Journal of Occupational Rehabilitation, Vol. 15, No.

4, December 2005 (

C 2005)

DOI: 10.1007/s10926-005-8031-2

Prevention of Work Disability Due to Musculoskeletal

Disorders: The Challenge of Implementing Evidence
Patrick Loisel,1,10 Rachelle Buchbinder,2,3 Rowland Hazard,4 Robert Keller,5
Inger Scheel,6 Maurits van Tulder,7,8 and Barbara Webster9

Background: The process of returning disabled workers to work presents numerous chal-
lenges. In spite of the growing evidence regarding work disability prevention, little uptake
of this evidence has been observed. One reason for limited dissemination of evidence is the
complexity of the problem, as it is subject to multiple legal, administrative, social, political,
and cultural challenges. Purpose and methods: A literature review and collection of experts’
opinion is presented, on the current evidence for work disability prevention, and barriers to
evidence implementation. Recommendations are presented for enhancing implementation
of research results. Conclusion: The current evidence regarding work disability prevention
shows that some clinical interventions (advice to return to modified work and graded activ-
ity programs) and some non-clinical interventions (at a service and policy/community level
but not at a practice level) are effective in reducing work absenteeism. Implementation of
evidence in work disability is a major challenge because intervention recommendations
are often imprecise and not yet practical for immediate use, many barriers exist, and many
stakeholders are involved. Future studies should involve all relevant stakeholders and aim
at developing new strategies that are effective, efficient, and have a potential for successful
implementation. These studies should be based upon a clearer conceptualization of the
broader context and inter-relationships that determine return to work outcomes.
KEY WORDS: work disability; occupational health; health plan implementation; evidence-based medicine;
intervention studies.

1 Disability Prevention Research and Training Center, Université de Sherbrooke, Longueuil, Québec, Canada.
2 Monash Department of Clinical Epidemiology at Cabrini Hospital, Malvern Victoria, Australia.
3 Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.
4 Departments of Orthopaedics and Medicine, Dartmouth Medical School, Lebanon, New Hampshire, USA.
5 Maine Medical Assessment Foundation, Augusta, Maine, USA.
6 The Norwegian Back Pain Network, Ullevål University Hospital, Oslo, Norway.
7 Institute for Research in Extramural Medicine, VU University Medical Center, Amsterdam, The Netherlands.
8 Institute for Health Sciences, Free University, Amsterdam, The Netherlands.
9 Liberty Mutual Research Institute for Safety, Center for Disability Research, Hopkinton, Massachusetts, USA.
10 Correspondence should be directed to Patrick Loisel, Disability Prevention Research and Training Centre,
Université de Sherbrooke, 1111 St-Charles West, Suite 101, Longueuil, Québec J4K 5G4 Canada; e-mail: patrick.
loisel@usherbrooke.ca.

507
1053-0487/05/1200-0507/0

C 2005 Springer Science+Business Media, Inc.
508 Loisel et al.

INTRODUCTION

The process of returning a disabled worker to work presents numerous challenges to

employees, employers, healthcare providers, and insurers. A few decades ago, a biomedi-
cal approach toward preventing musculoskeletal disability, especially in back pain, seemed
achievable. The leading explanatory model for back pain and sciatica was the abnormal
intervertebral disc, and the best protection was thought to be through reducing loads on the
disc. Interventions were developed by physical therapists to teach relevant biomechanical
principles along with self-care exercises, and to help employers with workplace modifi-
cations. This was the essence of the back school (1) and ergonomic movements, which
became very popular, but had no effect on return to work (RTW). This lack of success has
led to the development of new biopsychosocial (2) and disablement (3,4) models that shift
the focus from fixable anatomic causes toward more complex systems in which stakeholder
interactions (spouses, family, employer, insurance carrier, and attorney), and particularly
the role of the individual, are stressed. At the same time, patient education has been aug-
mented by the shared medical decision making model in which best evidence is presented
to the patient in expectation that the person with the problem, armed with the best data,
will make the most appropriate clinical decisions for themselves (5).
In spite of the growing evidence for specific interventions in work disability pre-
vention, little uptake has been observed in typical settings, apart from controlled studies.
Possible explanations include the complexity of a problem that is subject to multiple legal,
administrative, social, political, and cultural obstacles, and the multitude of factors and
stakeholders in the arena of work disability prevention (Fig. 1). Applying new knowledge
in disability prevention may not only mean changing clinical care, but also implementing
administrative and social changes.
This article will present the current evidence on work disability prevention, as a
background for discussion of barriers to evidence implementation and concludes with
recommendations for enhancing implementation of research results in this field.

