ) was associated with delayed time to injury cl aim closure when the company had access to early intervention treatment . Only the covariate of serious injury was associated with delayed time to injury cl aim closure in the company when it had access to occupational management ( hazard rate ratio 1.67 , 95 % confidence interval 1.05–27.20 ) . Conclusions . It is recommended that an occupational management approach , in comparison to early intervention treatment and st and ard care , be considered for management of occupational injuries OBJECTIVES The purpose of this study was to assess the effects of early part-time sick leave on return to work ( RTW ) and sickness absence among patients with musculoskeletal disorders . METHODS A r and omized controlled trial was conducted in six occupational health units of medium- and large-size enterprises . Patients aged 18 - 60 years with musculoskeletal disorders ( N=63 ) unable to perform their regular work were r and omly allocated to part- or full-time sick leave . In the former group , workload was reduced by restricting work time by about a half . Remaining work tasks were modified when necessary , as specified in a " fit note " from the physician . The main outcomes were time to return to regular work activities and sickness absence during 12-month follow-up . RESULTS Time to RTW sustained for ≥4 weeks was shorter in the intervention group ( median 12 versus 20 days , P=0.10 ) . Hazard ratio of RTW adjusted for age was 1.60 [ 95 % confidence interval ( 95 % CI ) 0.98 - 2.63 ] and 1.76 ( 95 % CI 1.21 - 2.56 ) after further adjustment for pain interference with sleep and previous sickness absence at baseline . Total sickness absence during the 12-month follow-up was about 20 % lower in the intervention than the control group . Compliance with the intervention was high with no discontinuations of part-time sick leave due to musculoskeletal reasons . CONCLUSIONS Early part-time sick leave may provide a faster and more sustainable return to regular duties than full-time sick leave among patients with musculoskeletal disorders . This is the first study to show that work participation can be safely increased with early part-time sick leave Objectives To evaluate whether adjuvant occupational therapy ( OT ) can improve the effectiveness of treatment-as-usual ( TAU ) in sick-listed employees with major depression . Methods In total , 117 employees sick-listed for a median duration of 4.8 months ( IQR=2.6 to 10.1 months ) because of major depression were r and omised to TAU  ( n=39 ) or adjuvant OT ( TAU+OT ; n=78 ) . OT ( 18 sessions ) focussed on a fast return to work ( RTW ) and improving work-related coping and self-efficacy . The primary outcome was work participation ( hours of absenteeism+ duration until partial/full RTW ) . Secondary outcomes were depression , at-work functioning , and health-related functioning . Intermediate outcomes were work-related , coping and self-efficacy . Blinded assessment s occurred at baseline and 6 , 12 and 18 months follow-up . Results The groups did not significantly differ in their overall work participation ( adjusted group difference=−1.9 , 95 % CI −19.9 to + 16.2 ) . However , those in TAU+OT did show greater improvement in depression symptoms ( −2.8 , −5.5 to −0.2 ) , an increased probability of long-term symptom remission ( + 18 % , + 7 % to + 30 % ) , and increased probability of long-term RTW in good health ( GH ) ( + 24 % , 12 % to 36 % ) . There were no significant group differences in the remaining secondary /intermediate outcomes . Conclusions In a highly impaired population , we could not demonstrate significant benefit of adjuvant OT for improving overall work participation . However , adjuvant OT did increase long-term depression recovery and long-term RTW in GH ( ie , full RTW while being remitted , and with better work and role functioning ) . Trial Registration Dutch Trial Register NTR2057 & NA ; The current investigation studied the effectiveness of a secondary prevention program for nurses with back pain who were deemed at risk for developing a chronic problem . A 2 × 3 repeated measures design was employed with 2 groups and 3 assessment periods . The treatment group received an intervention design ed to reduce current problems , but above all to prevent reinjury and minor pains from becoming chronic medical problems , and it included a physical and behavioral therapy package . The control group was placed on a waiting‐list . Results indicated that the treatment group had significantly greater improvements than the control group for pain intensity , anxiety , sleep quality and fatigue ratings , observed pain behavior , activities , mood , and helplessness . These differences were generally maintained