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Int Arch Occup Environ Health (2009) 82:427–434
DOI 10.1007/s00420-008-0346-9
Outpatient rehabilitation of workers with musculoskeletal
disorders using structured workplace description

Stephan W. Weiler · Kay Peter Foeh · Anke van Mark ·
Rene Touissant · Nina Sonntag · Annette Gaessler ·
Johannes Schulze · Richard Kessel

Received: 6 March 2007 / Accepted: 25 June 2008 / Published online: 9 August 2008
©Springer-Verlag 2008
ObjectivesIn most industrialized countries musculoskele-

tal disorders contribute considerably (25%) to illness induced work absence. A special interest to reduce worker absences exists in highly specialized industries such as jet manufacturing, where speciWc knowledge is hard to replace. We investigated the reduction and sustainability in sick leave days by a workplace oriented outpatient rehabili- tation program based on structured information exchange between occupational physicians and therapists.

MethodsSick leave days reduction and return-to-work-

ratios were analysed for 79 male blue collar workers with musculoskeletal disease, who voluntarily participated in an outpatient rehabilitation treatment between 2002 and 2005. During rehabilitation therapy standardized workplace

descriptions were given to the therapists and individual return-to-work (rtw) schemes were implemented. Therapy lasted from 3 to 4 weeks followed by workplace reintegra- tion. OV-work-time was calculated from 0 to 6 years before and 0 to 3 years after rehabilitation from insurance and industrial medical reports.

ResultsA total of 97% of the patients returned to their

original job at the workplace, usually directly after the rehabilitation. Average sick leave days per year were reduced

48.8§ 32.8 days

to 34.2§ 37.3 days after the rehabilitation. The therapy interrupted an increase in sick leave days over the years stabilizing absence at a low level for at least 2 years. Duration of illness related work absence was the only sig- niWcant predictor for sick leave reduction (P < 0.05). Other common risk factors for musculoskeletal diseases like smoking or body mass index did not signiWcantly inXuence the therapeutic eVect.

ConclusionsOur results support evidence that informa-

tion exchange for workplace description and rehabilitation therapist may help to reduce sick leave days and achieve very high rtw-ratio. However it is important to observe the eVects of this shared information for longer intervals.

KeywordsMusculoskeletal disease · Airplane assembly ·
Outpatient vocational rehabilitation
Musculoskeletal disorders account for a large part of work
disability in most industrialized countries (Franche et al.
2005). These disorders are responsible for 25% of illness-
induced workplace absence in Germany and 30% in the
USA (RKI2 0 06; BLS20 06), and are the second most
All authors have contributed substantially to this article and thereby
fulWlling the criteria of authorship.

S. W. Weiler (&) · A. van Mark · R. Kessel
Institute of Occupational Medicine, University of Luebeck,
Ratzeburger Allee 160, 23538 Luebeck, Germany
e-mail: info.contact@uni-luebeck.de

K. P. Foeh · N. Sonntag · A. Gaessler
Airbus Deutschland GmbH, Medical Services Hamburg NDAM,
Hamburg, Germany

R. Touissant
Department for Orthopaedics,
Medica Hospital Leipzig, Leipzig, Germany

J. Schulze
OYce of the Dean, Faculty of Medicine,
Johann Wolfgang Goethe-University Frankfurt/Main,
60590 Frankfurt/Main, Germany

Int Arch Occup Environ Health (2009) 82:427–434

common reasons for physician consultations as well as early retirement (Osborne et al.2 00 7). This emphasizes the importance of interventions to reduce such eVects.

The prevalence of musculoskeletal pain increases with age with a maximum in theWfth and sixth decade, but is rel- evant in younger persons too (Bigos et al.1 9 86; Punnett et al.2 0 04; Schmidt and Kohlmann20 0 5). In general women are more aVected by pain disorders including mus- culoskeletal pain (Andersson19 8 1; Punnett et al.20 04; Schierhout et al.1 9 95), probably due to increased pain rec- ognition, pain processing or memoralization (RKI2 00 6). In addition iatrogenic factors have been discussed as contrib- uting factors like gender-speciWc physician–patient interac- tion (Burton et al.1 98 9) to account for the otherwise unexplained gender preference. Other known risk factors are repetitive work strain as well as psychosocial factors like eVort/reward imbalance, high work demands, stress and dissatisfaction (Anema et al.2 0 04; Hoogendoorn et al.

2002; Nahit et al. 2003; Punnett et al. 2004; Pincus et al.

Occupational risk factors for the onset and recurrence of musculoskeletal complaints are reported for many indus- trial sectors, e. g. healthcare, forestry, manufacturing and food processing (Punnett et al.2 0 04; Häkkinen et al.2 00 1) and consist of work related strains like heavy loadings (Frost et al.2 00 2), awkward postures (Hoogendoorn et al.

2002; Andersson 1981; Svensson and Andersson 1989;

Bernard19 9 7), vibrations (Andersson1 9 81; Boshuizen et al.1 9 92; Fredriksson et al.2 0 02; Bernard1 9 97) and con- tinuous standing (Svensson and Andersson1 98 9; Andersen et al.2 00 7). After becoming chronic musculosceletal disor- ders remain a challenge both in diagnosis and treatment (Koes et al.2 00 6; Walker-Bone and Cooper20 05); thus, ergonomic optimisation of working conditions is a prime factor to decrease musculosceletal diseases within the limi- tations of workplace demands.