SUMMARY OF CURRENT EVIDENCE ON WORK DISABILITY

PREVENTION FOR MUSCULOSKELETAL DISORDERS

Most of the literature in work disability prevention involves low back pain (LBP),
as it is the most costly disabling musculoskeletal condition. Most LBP trials use pain
intensity and functional status as primary outcome measures, thus are not informative with
respect to RTW. However, several systematic reviews have summarized those investigations
that do report RTW outcomes. Reviews of studies on multidisciplinary treatment for LBP
have found moderate evidence of positive effectiveness for RTW, and that a workplace
visit increases the effectiveness (6–8). Evidence regarding vocational outcomes of similar
interventions for chronic LBP is less conclusive (9). Physical conditioning programs that
include a cognitive-behavioral approach plus intensive physical training (specific to the job
or not) seem to have RTW advantages with chronic back pain, compared to usual care (10).
Other interventions, such as advice to return to modified work and graded activity programs,
are also effective in speeding up RTW (Table I). However, attempts to alter doctors’ advising
behavior about RTW, more often than not, fail (11,12). Service level interventions that aim
Prevention of Work Disability, Implementing Evidence 509

Fig. 1. The arena in work disability prevention (figure adapted from Loisel et al. (87)).

to achieve earlier RTW through more complex systems support are effective (13–16). They
are designed to change how people work together across different community service
institutions, and may include organizational system changes, or new, specialized services.
It is difficult to pinpoint what does and does not work in these large-scale community-level
interventions or policy initiatives (17,18).
Interventions involving diverse stakeholders in the workplace can also improve RTW.
The Michigan Disability Prevention Study reported that management policies and practices
that promoted a people-oriented culture resulted in decreased disability duration and costs
(19). Shaw et al. (20) reported that supervisors can be trained to respond to an employees’
LBP complaint with concern, avoiding an adversary relationship, and encouraging the
employee to seek appropriate medical treatment, with workplace accommodation. In using
this approach at a meat packing facility, new claims decreased by 47% and active lost-time
claims by 18% (21).
Waddell (22) emphasized the importance of the individual’s decision of whether to
RTW. Thus, better understanding of the meaning (thoughts, beliefs and attitudes) patients
attribute to their pain may be a critical step toward improving RTW outcomes. It may
be more effective to address an individual’s fear of re-injury than to provide a medical
information pamphlet. Employee education regarding musculoskeletal conditions, such as
LBP, through reassuring messages delivered at the acute level can prevent disability (23).
The media is a leading source of information for both patients and doctors about
important health issues (24), and its use is an established health promotion strategy (25).

Table I. Selection of Important Single Studies in Relation to RTW for People on Sick Leave With Back Pain (Table Adapted From Scheel (75))
Measuring Classification of studies
Effects of early RTW “Laboratory style” intervention
interventions trial
Clinical intervention trials
Effects of advice for early RTW Clinical intervention trials
Effects of non-clinical Practice level intervention trials
interventions to promote early RTW
Service level intervention trials
Policy/community intervention
evaluations
a Trials on advice of activity are included as, in principle, they are considered to apply equally to work (Waddell).
510
Supporting the question Identified studiesa Effects on RTW
Is early return to modified duties Wiesel et al. (80) Negative
effective in reducing time off?
Is a graded activity program Lindström et al. (81) Positive
effective in speeding up RTW? Staal et al. (82) Positive
Is (physician’s) advice to return Malmivaara et al. (83) Positive
to modified work effective in Burton et al. (84) Promising
reducing sick leave and
disability for back pain
patients?
Are interventions to change Hazard et al. (11) No effect
(physician’s) practice on Verbeek et al. (12) No effect
promoting early return to
modified work effective in
reducing sick leave and
disability for back pain
patients?
Are re-organization of, or Loisel et al. (13) Positive
provision of, new services to Rossignol et al. (14) Promising
support early return to Indahl et al. (16) Positive
modified work effective in Hagen et al. (15) Positive
reducing sick leave and Anema (85) and Steenstra (86) Positive
disability for back pain
patients?
Are public policy initiatives to Buchbinder et al. (17) Promising trend
support early return to Scheel et al. (18,75) No effect
modified work effective in
reducing sick leave and
disability for back pain
patients?
Loisel et al.
Prevention of Work Disability, Implementing Evidence 511