at the 6 month follow‐up . In addition , the treatment group broke a trend for increasing amounts of pain‐related absenteeism , while the control group did not . Taken as a whole , the results suggest that a secondary prevention program aim ed at altering life style factors may represent an effective method for dealing with musculoskeletal pain problems In a prospect i ve , r and omized study , primarily design ed to test the efficacy of activation on consecutive blue-collar workers sick-listed for 6 weeks due to subacute low back pain , 25 % of the workers were excluded for medical reasons . In the intervention study ( n = 103 ) , only a minority of cases ( 6 % ) had ' true ' subacute complaints , i.e. no prior history of low back pain .  Subjective reports on general well-being , health status and work-related ergonomic factors were significantly lower or worse in patients than in reference sample s. The r and omized intervention study could establish a significant effect of grade d activation on work return , but the effect seemed to be restricted to patients moderately disabled , i.e. one-third of the subacute low back pain patients included . A predictive four-factor model on work return increased the possibility of identifing nonresponders ( chronic low back pain ) more than threefold with a specificity ( 91 % ) and sensitivity ( 74 % ) comparable to that of clinical disc herniation . The history of a prolonged disablement process , cognitive factors , pain behavior and mentally straining ergonomic factors seemed to be of importance . Psychological reactions , or ' barriers to recovery ' , were slightly different in treatment and control groups but the type of intervention did not significantly alter the predictive model , suggesting that subsets of the study sample may benefit from other optional functional approaches . Descriptive characteristics of the study sample emphasized that subacute low back pain patients can not be conceptualized as a homogeneous group . Four sub-groups could be identified : ( a ) specific medical disorders ; ( b ) spontaneous recovery group ; ( c ) moderately disabled back pain patients ; and ( d ) nonresponders . The results support proposals that treatment should be tailored according to individual needs and that better case management should have priority for those belonging to the nonresponder group OBJECTIVE Validation of a salutogenic theory for return to work ( RTW ) and an associated program process theory . METHODS A longitudinal non-r and omized one-year trial study design was used with a two-year follow-up and with comparison to a reference group . Changes in attitudes and active behaviour in the intervention group and at the workplace were supported by cognitive and behavioural approaches . PARTICIPANTS The intervention group included 118 unskilled Danish public employees and privately employed house-cleaners on sick leave due to musculoskeletal and /or common mental illnesses . RESULTS Significant improvements of work ability index and perceived health ( SF36 subgroups ) were reported . A significantly higher RTW and a shorter sick leave than in the reference group also emerged . Positive predictors of RTW were keeping the pre-sick-leave job and improving work ability index and physical impairment/role physical . Decline in self-efficacy was a negative predictor . CONCLUSIONS Support for the theory and associated program process theory was found . The intervention seemed to influence RTW and the employees ' attitudes , behaviour and health by affecting comprehensibility , meaningfulness and manageability . Sustainable RTW emerged from a synergism of support from the work place and improved personal re sources , especially such as concern mental health . The approach is consistent with integrating health promotion in RTW STUDY DESIGN A 2-year prospect i ve inception cohort study of back injury in nurses . OBJECTIVES To determine the extent to which characteristics of nurses , of the injury , and of the workplace predict occurrence and duration of time loss from work after back injury . SUMMARY OF BACKGROUND DATA During 2 years , 320 nurses incurred 416 back injuries at a large teaching hospital in Winnipeg , Canada . Nurses injured on preselected wards were targeted for early intervention , including provision of modified work , whereas nurses injured on other wards received the usual care . METHODS Time loss attributable to the back injury during the 6 months after injury was analyzed . Three statistical models were used to examine occurrence of time loss ( logistic regression ) , duration of time loss ( Tobit regression ) , and duration of time loss once an injury incurring time loss had been documented ( least-squares regression ) . RESULTS In 218 