1. A nation-wide programme for early rehabilitation of low back pain workers Pr Philippe Mairiaux, Chair Scientific Council, Belgian Fund for Occupational Diseases and School of Public Health, University of Liège European “Lighten the load” Summit 26th Feb 2008, Bilbao

2. Project background - 2004 A “multidisciplinary back rehabilitation” program (meeting international guidelines) becomes part of the medical treatments taken in charge by the Belgian Health care system. A “multidisciplinary back rehabilitation” program (meeting international guidelines) becomes part of the medical treatments taken in charge by the Belgian Health care system. After years of discussion, social agreement between employers and trade unions endorsed by the Belgian government : access to compensation for some occupational diseases restricted AND recognition of “work-related” diseases (before only occupational ones were compensated) : this new category will benefit from prevention programs After years of discussion, social agreement between employers and trade unions endorsed by the Belgian government : access to compensation for some occupational diseases restricted AND recognition of “work-related” diseases (before only occupational ones were compensated) : this new category will benefit from prevention programs

3. Project background 2004 : Back pain becomes the 1 st recognised work-related disease 2004 : Back pain becomes the 1 st recognised work-related disease a “Royal decree” allows the Fund for Occupational Diseases (FOD) to launch a pilot project for back pain prevention a “Royal decree” allows the Fund for Occupational Diseases (FOD) to launch a pilot project for back pain prevention among nursing staff exposed to back pain risk factors in general or geriatric hospitals among nursing staff exposed to back pain risk factors in general or geriatric hospitals

4. The Belgian health care multidisciplinary back rehabilitation program + Pain emotional components by a psychologist Ergonomics module by a trained team member 36 sessions (max) of 2 hr duration

5. The FOD back prevention project – a return to work program è Medical axis Incentives to the worker/patient for entering the Health Insurance back rehabilitation program (no charge for the patient) Incentives to the worker/patient for entering the Health Insurance back rehabilitation program (no charge for the patient) è Workplace axis Promoting an ergonomic analysis of the worker tasks (250 € incentive for the employer) Promoting an ergonomic analysis of the worker tasks (250 € incentive for the employer)  Networking Caring physicians (GP’s, rehabilitation physicians,…) and occupational health physicians (OP) Caring physicians (GP’s, rehabilitation physicians,…) and occupational health physicians (OP)

6. Medical axis : 45 rehabilitation centres under contract with FOD 10 2 4 4 3 6 6 2 3 1 0 6 Are providing the multidisciplinary back program

7. FOD back prevention project è Workplace axis OH service and occupational health physician tasks: i OH service and occupational health physician tasks: informing employers and target people, assessing inclusion criteria for applicants, stimulating ergonomics analysis, looking for work accommodations to facilitate RTW 22 OH services at the country level  Pilot project duration 12 months starting March 1 st 2005 (and prolonged since for 1 more year March 2007) 12 months starting March 1 st 2005 (and prolonged since for 1 more year March 2007)

8. Target population Hospital staff performing manual handling of patients Hospital staff performing manual handling of patients AND being off work due to non-specific low back pain AND being off work due to non-specific low back pain Ø Since minimum 4 weeks and maximum 3 months AND without a surgical indication or other medical conditions precluding the participation AND without a surgical indication or other medical conditions precluding the participation AND willing to participate on a voluntary basis AND willing to participate on a voluntary basis

9. Evaluation study 1 st year project: intermediate outcomes measure Data collection about the participants : Data collection about the participants : Application forms : demographic variables, low back pain history and clinical data at entry Application forms : demographic variables, low back pain history and clinical data at entry End of rehabilitation reports; number treatment sessions received; RTW yes / no End of rehabilitation reports; number treatment sessions received; RTW yes / no Form completed by OP when worker resumes work Form completed by OP when worker resumes work Phone survey data (June and July 2006) Phone survey data (June and July 2006) Summary results : favourable (i.e 79% return to work before 18 th rehab session, 98,7% before treatment end) but no control group… Summary results : favourable (i.e 79% return to work before 18 th rehab session, 98,7% before treatment end) but no control group…

10. Evaluation study 1 st year project - process evaluation Aiming at describing: Aiming at describing: information spreading, information spreading, rate of participation, rate of participation, admission procedures and paths, admission procedures and paths, rehab treatment length, rehab treatment length, practical measures taken in the hospitals for facilitating return to work….etc practical measures taken in the hospitals for facilitating return to work….etc Additional data collection : Additional data collection : Discussion transcripts of the information sessions organised in the country for promoting the program Discussion transcripts of the information sessions organised in the country for promoting the program Interviews with program stakeholders Interviews with program stakeholders Phone interviews of a random sample of general practitioners (Oct 2005) Phone interviews of a random sample of general practitioners (Oct 2005)

