Components of primary care multimodal rehabilitation and their association with changes in sick leave: An observational study

1 Introduction

The main reasons that employees take sick leave from work in Northern Europe include mental health problems such as stress, depression and anxiety, and chronic musculoskeletal pain [1–3]. Moderate to severe chronic nonmalignant musculoskeletal pain occurs in about 20% of the Swedish population [4], which is similar to an estimated 19% prevalence throughout all of Europe [5]. In Sweden, adaptation disorders, abnormal and excessive reactions to identifiable life stressors and reactions to severe stress, are the fastest growing cause of sick leave. These disorders are more prevalent among women than men [6]. Up to 44% of all sick leave taken in Sweden is related to mental illness [6]. The average duration of sick leave is increasing, especially among unemployed people suffering from mental illness [3]. In Sweden, unemployed people registered with the Swedish Public Employment Service can obtain sickness benefits [3].

Prolonged pain, work-related stress, depression and anxiety, and low confidence in one’s ability to cope negatively affect work capacity [7–12] and make return to work (RTW) more difficult and stressful [7–12]. In the case of complex disabilities, more extensive multiprofessional rehabilitation efforts are often required to improve the health and quality of life of patients [12, 13]. However, the resources devoted to rehabilitation of patients on sick leave for mental illness and musculoskeletal pain in Sweden are estimated to be small in comparison with the costs of production loss [14]. Some 20–40% of patients visiting primary care units in Sweden suffer from pain, which is chronic in about half of the cases [15, 16]. Chronic pain may result in long-term sick leave, and the socioeconomic burden of patients with chronic pain is about €32 billion per year in Sweden [2]. The annual socioeconomic burden of patients with mental illness was about 70 billion Swedish crowns in 2015 [17].

To address increases in sick leave for generalized or nonspecific chronic pain in the neck, back, or shoulders and for mild to moderate mental illness, the Swedish Government and the Swedish Association of Local Authorities and Regions entered into an agreement on a “Rehabilitation Guarantee” in 2008, which has since been renewed annually [18]. The primary aim of the “Rehabilitation Guarantee” was to provide County Councils with financial support for evidence-based rehabilitation of working-age patients with chronic pain and long-term mild to moderate mental illness. The objective was to promote RTW and prevent sick leave among patients in whom such conditions last for more than 3 months.

The “Rehabilitation Guarantee” mandates that evidence-based methods such as MMR should be used for pain rehabilitation in primary care settings [15]. MMR has primarily focused on health improvement and not specifically on work-life oriented rehabilitation [15]. In MMR, a multidisciplinary team of health professionals coordinate physiological, psychological, and occupational therapeutic interventions. Rehabilitation may include functional training, physical exercise, body awareness training, education, lifestyle changes, coping strategies for daily life, and cognitive behavioral therapy (CBT) or interpersonal psychotherapy (IPT) from a biopsychosocial perspective to achieve goals defined collaboratively with the patient [15, 18].

Depending on the severity of the disorder and the team's capacity and competence, MMR is provided at two levels in Sweden. MMR1 is usually offered in a primary health care setting, while MMR2 is also offered at the specialist level at university hospitals or regional county hospitals. MMR2 is indicated for complex problems that greatly interfere with daily activities. MMR2 teams should have clinical skills and in-depth knowledge in pain rehabilitation. A social counselor, psychologist, or psychotherapist should be included in MMR2. Even though MMR principles are consistent, health care units differ in their organization and in the content of the rehabilitation and the specific methods used.

This study focuses on MMR1, which was most commonly used in regional primary care settings during the study period. According to the “Rehabilitation Guarantee,” MMR1 should consist of 2–3 sessions per week for at least 4–8 weeks. Teams must include at least three different types of health professionals, including a physician and someone with basic education in CBT. The target was to treat at least 20 patients per year. Cooperation with the Swedish Social Insurance Agency was recommended for cases involving work-related problems and to facilitate contact with the employer if needed.

Self-reported health measures are frequently used as primary outcome measures in MMR research and have shown improvements in health perception and self-reported work ability [19–21]. In a qualitative study [22], patients reported greater empowerment, a sense of increased living space (meaning a more open mind for participation in society), increased embodied knowledge, and a regained hope.