of the 416 injuries , the injured nurse consented to interview . Whereas perceived disability was related to whether a time loss injury would ensue , self-reported pain was strongly related to the duration of time loss once an injury had become a time loss injury . Duration of time loss was reduced by participation in the return-to-work program . Mechanism of injury , specifically injury occurring while lifting patients , result ed in greater time loss . CONCLUSIONS Focusing on reducing the perception of disability at the time of injury is critical to preventing time loss , but once time loss has occurred , offer of modified work and attention to pain reduction are warranted . The findings add to the evidence that workplace-based intervention programs can be effective in reducing the morbidity result ing from back injury The aim of this study was to compare the effectiveness of work-related cognitive-behavioral treatment ( W-CBT ) with that of cognitive-behavioral treatment as usual ( CBT-AU ) for employees on sick leave as a result of a major depressive disorder ( MDD ) . We collected data for 26 matched out patients at pre- and posttreatment , as well as at 1-year follow-up . Outcome measures were the days of incapacity to work ( DIW ) as well as self-report measures ( Beck Depression Inventory [ BDI ] , Symptom Checklist 90-R [ GSI ] , Life Satisfaction Question naire [ FLZ ] ) . We analyzed data with hierarchical linear modeling in a 2-level model . Therapy effects were defined in 3 ways : effect size ( ES ) , response ( based on the reliable change index ) , and remission compared with the general population 's symptom level . The DIW were reduced significantly after both types of treatment , but employees showed even fewer DIW after W-CBT . At follow-up , significantly more employees were working as a result of W-CBT than with CBT-AU . Significant improvements on scores of self-rating measures corresponded with moderate-to-large effect sizes for both treatment types . Approximately 2 thirds of the treated employees were categorized as unimpaired on BDI scores at posttreatment and at follow-up . At least 1 half of the employees were classified as unimpaired on GSI scores at both assessment points . In future research , a r and omized controlled trial should be conducted using a larger sample size to investigate the impact of moderators ( e.g. , employees at different branches of the company ) . Findings provided support for using common CBT techniques to enhance return to work without losing expected improvements at the symptom level Objectives To evaluate the effectiveness of a participatory workplace intervention compared with usual care for sick-listed employees with distress , with regard to return to work ( RTW ) within the 12-month follow-up . Methods Employees with distress and sick-listed for 2–8 weeks were r and omised to a  workplace intervention ( n=73 ) or to usual care  ( n=72 ) . The participatory workplace intervention is a stepwise process involving the sick-listed employee and their supervisor , aim ed at reducing obstacles for RTW by reaching consensus about an action plan for RTW . Outcome variables were lasting RTW , cumulative sickness absence and stress-related symptoms . Results Overall , an HR of 0.99 ( 95 % CI 0.70 to 1.39 ) indicated no effect of the workplace intervention on lasting RTW . However , the workplace intervention significantly reduced the time until lasting RTW for employees who at baseline intended to return to work despite symptoms with an HR of 2.05 ( 95 % CI 1.22 to 3.45 ) . Employees who intended to return to work despite symptoms returned to work after 55 days in the workplace intervention group and 120 days in the usual care group . No such effect of the intervention was found for employees without baseline intentions to return to work despite symptoms ( HR=0.78 , 95 % CI 0.47 to 1.28 ) . Conclusions No overall effect of the participatory workplace intervention on lasting RTW was found . The workplace intervention appeared effective on lasting RTW for employees who at baseline intended to return to work despite symptoms . For employees who showed no baseline intention to return to work , the intervention did not have any effect . Other approaches are needed for this subgroup . This trial has been registered at the Dutch National Trial Register IS RCT N92307123 Introduction In an earlier study , Gatchel et al. ( J Occup Rehabil 13:1–9 , 2003 ) demonstrated that participants at high risk for developing chronic low back pain disability ( CLBPD ) , who received a biopsychosocial early intervention treatment program , displayed significantly more symptom improvement , as well as cost savings , relative to participants receiving st and ard care . The