11. Flow chart of program participation (first 12 months) Medical data N = 76 Phone survey Responses : 74 Refusal : 2 No contact : 7 Report end rehab. N = 74 Participants N = 83 Drop-outs : 6 Lost to F-up : 2 Accepted cases N = 91 Rejected N = 11 Applications N = 102

12. Process evaluation a few striking results (Very) low rate of participation (102 applications versus about 300 expected during 1 st year) (Very) low rate of participation (102 applications versus about 300 expected during 1 st year) Imbalance in the program application : medical component >> workplace intervention Imbalance in the program application : medical component >> workplace intervention

13. Barriers to participation : target population not aware of the program Information challenge ! How to disseminate quickly information to 172 hospitals, hundreds of nursing homes for elderly people, about 90.000 nursing staff, 22 OH prevention services (and their 600-700 OP’s), 36 rehabilitation centres, hundreds of caring physicians, …? Information challenge ! How to disseminate quickly information to 172 hospitals, hundreds of nursing homes for elderly people, about 90.000 nursing staff, 22 OH prevention services (and their 600-700 OP’s), 36 rehabilitation centres, hundreds of caring physicians, …?

14. Barriers to participation : target population not aware of the program Trade unions in health care sector not so keen to push for a program that they perceived as discriminating against staff categories other than nursing Trade unions in health care sector not so keen to push for a program that they perceived as discriminating against staff categories other than nursing In a given hospital, expected number of nurses on sick leave > 4 weeks for LBP is per se low (estimated incidence : 5 to 8/1000 per year) employers or OH services may have other priorities… In a given hospital, expected number of nurses on sick leave > 4 weeks for LBP is per se low (estimated incidence : 5 to 8/1000 per year) employers or OH services may have other priorities…

15. Barriers to participation When aware of the program, back pain sufferers in nursing may not be motivated to participate When aware of the program, back pain sufferers in nursing may not be motivated to participate Their GP are afraid not to get the patient back after the treatment in the centre or are putting more emphasis on passive treatments for LBP Their GP are afraid not to get the patient back after the treatment in the centre or are putting more emphasis on passive treatments for LBP The opportunity to meet the OP during the sick leave still not known by many workers The opportunity to meet the OP during the sick leave still not known by many workers Wrong beliefs : “movement would aggravate my injury” Wrong beliefs : “movement would aggravate my injury” Privacy : “the rehab centre being in my own hospital, everybody will know my health problem and status” Privacy : “the rehab centre being in my own hospital, everybody will know my health problem and status”

16. Barriers to a balanced application of the program Medical rehabilitation component : Medical rehabilitation component : Benefits from the support given by the health care system : content and procedures precisely defined, standardised assessment tools, good return on investment if applied at a large scale Benefits from the support given by the health care system : content and procedures precisely defined, standardised assessment tools, good return on investment if applied at a large scale Workplace intervention much less developed: Workplace intervention much less developed: content not so well formalized content not so well formalized money incentives too low from the OH services point of view money incentives too low from the OH services point of view difficult to carry out if a prevention policy has not been endorsed by the employer and the workers representatives difficult to carry out if a prevention policy has not been endorsed by the employer and the workers representatives employers’ culture of 100% fitness for work does not match the program aim : facilitating an early return to work employers’ culture of 100% fitness for work does not match the program aim : facilitating an early return to work

17. Conclusion The availability of an evidence supported intervention model (like the Sherbrooke model) was key in the introduction of a multidisciplinary back rehab program in the Belgian health care system The availability of an evidence supported intervention model (like the Sherbrooke model) was key in the introduction of a multidisciplinary back rehab program in the Belgian health care system The implementation process of such an evidence-based intervention at a country level is another story and warrants more research in the future The implementation process of such an evidence-based intervention at a country level is another story and warrants more research in the future If starting such an intervention directly at a national level should theoretically not be advised, should we restraint social forces when they are going in the right direction ? If starting such an intervention directly at a national level should theoretically not be advised, should we restraint social forces when they are going in the right direction ?

18. Continuing story … May 27 th 2007 : Royal Decree The “pilot” project is given permanent status May 27 th 2007 : Royal Decree The “pilot” project is given permanent status Target population extended to all workers in Belgium, whatever the industry sector, exposed to back pain risk factors (manual handling, or whole body vibration) Target population extended to all workers in Belgium, whatever the industry sector, exposed to back pain risk factors (manual handling, or whole body vibration)

19. Workers included in the project

20. Participation trends 2005 Applications : 122 Applications : 122 Women : 91,8 % Women : 91,8 % Health care: 100 % Health care: 100 % Building industry : 0 Building industry : 02007 284 284 71,1 % 71,1 % 66,5 % 66,5 % 6,3 % 6,3 %

21. Thank you for your attention !