The value of a media campaign as a means of reducing back pain disability was recently
demonstrated by the results of a highly successful campaign that took place in Victoria
(Australia) between 1997 and 2000 (see boxed Example 1) (17,26,27).
Evidence-based practice is important, as clinical decisions that are not evidence-based
are associated with prolonged disability (61). A recent systematic review of international
guidelines for care of LBP (28) demonstrated quality problems including absence of proper
external review, lack of attention to organizational barriers and cost implications, and lack of
information on the independence of editors and developers. Yet, there is general agreement
on numerous fundamental issues including rapid and early diagnostic triage, identifica-
tion of potential psychosocial and workplace barriers for RTW, and advice that LBP is a
self-limiting condition and that remaining at work or early RTW should be encouraged
(28).

CHALLENGES IN IMPLEMENTATION OF RESEARCH EVIDENCE

Implementing new evidence in health care is challenging and many factors that either
impair or improve evidence implementation remain unclear. A systematic review of 102
trials of interventions to improve professional practice showed that “there are no magic
bullets for improving quality of care” (29). Findings indicate that passive strategies (such as
providing access to medical education materials) are ineffective, most other interventions
are effective under some circumstances, but none are effective under all circumstances (30).
Multifaceted interventions targeting several explicitly identified barriers to change seem to
be more effective than single interventions (30).
The paradigm shift from biomedical to a biopsychosocial model of disability transfers
responsibility for outcomes from the healthcare provider–patient relationship to a multi-
player decision-making system influenced by complex professional, legal, administrative,
and cultural (societal) interactions. Investigations to shed light on both the barriers and
facilitators to the uptake of evidence on new RTW interventions should be based upon a
sound theory, not only to further our understanding of implementation issues, but also to
ensure comprehensiveness of the investigation. For example, it is not sufficient to merely
ask the relevant stakeholders about their attitudes toward the intervention in question. In the
case of active sick leave (see boxed Example 2), when asked, more than 90% of patients,
doctors, employers, and insurance officers were supportive regarding the use of active sick
leave and believed that early RTW would provide positive health effects as well as reduce
sick leave and disability. Paradoxically, less than 1% of eligible patients were actually using
the scheme at the time (31).
Factors that influence change of clinical practice may be related to the knowledge,
skills and attitudes of healthcare providers, or to the social, organizational, economic and
legal context in which they work (32). This is also true for the wider spectrum of stake-
holders exposed to new ideas on RTW strategies. Rogers’ five-stage theory on diffusion
of innovations may provide a useful theory for investigating barriers to change and de-
signing implementation strategies for RTW interventions. It has been cited as an analysis
framework in health care on several occasions (33). Rogers defines innovation diffusion as
the process by which an innovation is communicated through certain channels over time
among members of a social system (34). In this process, an individual will pass from initial
knowledge of an innovation to forming an attitude toward the innovation, to a decision to
512 Loisel et al.

adopt or reject, to implementation and use of the new idea, and to the confirmation of this
decision (34).
However, implementation strategies for RTW interventions may be targeted at differ-
ent levels of the social system. They may be targeted at the level of disabled workers, at
the level of healthcare providers and/or employers, or at a wider system level, and the the-
oretical framework should be relevant to the level chosen (35). When aiming to implement
the use of research evidence among policymakers or powerful stakeholders with strong
political values, it is likely that Rogers’ theory would not apply. By their two-community
thesis (or two-culture thesis), Caplan et al. (36) provide useful insight into the relationship
between researchers and policymakers. They describe the policymaker and the researcher
as members of two cultures, who lack the will or ability to relate to each other’s perspective.
In a systematic review of literature on policymakers’ perception of barriers to the use of
research evidence, Innvaer et al. (37) found that the most commonly identified barriers were
mutual mistrust and lack of personal contact, in addition to lack of timeliness, relevance
and availability.
Thus, implementing research evidence on RTW strategies is even more difficult than
changing practice behaviors among physicians. The arena of work disability encompasses
not only the health care field, but also involves workplace, compensation, and societal
issues (Fig. 1). RTW strategies are often complex interventions consisting of many ele-
ments and involving multiple stakeholders inside and outside of the workplace. To develop
implementation strategies will require identifying each of the stakeholders and associated
barriers, as well as constraints in the communication among them (38). For example, a
strategy involving gradual return to modified work may require actions and decisions made
by the patient, his physician, the employer, the occupational health staff and a third party
payer (Fig. 1) – each with their own values, objectives, interests and training. For each,
there may be unique barriers to the uptake of best evidence.