In another qualitative study [23], patients with severe whiplash-associated disorders reported having more tools to manage their pain and a renewed ability to perform daily activities and RTW after MMR. Nevertheless, no report has convincingly shown that MMR increases RTW faster or that MMR patients return to the same work ability level as prior to their disability to a higher extent [24, 25]. In Sweden, people can work part-time, depending on the assessment of their degree of work ability, and sickness benefits can be paid at 25%, 50%, 75%, or 100%. A gradual return to work is often used after extended periods of sick leave [26]. The strongest predictor of reduced sick leave after MMR is prior sickness absence [19, 20]. Moreover, sick leave benefits decrease with MMR, regardless of the current sick leave situation (none, part-time, full-time, or full-time permanent sick leave) of patients with chronic pain [26, 27]. There are many important aspects to consider when studying sick leave benefits and RTW [3, 6]. Contradictory results such as non-return to work may reflect a lack of clearly defined goals and guidelines for RTW, as well as differences in the training of caregivers and their attitudes toward RTW [28].

Despite evidence that MMR is effective, knowledge about its organizational aspects is lacking, and it is not known whether the content and the specific rehabilitation methods used are associated with the amount of sick leave after MMR. In addition, the long-term effectiveness of MMR has yet to be assessed [21, 34]. Therefore, the aim of this study was to investigate whether the organization, structure, rehabilitation content, and specific methods used in regional primary care MMR1 were associated with changes in sickness benefits (days with received sick pay) between the 12-month periods before and after completion of MMR.

2 Material and Methods

3 Results

Demographic and clinical characteristics of the patients who received MMR1 are summarized in Table 1. A large majority were women (84%). The mean age for both sexes was 49 years, and the majority (52%) had secondary school as their highest completed educational level. The two most frequent primary sick leave diagnoses were musculoskeletal disorders and mental disorders.

This study shows that the organization of MMR1 teams, the content of rehabilitation, and the specific methods used vary widely. About half of all units were organized in a way that enabled teamwork according to the guidelines. The majority of teams did not fulfill the requirements spelled out in the “Rehabilitation Guarantee” in 2013. The most common health professions included in MMR1 teams were physicians and physiotherapists, followed by occupational therapists and psychologists or CBT therapists. More than half of the primary care units fulfilled the combined criteria for health professions represented on the team and CBT 1 competence. Only 31 of the units (58%) met the combined criteria of including three of the stated professions and one provider trained to at least CBT level 1. The absence of such competence in MMR1 teams may have negatively affected rehabilitation results, given the high frequency of sick leave due to mental disorders among patients. However, this was not statistically demonstrated in this study.

Even though the MMR1 units were required to have in-depth knowledge of pain relief and rehabilitation, only 24 of 53 units reported having such competence. This type of knowledge, along with geographic proximity, had a potentially positive effect on MMR1 outcomes in terms of sick leave. In a previous study, patients with severe pain and complex situations in general benefited more from MMR than patients with minor problems [34]. Severe chronic pain often produces long-term consequences, sequelae, and life impacts. This underlines the importance of in-depth competencies in pain rehabilitation being represented in a team-based MMR approach.

It seems that the same interventions do not help everyone to the same degree. A register study of pain rehabilitation for Swedish patients concluded that stronger connections between clinical pictures and the content of MMR would help improve results [33]. In order to establish a proper rehabilitation plan, and to better understand the primary problem, the care provider should see the patient in his or her entire context. This requires clinical experience and in-depth knowledge among team members. Only 26% of the units met the requirement to treat at least 20 MMR1 patients per year; 51% of the units enrolled fewer than 10 patients per year. The minimum annual number of patients was set to maintain experience and competence in the treatment of patients with long-term pain.

Other authors have concluded that unclear guidelines are a barrier to implementing MMR [28, 34]. One such barrier could be uncertainty about whether patients fulfill the criteria for achieving MMR, as could have been the case in the present study. All units met the criterion for program length; however, 15 of the units did not meet the criterion for organized weekly activities, as they had at most 10 hours of activities per week, including homework. One possible reason for this is that many teams had few patients and therefore offered only individual treatments and no standardized rehabilitation program. Again, we agree with the conclusion of a previous report [21], which states that better standardized measurements and rehabilitation programs at both the group and the individual level are needed to evaluate MMR in clinical work and research [21, 34].