purpose of the present study was to exp and on these results by examining whether the addition of a work-transition component would further strengthen the effectiveness of this early intervention treatment . Methods Using an existing algorithm , participants were identified as being high-risk ( HR ) or low-risk ( LR ) for developing CLBPD . HR participants were then r and omly assigned to one of three groups : early intervention ( EI ) ; early intervention with work transition ( EI/WT ) ; or st and ard care ( SC ) . Participants provided information regarding pain , disability , work status , and psychosocial functioning at baseline , periodically during treatment , and again 1 year following completion of treatment . Results At 1-year follow-up , no significant differences were found between the EI and EI/WT groups in terms of occupational status , self-reports of pain and disability , coping ability or psychosocial functioning . However , significant differences in all these outcomes were found comparing these groups to st and ard care . Conclusion The addition of a work transition component to an early intervention program for the treatment of ALBP did not significantly contribute to improved work outcomes . However , results further support the effectiveness of early intervention for high-risk ALBP patients Objective : To evaluate the cost-effectiveness and cost-utility of a return to work ( RTW ) program for workers on sick-leave due to low back pain ( LBP ) , comparing a workplace intervention implemented between 2 to 8 weeks of sick-leave with usual care , and a clinical intervention after 8 weeks of sick-leave with usual care . Design : Economic evaluation alongside a r and omised controlled trial ( RCT ) . Study population : Workers sick-listed for a period of 2 to 6 weeks due to LBP . Interventions : 1 . workplace assessment , work modifications and case management ) . 2 . physiotherapy based on operant behavioural principles . 3 . usual care : provided by an occupational physician . Outcomes : The primary outcome was return to work ( RTW ) . Other outcomes were pain intensity , functional status , quality of life and general health . The economic evaluation was conducted from a societal perspective . Outcomes were assessed at baseline ( after 2–6 weeks on sick-leave ) , and 12 weeks , 26 weeks , and 52 weeks after the first day of sick-leave . Results : The workplace intervention group returned to work 30.0 days ( 95 % CI=[3.1 , 51.3 ] ) earlier on average than the usual care group at slightly higher direct costs ( ratio of 1 day : € 19 ) . Workers in the clinical intervention group that had received usual care in the first 8 weeks returned to work 21.3 days ( 95 % CI= [ −74.1 , 29.2 ] ) later on average . The group that had received the workplace intervention in the first 8 weeks and the clinical intervention after 8 weeks returned to work 50.9 days ( 95 % CI=[−89.4 , −2.7 ] ) later on average . A workplace intervention was more effective than usual care in RTW at slightly higher costs and was equally effective as usual care at equal costs on other outcomes . A clinical intervention was less effective than usual care and associated with higher costs . Conclusion : The workplace intervention results in a safe and faster RTW than usual care at reasonable costs for workers on sick-leave for two to six weeks due to LBP OBJECTIVES --The aim was to combat occurrence of  chronic occupational back pain .  METHODS --A multidisciplinary model to manage back pain that includes both clinical and ergonomic approaches has been developed . Early detection , early clinical and ergonomic evaluations , and early active treatment make up the cornerstone of management . Detection of cases starts after four weeks of absence from work . An ergonomic intervention is implemented at six weeks . A medical specialist is involved at eight weeks . If return to work is not possible after 12 weeks , a functional recovery therapy followed by a therapeutic return to work is implemented . A multidisciplinary team decides if return to original or modified work is possible or if vocational rehabilitation is necessary . This model has been implemented by the investigators in the Sherbrooke ( Quebec , Canada ) area , and is presently being evaluated through a r and omised trial in 31 industrial settlements ( about 20,000 workers ) . A cluster r and omisation of industries and workers will allow separate testing of ergonomic and clinical interventions . RESULTS --One year after implementation , 31 of 35 of the eligible industrial sites participated in the study and 79 of 88 of the eligible workers affected by recent back pain had agreed to participate .  