Healthcare Providers

Various healthcare providers may be involved in the treatment of LBP in occupational

care. Depending on the country, regulations, and ways of practice, many different medical
and non-medical healthcare providers may be involved. The occupational physician, family
physician or a case manager may have a central role in the management of non-specific
musculoskeletal disorders. It is important that information and treatment are consistent
across professions, and that healthcare providers closely collaborate with each other. How-
ever, implementing evidence in the healthcare sector may be time-consuming, expensive,
labor intensive and thus difficult to sustain over time (see boxed Example 3).
Despite the proliferation of evidence-based guidelines, a number of studies have found
a persistent lack of provider adherence (39–42). Suggested barriers to following practice
guidelines include lack of awareness, knowledge, familiarity, self-efficacy, outcome ex-
pectancy; and inertia of previous practice or external barriers (43). Lack of knowledge may
stem from the volume of information, time required to stay current, or a lack of guideline
accessibility. Providers may not agree with the guidelines due to differences in evidence
interpretation; their belief that recommendations are not applicable, impractical or too rigid
to apply to their patients; are not cost-beneficial; or they lack confidence in the guideline
panels (44,45). Also, providers may believe that guideline recommendations will not lead
Prevention of Work Disability, Implementing Evidence 513

to expected outcomes, or that they will be unsuccessful in achieving the desired outcome.
Providers may also have difficulty overcoming the inertia of their established practice
patterns. Linton et al. (46) found that providers treating LBP may hold alternative beliefs
regarding the association of pain and activity that may influence their practice behavior. Ex-
ternal barriers include patient demands for care that are not evidence-based, and providers’
lack of paid time to answer questions or provide information regarding psychosocial issues
or to counsel patients regarding the evidence supporting their recommendations (47). Other
external barriers include lack of resources and malpractice concerns. Studies of specialty
and surgical referrals for LBP indicate that referrals are over-utilized and cases could be
better managed conservatively (48).

Patients

It has been recommended that the guideline-development process should consider

patient expectations regarding diagnosis, communication, and involvement in decision-
making (49), along with informing practitioners of the scientific evidence that should be
combined with clinical judgment and patient input, resulting in a shared decision-making
process. However, to what extent can patients’ expectations be addressed? Also, patients
usually adhere to the biomedical model diffused in the media, making their expectations
inconsistent with the biopsychosocial model that would best suit their conditions. For
example, patients and physicians may interpret age-related degenerative changes as the
cause of their acute symptoms and inappropriately restrict activity (50). Patients may also
request more testing and passive medical interventions, delaying initiation of functional
restoration (51). Ordering more tests and pain-related treatments may also reinforce a
patient’s false expectations for a “cure” (50). Despite the perception that a diagnostic study
is necessary for patient satisfaction, Deyo and Diehl (52) found that satisfaction was actually
more closely related to patient perceptions that they received an adequate explanation.
Hence, reassurance is a key factor, especially for patients who have an overly negative
perspective on their future (53), and physicians may have the capability to effectively
reassure their patients. However, studies have shown that in many cases the way physicians
make reassurances may have the opposite effect of enhancing patient’s fears (54).

Workplace

There has been little research to identify workplace barriers. It has been suggested
that some employers may be hesitant to invest in resources, and dedicated personnel due
to the perceived added expense (55). Inside the workplace, the actions and attitudes of line
management and co-workers are important factors in the success of workplace-based RTW
interventions. Although proactive and supportive communication from supervisors follow-
ing a work accident results in reduced disability duration, supervisors do not necessarily
have the required skills for this (20). Other evidence supports the importance of workplace
organizational factors, such as supportive disability management policies and procedures,
people-oriented culture, collaboration between employer and union, upper management
“buy-in” of health and safety practices and worker legitimacy and dignity (19,56–58).
Thus, when implementing a workplace-based RTW intervention, the researcher is faced
514 Loisel et al.

with the challenging task of creating an environment of trust for both the employer and
the worker. The expanding use of modified work may also reinforce the idea that reducing
physical demands is intended to protect fragile body parts. However, the emerging evi-
dence on modified work procedures (8) shows that its effectiveness is not causally linked
to physical protection, and thus might be due to other impacts, such as maintaining a link
with the workplace.

