Can Chiropractors Contribute to Work Disability Prevention Through Sickness Absence Management for Musculoskeletal Disorders? – A Comparative Qualitative Case Study in the Scandinavian Context
SOURCE: Chiropractic & Manual Therapies 2018 (Apr 26); 26: 15
Mette Jensen Stochkendahl, Ole Kristoffer Larsen, Casper Glissmann Nim, Iben Axén, Julia Haraldsson, Ole Christian Kvammen, and Corrie Myburgh
Nordic Institute of Chiropractic and Clinical Biomechanics,
Campusvej 55, DK-5230
Odense M, Denmark.
BACKGROUND: Despite extensive publication of clinical guidelines on how to manage musculoskeletal pain and back pain in particular, these efforts have not significantly translated into decreases in work disability due to musculoskeletal pain. Previous studies have indicated a potential for better outcomes by formalized, early referral to allied healthcare providers familiar with occupational health issues. Instances where allied healthcare providers of comparable professional characteristics, but with differing practice parameters, can highlight important social and organisational strategies useful for informing policy and practice. Currently, Norwegian chiropractors have legislated sickness certification rights, whereas their Danish and Swedish counterparts do not. Against the backdrop of legislative variation, we described, compared and contrasted the views and experiences of Scandinavian chiropractors engaging in work disability prevention and sickness absence management.
METHODS: This study was embedded in a two-phased, sequential exploratory mixed-methods design. In a comparative qualitative case study design, we explored the experience of chiropractors regarding sickness absence management drawn from face-to-face, semi-structured interviews. We subsequently coded and thematically restructured their experiences and perceptions.
RESULTS: Twelve interviews were conducted. Thematically, chiropractors’ capacity to support patients in sickness absence management revolved around four key issues: issues of legislation and politics; the rationale for being a sickness absence management partner; whether an integrated sickness absence management pathway existed/could be created; and finally, the barriers to service provision for sickness absence management.
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CONCLUSIONS: Allied healthcare providers (AHPs), in this instance chiropractors, with patient management expertise can fulfil a key role in sickness absence management and by extension work disability prevention when these practices are legislatively supported. In cases where these practices occur informally, however, practitioners face systemic-related issues and professional self-image challenges that tend to hamper them in fulfilling a more integrated role as providers of work disability prevention practices.
KEYWORDS: Chiropractic; Interview; Policy; Qualitative; Sickness absence; Work disability prevention
From the FULL TEXT Article
Musculoskeletal pain is a major cause of work disability with enormous socioeconomic consequences. Back pain-related disorders alone are costly and responsible for up to one quarter of days off work in European countries like Sweden  and Denmark , and in Norway four out of ten sickness certifications are based on a musculoskeletal diagnosis. 
For patients with musculoskeletal pain or other work-related problems, general practitioners (GPs) are the traditional gatekeepers to workers’ compensation through sickness certification in the majority of European countries, but studies from the UK and Scandinavia have indicated that GPs question the relevance of work-related issues to their primary healthcare provider role. [4–8] Restraints in terms of time and resources and of lack of knowledge around judging capacity to work have been identified as major barriers for GPs to engage with social workers and workplaces. [9, 10] Furthermore, some GPs would prefer not to be part of the sickness certification system, suggesting the alternative of an authoritative individual to whom they could refer patients. [7, 11] This leaves a missed potential for relevant workplace assessments, and for engaging in dialogue with the patient and the employer regarding work accommodations. Further, to provide evidence-based guidance to encourage early self-management and a continuation, or early resumption of work activities , such a dialogue is necessary. The GPs’ solitary role in sickness certification may also result in lack of collaboration between clinicians and other stakeholders, which has been identified as detrimental for a positive return to work outcome. 
The use of allied healthcare providers (AHP), like physiotherapists, chiropractors and manual therapists, within the field of musculoskeletal pain is gaining popularity amongst patients, especially in the working population.  AHP are also more often sought out as the first points of contact and principal providers of healthcare for individuals with musculoskeletal conditions. [15, 16] This poses a challenge for the continuity and coordination of care when sick leave certification is required as many of these patients may not see another practitioner about their back pain , while others may also consult their GP. In the context of work, the integration of healthcare professionals may be even more challenging as outcomes are not merely dependent on high quality healthcare, but also the collaboration of multiple stakeholders inside and outside the healthcare sector and the workplace. 
As the population ages and the current health reforms focus on shifting secondary care services into the community, demands on GPs and primary healthcare continue to rise. [18, 19] Despite the publication of clinical guidelines on how to manage musculoskeletal pain in general and back pain in particular, these efforts have not significantly translated into decreases in work disability due to musculoskeletal pain as evident by the continuously high costs to society. With the substantial cost implications of work disabilities for national economies, there is a need for improvement in the way healthcare systems and their actors incorporate work disability prevention (WDP) in their service for individuals with musculoskeletal conditions. Moreover, there is a need for improving the communication and collaboration between the healthcare actors, employees and workplaces. Previous studies have indicated a potential for better work disability outcomes by formalized, early referral patterns to AHPs familiar with occupational health issues. [20, 22] Therefore, one potential strategy could be to integrate WDP in the model of care provided by AHPs [20–22] for patients with musculoskeletal disorders.