Ergonomic and clinical interventions  have been implemented as planned . Only three workers dropped out . Hence this global clinical and ergonomic management programme has been shown to be feasible in a general population . CONCLUSION --A global management programme of back pain joining ergonomic and clinical intervention with a multidisciplinary approach has not been tested yet . Linking these two strategies in a same multidisciplinary team represents a systemic approach to this multifactorial ailment . During the first year of this trial we did not find any conflict between these two interventions from the employer 's or worker 's point of view Study Design . R and omized controlled trial . Objectives . To Investigate the long-term effectiveness , costs , and effect modifiers of a mini-intervention , provided in addition to the usual care , and the incremental effect of a worksite visit for patients with subacute disabling low back pain ( LBP ) . Summary of Background Data . A mini-intervention was earlier proved to be an effective treatment for subacute LBP . Whether the beneficial effect is sustained is not known . Furthermore , modifiers of a treatment effect are largely unknown . Methods . A total of 164 patients with subacute LBP r and omized into a mini-intervention  ( A , n = 56 ) ,  a mini-intervention plus a worksite visit  ( B , n = 51 ) , or the  usual care  ( C , n = 57 ) . Mini-intervention consisted of a detailed assessment of the patients ’ history , beliefs , and physical findings by a physician and a physiotherapist , followed by recommendations and advice . The usual care patients received the conventional care .  Pain , disability , health-related quality of life , satisfaction with care , days on sick leave , and health care consumption and costs were measured during a 24-month follow-up . Thirteen c and i date modifiers were tested for each outcome . Results . There were no differences between the three treatment arms regarding the intensity of pain , the perceived disability , or the health-related quality of life . However , mini-intervention decreased occurrence of daily ( A vs. , C , P = 0.01 ) and bothersome ( A vs. C , P < 0.05 ) pain and increased treatment satisfaction . Costs result ing from LBP were lower in the intervention groups ( A 4670 Euros , B 5990 Euros ) than in C ( C 9510 Euros ) ( A vs. C , P = 0.04 ; and B vs. C , not significant ) . The average number of days on sick leave was 30 in A , 45 in B , and 62 in C ( A vs. C , P = 0.03 ; B vs. C , not significant ) . The perceived risk for not recovering was the strongest modifier of treatment effect . Mental and mental-physical workers in A and B were less often on sick leave than those in C. Conclusions . Mini-intervention is an effective treatment for subacute LBP . Despite lack of a significant effect on intensity of low back pain and perceived disability , mini-intervention , including proper recommendations and advice , according to the “ active approach , ” is able to reduce LBP-related costs . The perceived risk of not recovering was the strongest modifier of treatment effect . In alleviating pain , the intervention was most effective among the patients with a high perceived risk of not recovering Purpose . The aim of this study was to determine the impact of a vocational training programme on short- and long-term results after psychosomatic rehabilitation . Method . 1,590 in patients were screened for vocational integration . A high-risk group of 266 patients was r and omly assigned to the vocational training programme plus psychosomatic treatment ; treatment- as- usual served as a control condition . An occupational training was conducted at local companies , closely integrated into psychosomatic treatment . Vocational attitudes and adjustment were studied at intake , discharge , three , 12 and 24 month follow-ups . Results . More than half of the study participants were unemployment and /or long-term work-disabled  harbouring strong  negative attitudes toward return to work  . Forty-six percent of the intervention group declined from participation , but complied with follow-up investigation . At discharge , participants of the vocational training programme had become more optimistic regarding resuming work . One year following discharge , participants of the training programme reported less absence from work . After 24 months , vocational adjustment had improved considerably among programme participants , and declined among controls and refusers . Conclusion . An intensive vocational training programme is effective in promoting positive attitudes to work , reducing work disability and promoting return-to-work . However , a r and omized design may be not optimal ; evaluation necessitates long-term follow-up Study Design . A pre‐ versus postintervention with concurrent