Insurer

Workers’ compensation boards (WCB) and various public or private insurance systems
compensate for lost wages and medical expenses incurred as a result of work-related in-
juries or illnesses. As insurance personnel may have financial authority, they may influence
the whole intervention process (see boxed Example 4) and may not be highly motivated to
pursue best evidence. Although the insurer’s aim is returning the injured workers to work
in order to end compensation, the compensation process may have anti-therapeutic conse-
quences (59). For example, to satisfy an insurance requirement, a worker must demonstrate
that he has a physical problem. This in turn may thwart a rehabilitation intervention that is
trying to reassure the worker regarding his condition and hoping to change his perception.
Insurers may be reluctant to support psychologically based interventions, as these might
imply an extension of liability for new diagnoses.
Some WCB jurisdictions have used financial incentives. For example, the Québec
WCB (CSST) has developed a financial incentive policy, especially for larger workplaces,
which have lower charges if they rapidly return their employees to modified duties and
higher charges for prolonged disability. Most employers have responded to these incentives,
but sometimes in an inappropriate way (i.e., in implementing inappropriate modified duties
[too heavy or too light] or appealing most cases). This may reflect a lack of appropriate
training of management regarding the recent evidence in the field as well as the lack of
communication among stakeholders in the disability process.

Societal Context

Implementation efforts of research evidence on RTW strategies may also be targeted

at policymakers and political stakeholders to promote the use of evidence in policy de-
cisions regarding regional or national systems (see boxed Example 5). Evidence on the
effectiveness of strategies to improve the use of research results in policy decision-making
is scarce. Nonetheless, it is commonly suggested that researchers and policymakers should
communicate directly and, if possible, be involved in each others’ processes (36,37,60).
It should be noted that various concepts of changing individual professional behavior do
not apply in the same way to policymakers. Each key person targeted for implementation
efforts represents a larger body of political values or organizational strategies. These values
will always guide decisions, and if an innovation is in conflict with these values it will
rarely be adopted.
In some systems, powerful medicolegal forces enforced by laws and regulations
may result in healthcare providers, employers and insurers adopting adversarial processes
that are contradictory to evidence regarding disability prevention (61). In addition, the
Prevention of Work Disability, Implementing Evidence 515

socio-political environment that surrounds the workplace may influence the outcome of
RTW interventions. For example, economic difficulties and unemployment may lead to
personnel layoffs, which in turn may be associated with longer duration of work disability.
Also, changes in political parties may greatly influence project implementation (see boxed
Example 1).

Intervention Development Methodology

Another rarely considered barrier is the lack of clear methodology for intervention
design. Recently, an effort has been made by social scientists to bring theorization to social
intervention assessment, by scrutinizing the way they were developed, before assessing
their implementation and outcome (62). However, these methods have rarely been used
in the field of work disability prevention (63). As the proposed interventions in work
disability prevention are often complex, made of multiple components and delivered by
several stakeholders from different organizations, this leads to difficulty in replicating them
in other settings.

RECOMMENDATIONS FOR DEVELOPING APPLIED RESEARCH

IN WORK DISABILITY PREVENTION

Dissemination and implementation of best strategies to reduce work disability remains

an unsolved challenge. We must recognize that current evidence-based recommendations
for RTW are often imprecise, conceptual or not yet practical for immediate field use. For
some aspects of RTW, more precisely focused studies building on present knowledge, are
required before general dissemination. Providing recommendations to clinicians, employers
and decision makers may be difficult beyond a few general principles and tools derived
from current evidence for patients/workers having work disability from musculoskeletal
disorders. As a result, we need research aimed at developing more tools that can be adapted
to the specific legal, social, administrative and cultural context where they are to be applied.