The foundation of MMR is a well-functioning collaboration among team members and working together with the patient to establish a common goal [15]. More than half of the units reported having joint meetings between the team and the patient during the rehabilitation period. Almost half of the teams had regular weekly meetings. Establishment of a joint target plan was quite common. However, many teams were spread out over a large geographical area, which may have affected the results.

Our findings suggest that patients who were on sick leave before enrolling in MMR will most likely continue their sick leave after completing MMR. These results are in accordance with an MMR evaluation at the Karolinska Institute (KI) [19, 20], at least when estimating net days of sick leave. To reduce sick leave burden, the authors of that study suggested that rehabilitation should start within the 60 first days of sick leave. However, based on the Swedish Quality Registry for Pain Rehabilitation, sick leave benefits for patients with chronic pain decrease over time with MMR, regardless of their current sick leave situation [26]. On average, the patients in our study had sick leave significantly longer than 60 days. The median for gross days of sick leave was about four months. A quarter had been on sick leave for more than nine months and a quarter for fewer than 42 days before the start of MMR. We agree that MMR should be initiated in the early phase of sick leave, especially considering the regulations of the Swedish Social Insurance Agency and the extended rehabilitation responsibility of employers in Sweden. The results showed that there was a difference in gross days but not in net days of sickness benefits after MMR.

The chances of a successful outcome, i.e. fewer days of sickness benefits, were evidently higher for patients with a history of long-term sick leave than for patients with only a few days of sickness benefits before MMR. One should however be careful in interpreting the results, since a patient with a long history of sick leave prior to MMR start could have exceeded the maximum compensation that the person is entitled to receive from the insurance system during the time of the study. In most cases, a gradual return to work is important after long-term sick leave [26], for example starting at 25% and gradually increasing to 100%. The time needed to return to full-time employment can thus vary, which might have impacted the significant reduction in gross days in the present study.

Mental illness was common among our participants, and females were overrepresented; these findings are consistent with previous MMR studies [37, 20]. The prevalence of mental illness [38] and chronic pain [5, 39] in general populations are higher among women than men. The causes of a higher incidence of chronic pain in women are multifactorial, where a number of factors such as neurobiological and social factors play a role, i.e. sex and gender [40]. As previously noted [34, 37], future MMR should be improved and better adapted to a biopsychosocial model. In a recent meta-analysis of MMR interventions for patients with chronic nonspecific back pain, treatment success did not differ between MMR programs that provided predominantly physical treatment, predominantly psychological treatment, or a combination of these. The conclusion of that study, stating that more research is needed to determine whether treatment outcome is affected by more tailored treatment that takes individual factors into account [41], is in line with the conclusions of the present study.

Factors other than self-reported pain seem to be more often associated with assignment to MMR [42]. Studies of referral patterns and decision-making processes may give a better understanding of the clinical practice by which patients are assigned to MMR [43]. The presence of common goals set by the team and patient and the willingness of patients and caregivers to cooperate with external actors regarding RTW are of major importance in MMR [28, 32]. MMR programs also need to be designed to provide long-term follow-up of patients’ work status [31]. Employment status is an important predictor for improved physical and emotional functioning one year after MMR [44]. We had no information about our participants’ work status. Some may have been unemployed and on sick leave, while others were employed but did not work for a long time. It is likely that stigma causes problems for individuals with complex health problems in the RTW process. Workplace-based rehabilitation might be used to earlier address musculoskeletal or psychological/stress-related problems. However, a model tested with an early team assessment of 779 employees who been on sick leave for 90 days encountered many challenges and illustrated the need for coordination when multiple stakeholders are involved [45].

5 Conclusion

In-depth competence and knowledge about the complex health care need of patients seem to be important factors for MMR teams to be successful in reducing sickness benefits for patients with nonspecific chronic pain and mental illness. Further research is needed to elucidate the optimal combination of primary care MMR components for increasing the return-to work rate and to determine whether involvement of the Social Insurance Agency or employers could support and further contribute to recuperation and help patients regain their previous work capacity.