control group design was used to investigate the effect of a workplace‐based early intervention program on perception of disability in nurses with low back injury . Objectives . This report examines changes over time in the components of the Oswestry Low Back Pain and Disability Question naire in two groups of back‐injured nurses‐those who received the early intervention program ( study ) and those who were not offered the program ( control ) . Summary of Background Data . Early intervention programs can decrease morbidity , time lost from work , and compensation costs . Although perception of disability decreases , some residual disability remains , the nature of which is not clear . Methods . The Oswestry Low Back Pain and Disability Question naire scores of 40 study nurses and 118 control nurses at time of injury and at 6 months after injury were examined . Analysis of variance was used to compare changes in mean overall scores over time . The proportion of nurses reporting disability on individual components of the Oswestry Low Back Pain and Disability Question naire at each time period was compared with the results of a chi‐square test . Results . Overall Oswestry Low Back Pain and Disability Question naire scores were similar between study and control nurses at time of injury , but were significantly lower in study nurses at 6 months after injury . However , scores of individual Oswestry Low Back Pain and Disability Question naire components that related to job dem and s increased over time ; this was most apparent in lifting , particularly in study nurses . Conclusions . Although overall perception of disability decreased 6 months after injury , particularly in study nurses , disability in job‐related activities persisted . Residual disability after back injury should be addressed in workplace‐based prevention programs Study design . Population -based r and omized controlled trial . Objective . To assess the effectiveness of workplace intervention and grade d activity , separately and combined , for multidisciplinary rehabilitation of low back pain ( LBP ) . Summary of Background Data . Effective components for multidisciplinary rehabilitation of LBP are not yet established . Methods . Participants sick-listed 2 to 6 weeks due to nonspecific LBP were r and omized to workplace intervention ( n = 96 ) or usual care ( n = 100 ) .  Workplace intervention consisted of workplace assessment , work modifications , and case management involving all stakeholders . Participants still sick-listed at 8 weeks were r and omized for grade d activity  ( n = 55 ) or usual care ( n = 57 ) . Grade d activity comprised biweekly 1-hour exercise sessions based on operant-conditioning principles . Outcomes were lasting return to work , pain intensity and functional status , assessed at baseline , and at 12 , 26 , and 52 weeks after the start of sick leave . Results . Time until return to work for workers with workplace intervention was 77 versus 104 days ( median ) for workers without this intervention ( P = 0.02 ) . Workplace intervention was effective on return to work ( hazard ratio = 1.7 ; 95 % CI , 1.2–2.3 ; P = 0.002 ) .  Grade d activity had a negative effect on return to work ( hazard ratio = 0.4 ; 95 % CI , 0.3–0.6 ; P < 0.001 ) and functional status . Combined intervention had no effect . Conclusion . Workplace intervention is advised for multidisciplinary rehabilitation of subacute LBP . Grade d activity or combined intervention is not advised OBJECTIVE To identify subgroups of workers absent from work due to low back pain who are more or less likely to return to work earlier as a result of a grade d activity intervention  , and to investigate whether this intervention is effective in reducing pain-related fears and if so , whether these reductions in pain-related fears mediate return to work . METHODS A subgroup analysis was conducted on data from a previous r and omized controlled trial of 134 Dutch airline workers , which found that a behaviorally-oriented grade d activity intervention was more effective than usual care in stimulating return to work . The subgroup analyses added interaction terms to a Cox regression model that described the relationship between treatment allocation and return to work over 12 months of followup . Furthermore , we studied the effects of grade d activity on pain-related fears and added variables indicating a reduction in pain-related fears to the model in order to investigate their influence on return to work . RESULTS Statistically significant interactions were found for disability , fear-avoidance beliefs about physical activity , and fear-avoidance beliefs about work . No indication was found that the reduction in pain-related fears in the grade d activity group