“Diagnosing” Barriers and Facilitators in Implementing Best Evidence:

Changing Providers’ Focus

As outlined in Fig. 1, most barriers and facilitators to RTW are more related to
psychosocial, workplace and management issues than to the initiating physical disorder.
One obstacle to implementation might simply be that clinicians devote much more attention
to making a specific clinical disease diagnosis than to investigating and identifying the
barriers and facilitators of RTW. We advocate for altering the disease diagnosis perspective
towards work disability diagnosis, by investigating causal psychosocial and environmental
factors (64). Some preliminary attempts have been made (65–67) that should be repeated
and expanded, in order to give clinicians valid tools and clues to target the causes of
disability.
Possible research questions:
• Does a tool allowing clinicians to detect psychosocial factors lead them to use more
effective disability prevention strategies?
516 Loisel et al.

• Will an appropriate tool help clinicians or case managers to detect workplace ob-
stacles to RTW?

Providing Reassurance to the Worker

A key factor for RTW emphasized in most guidelines is worker’s reassurance. How-
ever, healthcare providers do not seem to be well trained in providing this. How to effectively
provide reassurance may be less straightforward than it may first appear (54). It may re-
quire a better understanding of the patients’ real fears, and improved techniques for training
healthcare providers on reassurance. As a result, a better understanding of the concept of
reassurance has to be developed and appropriate ways to provide reassurance to the worker
should be investigated.
Possible research questions:
• How can providers detect the real fears and disease representations of patients with
work disability?
• What are effective means of reassuring workers having work disability?

Helping Workplaces

More research is needed to identify workplace barriers and effective means to con-
vince management that establishing disability management programs is cost-beneficial (19).
Some attempts have been reported but they have not been generalized. In addition, commu-
nication between healthcare providers and workplaces is rarely done and may be difficult
in practice. In particular, the two worlds of clinical practice and workplace management
generally have different objectives and targets (e.g. health improvement vs. productivity
maintenance). Some work has recently been attempted to offer practical tools to facili-
tate this dialogue (68). Research efforts are needed to provide workplaces with validated
techniques to make critical improvements in these areas.
Possible research questions:
• What information does management need to overcome their barriers to the imple-
mentation of workplace disability programs?
• What kinds and conditions of modified work are effective to improve return to
regular work?
• How should employers and others communicate to healthcare providers specifics
about job demands, workplace reality and risk of prolonged work disability?

Bringing the Stakeholders on Side

Bringing the stakeholders onside has been recommended (69). However, the stake-
holders in the disability process have different interests, values and language, resulting in
contradictory actions that may reinforce patients’ anxiety, fears and misunderstandings. A
research agenda to develop more effective approaches for improved communication and
agreement among stakeholders is described by Franche et al. in this issue.
Prevention of Work Disability, Implementing Evidence 517

Possible research questions:

• What are the required skills of a professional dealing with disability prevention
issues?
• How should an effective regulation system that enhances stakeholders’ collaboration
be designed?

Modifying the Societal Context

As work disability is a complex systemic problem, some obstacles come from the
way social systems are designed. A better understanding of the disability problem and its
related human and financial costs by stakeholders and governments might help in making
appropriate changes in laws and regulations. Future research might involve legal experts
with proposals to reduce these negative side effects.
Possible research questions:
• How do different compensation systems compare in design and effectiveness?
• What are the societal/cultural factors that may impair/enhance RTW?

Intervention Development and Evaluation

Little information is available on the rationale of intervention design related to evi-

dence regarding work disability prevention. Moreover, several kinds of interventions are
mixed, making it difficult to recognize the essential components. Efforts should be made
to “open the black box” of these interventions (63) and to design appropriate interventions
in order to ensure that their content is in accordance with evidence as well as with the
social system and the stakeholders available to deliver the program. Bringing social science
methods including theory-based evaluation in this field would allow subsequent testing of
possible negative or positive interactions between program components. This will require
that intervention design be made on evidenced-based grounds and with the active partici-
pation of all stakeholders in the disability problem, which may vary depending on where
the program is to be delivered.
Possible research questions:
• What components, included in interventions for RTW, are really effective?
• What is the program theory of a designed intervention?

Exploring New Avenues

New strategies to improve the implementation of effective RTW interventions are

needed. Application of modern technologies such as the Internet is one promising avenue.
For example, Jeannot et al. (70) suggested that the use of clinical practice guidelines, via
the Web, during consultations with patients is acceptable to physicians. A recent trial has
also suggested that Internet-based self-help with telephone support based upon established
cognitive behavioral methods holds promise as an effective approach (71), with sustained
improvements in catastrophising, control over pain and ability to decrease pain (72). These
518 Loisel et al.

avenues may also be effective in developing needed provider skills to effectively address
RTW issues.
The Internet might also be an effective medium for managing workers’ compensation
claims. On-line interactive medical software programs could be used to enable streamlined
communication between the employee, employer, healthcare professionals and casework-
ers, and to identify issues and suggest action plans based upon the evidence (73). Further
work is needed to assess the effectiveness of these innovative new approaches.

