Definition: This is the first phase where absence of work occurs as a result of
LBP. Phase three is defined as absence from work due to LBP for up to six consecutive work days.
Significance: Phase 3 is distinguished from Phase 4 in the number of
consecutive days of work lost, that is 1-6. A common feature of most insurance systems in both the U.S. and in Europe is that it is during this time that a medical examination is required if a worker wants to be eligible for wage replacement, even though the exact timing of this requirement as well as the type of insurance carrier may vary. However, by the end of one week (i.e. the beginning of Phase 4) virtually every individual has now established contact with the medical system in addition to the insurance system, regardless of the local differences in policy.
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Frequency: From data reported in a prospective Swedish study of all sick-
listed patients among 49,000 subjects in Gothenburg, one can calculate that about 7.5% of working-age adults were disabled for up to one week because of LBP during a one year period.61 Not all patients who report an occupational injury or illness enter this phase, though the percentage of people who report an injury but do not stay away from work has not been published.
Measurement: Our operational definition of work-disability requires a
minimum of one work-day or one shift of not being able to perform the pre-injury job. The same definition is used by the U.S. Department of Labor Bureau of Labor Statistics.62 Assessment is not always straightforward. Four major alternatives exist:
(i) Work-disability defined as absence from work can be determined from payroll records. However, in order to link absenteeism with low back pain, an additional database is needed to determine the reason for absenteeism, (ii) When all employees are covered by health insurance and when the health insurance or the employer provide wage replacement payments based on a physician's diagnosis (regardless of whether the condition is work-related or not-as is the case in many European countries, Australia and in Canada-) the diagnosis might be available from health insurance records. However in the U. S., where health insurance typically does not substitute lost wages and where many employees are not covered by any health-care plan at all, the reason for work-disability has to be obtained through direct contact with the employee (self-report) or from the medical records maintained in the worker's compensation system, (iii) Retrospective self- report is not a reliable method to determine time off work.63 (iv) An assessment of work-disability based on worker's compensation data is more reliable but introduces a conservative bias, since LBP has to be perceived and formally
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reported by the employee as a work-related injury or illnesses in order to show up in the records.
Medical status: Short-term disability lasts about as long as the normal
healing period of uncomplicated acute LBP injury (minor strains and sprains, low impact injuries). Clinically, Phase 3 corresponds to acute LBP, which is considered to last no longer than one week by most clinicians.19 The employee may rely on self-treatment, medical care or alternative health care.
Worker's compensation: If the injury was reported, and if the injury was
judged to be work-related, any medical costs are reimbursed through worker's compensation in North America. In most U.S. systems the employee is not eligible for indemnity payments through worker's compensation during the first week. In European countries and New Zealand wage replacement takes place through health or disability insurance from day one on, regardless of whether the injury is work-related or not.
Interventions: It is during phase 3 when the injured employee experiences
first reactions from co-workers, supervisors or family members and makes first contact with the claim-adjuster as well as with the attending physician or nurse. It is conceivable that the quality of these initial contacts sets the tone for further communication and the mutual perception of involved parties, however, no data on risk factors or interventions specific to phase three have been published.
One intervention, although not limited to phase 3, did start in phase 3 and is therefore mentioned here: The Very Early Intervention Project carried out by the West Virginia Worker's Compensation Fund among coal miners.64 The study was based in part on the insight that intervention programs within one or two weeks
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after injury could not be accomplished using the formal written report of injury.
Therefore an early telephone contact was chosen as the alternative means for recruiting individuals into the intervention group. (A control group was handled the in the customary way) A trained nurse would visit the employee, evaluate his condition and with a questionnaire assess the risk for long-term disability. For people at high risk for long-term disability a nurse and a counselor would then offer counseling and guidance, and coordinate primary care, medical specialty and physical therapy services, and psychological_services if necessary. This form of improved case management beginning during week one after injury did not lower disability or any immediate costs compared to the normal administration of services. However, the researchers note, the intervention was hampered by lack of resources such as physical therapy in the rural area. Furthermore, the initial evaluation of every employee who had been out of work for up to 7 days might not be cost-effective, because most of them would have been expected to recover spontaneously. However, after one year, the medical costs of the intervention group stabilized in contrast to still increasing costs in the control group.