mediated more favorable return-to-work results in this group . CONCLUSION Workers who perceive their disability to be moderate and workers with moderate scores for fear-avoidance beliefs return to work more rapidly as a result of the grade d activity intervention than workers with higher scores . The return to work of workers receiving the grade d activity intervention is possibly independent from the reductions in pain-related fears caused by this intervention Study Design . A r and omized controlled trial in occupational health practice was conducted . Objective . To study the efficacy of early management of workers with low back pain by occupational physicians  , as compared with management by the supervisor only . Summary of Background data . Health care and university workers with back pain and on sick leave for less than 1 month were included in the study . Methods . Patients with low back pain for at least 10 days on sick leave were r and omly assigned to early management by the occupational physician ( n = 61 ) or to a reference group with management by the worker ’s supervisor during the first 3 months of sick leave  ( n = 59 ) . The patients were observed for 1 year and compared in terms of time until return to work , pain intensity , functional disability , and general health perception . The occupational physicians were provided with management guidelines . Results . No significant differences were found after 3 and 12 months of follow-up evaluation in terms of time until return to work ( hazard ratio , 1.3 ; 95 % CI , 0.90–1.90 ) or in terms of other health outcomes . Recurrences , however , occurred more frequently in the intervention group , but the total duration of sick leave in 1 year did not differ between the groups . Conclusions . The findings do not show a significant positive effect of an early intervention by occupational physicians on workers with low back pain . This might reflect the early phase of disability or the low intensity of the intervention result ing from overestimation of the physicians ’ compliance with the guidelines Objectives Workers with common mental disorders ( CMDs ) frequently experience recurrent sickness absence but interventions to prevent this are lacking . The goal of this study was to evaluate the effectiveness of the Stimulating Healthy participation And Relapse Prevention at work intervention in preventing recurrent sickness absence in workers who returned to work after sickness absence due to CMDs . Methods We performed a cluster-r and omised controlled trial with 3 months , 6 months and 12 months follow-up . Treatment providers were r and omised to either a 2-day training in the Stimulating Healthy participation And Relapse Prevention at work intervention , that is , a problem-solving intervention , or usual care . Primary outcome measures were the incidence of recurrent sickness absence and time to recurrent sickness absence . Secondary outcome measures were mental health complaints , work functioning and coping behaviour . Results 80 participants were r and omised in the intervention group and 78 in the control group . The adjusted OR for the incidence of recurrent sickness absence was 0.40 ( 95 % CI 0.20 to 0.81 ) and the adjusted HR for time to recurrent sickness absence was 0.53 ( 95 % CI 0.33 to 0.86 ) for the intervention group compared with care as usual . Conclusions This study demonstrates the 12-month effectiveness of a problem-solving intervention for reducing recurrent sickness absence in workers with CMDs and emphasises the importance of continuous attention in the post return to work phase for workers who have been on sickness absence due to CMDs
target: There was strong evidence that duration away from work from both MSK or pain-related conditions and MH conditions were significantly reduced by multi-domain interventions encompassing at least two of the three domains .
  There was moderate evidence that these multi-domain interventions had a positive impact on cost outcomes .
  There was strong evidence that cognitive behavioural therapy interventions that do not also include workplace modifications or service coordination components are not effective in helping workers with MH conditions in RTW .
  Evidence for the effectiveness of other single-domain interventions was mixed , with some studies reporting positive effects and others reporting no effects on lost time and work functioning .
background: Purpose The objective of this systematic review was to synthesize evidence on the effectiveness of workplace-based return-to-work ( RTW ) interventions and work disability management ( DM ) interventions that assist workers with musculoskeletal ( MSK ) and pain-related conditions and mental health ( MH ) conditions with RTW .