The Researcher’s Role

Being a researcher in intervention design, implementation, and assessment, requires

special skills. Not only are the usual skills required from a researcher (such as in depth
knowledge of the problem, methodological rigor, etc.), but special skills are also needed in
order to work in complex fields with many stakeholders with various interests, important
intervention costs, ethical issues, and systemic variations. Bringing the stakeholders onside
in order to implement and test interventions may prove to be difficult. Complex interdis-
ciplinary research teams are necessary to control multiple variables and interventions in
multiple settings. New research skills are required, demanding innovative training programs
for appropriate capacity building in this field (74). Also, conflicting roles may appear be-
tween researchers, clinicians and decision makers for new knowledge implementation. Is
implementation of knowledge a simple counseling role or also an intervention role for a
researcher? The frontier between these roles may be difficult to define.

Defining a Common Language

Work disability prevention is an emerging field and a common language has yet to
be defined. What is a “workplace intervention” and what is a “clinical intervention”? Are
ergonomic interventions purely physical human factors or do they also include cognitive
factors and working relationships? Does “intervention in an occupational context” mean
intervention for patients having work-related disorders or interventions provided in the
workplace? An effort should be made by researchers to develop precise definitions that will
help to make sure that research reports are well understood at the international level.

CONCLUSION

The current evidence regarding work disability prevention shows that some clinical
interventions (advice to return to modified work and graded activity programs) and some
non-clinical interventions (at a service and policy/community level but not at a practice
level) are effective in reducing work absenteeism. However, there seems to be no consen-
sus on the content of the interventions. Implementation of evidence is a major challenge,
because recommendations for RTW are often imprecise and not yet practical for imme-
diate use, many barriers exist, and many stakeholders are involved. Future studies should
involve all relevant stakeholders, consider legal, professional, administrative and cultural
environments and aim at developing new global RTW strategies that are effective, efficient
and have a potential for successful implementation.
Prevention of Work Disability, Implementing Evidence 519

Example 1: The Victorian WorkCover Authority mass media back campaign (17,26,27)

In 1997 the Victorian WorkCover Authority initiated a 3-year population-based mass

media campaign designed to alter population beliefs about back pain. The campaign
consisted primarily of television commercials that provided simple messages about back
pain in line with current evidence: back pain is not a serious medical problem; disability
can be improved and even prevented by positive attitudes; treatment should consist of
continuing to perform usual activities, not resting for prolonged periods, exercising and
remaining at work.
The campaign resulted in significant improvements in both community and doctors’
beliefs about back pain and this was accompanied by a decline in the number of back
claims and medical payments over the duration of the campaign. Furthermore, 3 years
after cessation of the campaign, there were still significant sustained improvements in
community beliefs about back pain. This data provides a compelling case for implemen-
tation of evidence regarding back pain through public policy initiatives. By influencing a
large proportion of the community simultaneously, it provided societal support for sus-
tained behavioral change. However, the completion of the campaign in 2000 coincided
with a change in elected government in Victoria. Despite the campaign’s success and
support from a wide range of stakeholders, other influences on policy making appear
to have taken precedence and there are currently no plans to reintroduce the campaign.
A similar approach, based upon radio commercials, has subsequently been successful
in Scotland and plans are underway to commence a similar radio media campaign in
Alberta, Canada.

Example 2: The Norwegian Active Sick Leave scheme (18,31,75,76)

Active Sick Leave (ASL) is a workers health insurance option provided by the National
Insurance Administration (NIA) that enables employees on sick leave to return to
modified duties at the workplace. NIA pays 100% of normal wages, thereby allowing the
employer to hire a substitute worker in addition to the one using the ASL-programme.
The scheme was introduced in 1993, but uptake was slow, and in 1995, less than
1% of eligible workers were registered as ASL-users, despite a broad political will
to expand the use of ASL. The NIA therefore funded a research project aiming to
provide stakeholders and decision makers at the national policy level with evidence-
based information on how to increase the use of ASL. Two implementation strategies
were designed and evaluated in a cluster-randomized trial involving local NIA offices,
general physicians, workers on sick leave with back pain and their employees in 65
municipalities. The implementation strategies were alike but for the addition of two pro-
active elements in one of them: a resource person to facilitate processes and a workshop
for general practitioners. Although both multifaceted and targeted at identified barriers,
only the pro-active implementation strategy had the effect of increasing the use of ASL.
This increase in use had, however, no measurable effects on overall days on sick leave,
disability pensions or quality of life while on sick leave.
520 Loisel et al.