This study was conducted to investigate the eVect of workplace oriented outpatient rehabilitation program based on structured information exchange between occupational physicians and rehabilitation therapists on the duration of sick leave.

In one German aircraft plant internal health reports stated excessive rates of sick leave due to musculoskele- tal complaints among airplane assembly workers and varnishers. Improvements in ergonomics were planned and implemented when possible to avoid strenuous pos- tures; however, physiological conditions could not always be met due to the special product geometry of air- planes.

It is hypothesised that even exchange of critical infor- mation between the stakeholders in disability manage- ment, e.g. workers and supervisors, can reduce sick leave times.

Study population

The study was performed by the Institute of Occupational Medicine, University of Luebeck, in cooperation with Air- bus Deutschland GmbH, Hamburg, Germany, and diVerent social insurance companies. The study sample consisted of 79 male aircraft workers age 25–56 years, with a mean of 40.4§ 8.0 years. A total of 42 worked as mechanics, 23 as painters, 14 workers had diverse occupations. Most of the patients suVered from back pain (n = 53, 67%), 9 patients (11%) from shoulder pain, 11 patients suVered from diverse knee illnesses (14%). Miscellaneous pain localisations were present in six patients (8%). Onset of complaints was given by 65 patients and was widely variable with 37 to 5,514days before rehabilitation started (mean of 730§ 1,101 days). For 14 patients onset data were missing or not reproducibly documented, with extremely diVerent onset dates given in the records.

Body mass index (BMI) ranged from 19.6 to 39.4 kg/m2 with a mean of 26.6§ 3.9 kg/m2 (median 25.8), other risk factors for musculoskeletal diseases are summarized in Table1.

Outpatient rehabilitation program

The evaluated program is the most intensive element of a stepwise intervention program to reduce sick leave due to musculoskeletal disorders at airbus industries (Table2). Eligible for this pre- post-intervention study were workers meeting grade IV criteria and volunteering for participation in a vocational outpatient rehabilitation between 2002 and 2005.

Following a written informed consent and clinical inves- tigation by occupational physicians the rehabilitation pro- gram was proposed if grading as “work ability at risk” was conWrmed. If therapy was approved by health insurance a structured occupational information sheet was given to the therapists. Those information included a standardized workplace description, ergonomic data sheet and photo

Table 1Risk factors for musculoskeletal disorders in the study popu-
lation 79 German aircraft plant workers
For comparison, data from the total German Population are given as re-
ported by the Robert Koch Institute (20 06)
(n = 79)
RKI2 006
Adipositas (BMI >30 kg/m2)
Psychosocial burden (on record)
No data
Performing regular sport activities 14
Int Arch Occup Environ Health (2009) 82:427–434

documentation of the workplace in addition to the usual patient history and clinicalWndings at study inclusion. Throughout the rehabilitation speciWc contacts were named at all cooperating institutions.

Outpatient rehabilitation lasted from 3 to 4 weeks with
daily treatment of approximately 4–6 h per day. After the
Wrst 8 days of treatment the most reasonable way of work-

place reintegration was evaluated (Fig.1), and occupational physicians were informed accordingly. Regularly multidis- ciplinary team conferences were held with therapists and Airbus health professionals to achieve optimal rehabilita- tion results and overcome communication diYculties.

For all patients annual sick leave days were calculated by the appropriate health insurance fund. Sick leave data were available for Airbus employees up to 5 years before treatment and up to 3 years following treatment.

Patient history of clinical data coding was done in retro- spect blinded to job or sick leave status. This was used to evaluate the eVect strength on sick leave changes (pre vs. post-treatment, patients vs. controls), duration of complaints (onset to rehabilitation), age, body-mass-index as well as the dichotomized factors smoking habits, regular sports, recorded psychosocial burden as independent risk factors.

We evaluated the relative strength of each factor by mul- tiple linear regression retaining all variables with a signiW- cant eVect for theF statistic. For statistical data analysis single missing values were substituted by variable mean values to allow multiple linear regression analysis. Analysis was conducted with SPSS 15.0 (SPSS Inc, Chicago, USA). We consider data in boxplots as outliers if they do notWt within 1.5–3 box-lengths from the 75th percentile or 25th percentile, extreme values are cases with the values more

Table 2Structured intervention programme at Airbus

on sick

Work ability/cumulative
sick leave (past 2 years)
Back pain characteristics
Not at risk/average
Behavioural therapy/preventive
back school program
Not at risk/<6 weeks
Ongoing or recurrent
Exercise therapy, 10£ 4 h
during 5 weeks
At risk/<6 weeks
Ongoing or recurrent

Return to work program, medical
therapy, 15–20£ 4 h during
3–4 weeks

High risk/>6 weeks

Outpatient rehabilitation, multiprofessional
team, 15–20£ 4 h during 3–4 weeks,
if needed: graded work

Fig. 1Flowchart of the outpa-

tient rehabilitation and return to work After the 8th day of treat- ment a “return to work” (rtw)

decision was made and all study
participants were scheduled
according to theXow chart

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