Example 3: The Maine Medical Assessment Foundation (77,78)

In the late 1980s the Maine Medical Assessment Foundation (MMAF), using the
epidemiological techniques of small area analysis, identified significant variations in
population-based rates of lumbar disc surgery in their state. Four hospital service areas
had demonstrated rapid increases in surgical rates from a level just below the state
average, to rates twice that of the state. The only change in the medical landscape was
the in-migration of three new spine surgeons into the region. Using educational feed-
back, the spine study group of the MMAF held peer group meetings with the surgeons
in the high rate area. The data was presented, debated and discussed. Without further
intervention, within a year, the high rates had decreased to the state average where they
remained for a number of years.
This outcome demonstrates the effectiveness of appropriately designed implemen-
tation of evidence—in this case the use of high quality epidemiologic data in a non-
threatening educational environment. While effective, this form of implementation has
barriers. It is time-consuming, expensive and labor intensive, and the analyses and
feedback of information must be an ongoing process. Constant changes in the medical
workforce, technology, regulations and health care financing require continual moni-
toring. After a number of years of successful work, the MMAF was unable to maintain
adequate funding and the organization ceased operation in 1992.

Example 4: The Quebec work rehabilitation consortium

In 2000, the WCB management and board of governors funded the creation of a provin-
cial public work rehabilitation consortium. This consortium, known as the Réseau en
réadaptation au travail du Québec (RRTQ), was a partnership of 11 work rehabilitation
institutions that specialize in musculoskeletal disorders in the province of Québec. The
mission of the RRTQ was to offer services that are based on scientific evidence in
order to prevent work disability situations and to promote the development of work
rehabilitation knowledge and practices through research and training.
Though the implementation of a pilot study of the work rehabilitation program went
well at four of these rehabilitation centers, there was reluctance of many WCB case
managers to send disabled persons to the rehabilitation teams. This reluctance was
due to the additional effort required, perception of loss of decision power and of role
conflict and case managers fear of losing their jobs. In spite of the fact that the RTW
rate was excellent for the treated patients, this opposition was strong enough to cause the
WCB management to stop the project to avoid internal conflicts, with possible negative
political adverse effects.
Prevention of Work Disability, Implementing Evidence 521

Example 5: Active Sick Leave—Implementing research results in practical policy-

making (75,79)

Four key stakeholder organizations were involved in a research project to re-structure

the return to work process. These organizations were the National Insurance Adminis-
tration, the Norwegian Confederation of Trade Unions, the Confederation of Norwegian
Business and Industry, and the Norwegian Medical Association. These organizations
all have a high impact on the development of policy on workers’ health and insurance
issues at a national level. The policy questions were translated into research questions
in agreement with the policymakers to ensure that the research would address the exact
questions that were important to policy decisions, and rigorous methods were applied
to provide trustworthy answers to these questions. The stakeholder representatives and
the researchers discussed and decided on outcome measures, data collection, interven-
tions, research design and interpretation of results, all in advance of the actual trial. The
intervention was active sick leave (ASL), a program of financial support for return to
work at modified duty.
The ASL-study concluded that while it is possible to increase the use of active sick
leave by pro-active intervention by a community facilitator, the increase is not likely to
result in economic benefits or improved health outcomes. This information would seem
both relevant and useful to policymakers when allocating resources, prioritizing services
and considering opportunity costs associated with ASL. However, in the short-term
there was little evidence that policymakers or major stakeholders invoked the results of
the trial. On the contrary, through a contract between the Norwegian Authorities and the
major stakeholders to reduce national sick leave by 20% in 2 years, employers were
offered monetary support up to 10.500 Euros (in addition to 100% wages) per worker on
active sick leave. This support was paid per day on active sick leave, thereby providing
an unfortunate barrier to full return to ordinary duties, at significantly added costs.

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