A case study – Hospital Clinico San Carlos, Madrid, Spain

Based on the pilot that rolled out at the Hospital Clinico San Carlos in Madrid, Spain, an Early Intervention programme should accommodate the following activities:

  • General practitioners or family doctors refer the patients to the “Early Intervention” clinic with the help of a form which reports an MSK as the cause of their temporary work disability
  • Rheumatologists collect the forms daily and process the data
  • The staff of the clinic contact the patients by telephone or email and offer them an appointment with a rheumatologist within five days from the form registration
  • At their first visit, patients receive: a specific diagnosis; expert clinical management; reassurance that no serious disease is present; instructions on self-management; instructions on taking medications; recommendations regarding physical activity and specific exercises; and indications for return to work before they are in remission (symptoms diminish, or disappear completely)
  • Patients with higher degrees of disability or pain receive immediate extra reassurance, information on pain-relieving positions and a telephone call or a second visit within 72 hours
  • Patients with low-back, neck, shoulder, arm, hand, knee, or foot pain are put on a three-level care system. They move to the second and third level after they spent a predefined period at the first level without improvement, or based on the judgement of the rheumatologist:
    • Level 1 (2-6 weeks) – diagnosis, pharmacologic treatment of pain and inflammation, pharmacologic treatment of anxiety and depression, peripheral intra- and periarticular injections, education and self-management instructions;
    • Level 2 (4-8 weeks) – maintenance of therapy plus and laboratory tests, radiography, computerised tomography, magnetic resonance imaging and electromyography;
    • Level 3 (determined by clinicians) – further diagnostic procedures, or referral for surgical or other specialised care; psychological support (CBT), and formal rehabilitation.
  • Temporary work disability forms are renewed each week until the patients are ready to get back to work, in which case a fit for work form is filled out, or they are registered with permanent work disability
  • The rheumatologists see the patients as many times as necessary throughout the programme, as well as keeping in touch with the primary care physicians who referred the patients

Care in the intervention group: stepwise scheme for diagnostic and therapeutic procedures – Hospital Clinico San Carlos, Madrid, Spain

  • Diagnosis based on clinical criteria: look for red flags
  • Pharmacologic treatment of pain, inflammation, anxiety, and depression
  • Peripheral intra- and periarticular injections
  • Education: Explanation of their specific diagnosis; Insistence that a serious disease was not present; Instructions on self-management; Instructions on how to take medications ; Indications for early return to work before a complete symptom remission; Patients with higher degrees of disability or abnormal pain received immediate care, extra reassurance and instruction on pain relieving positions plus extra visit within 72 hours
  • If no improvement after 2-6 weeks on Level 1


  • Maintenance of the therapy plus referral for formal rehabilitation
  • Look for red flags and yellow flags, carry out laboratory tests, radiographs, computed tomography (CT)/magnetic resonance imaging (MRI), and electromyogram (EMG)
  • If no improvement after 4-8 weeks on Level 2


  • Further diagnostic procedures, look for red flags and yellow flags
  • Referral for surgical advice or other specialized care

Efficacy outcomes – Hospital Clinico San Carlos, Madrid, Spain

  1. i-target1the number of days on sick leave per temporary work disability episode, determined for each syndrome category
  2. differences in mean and median duration of temporary work disability episode (control vs intervention group)
  3. total number of days of temporary work disability per 1,000 patients
  4. days saved per patient, calculated as (mean duration in control group) – (mean duration in intervention group)
  • Percentage of sick leave days saved per episode in the intervention group
  • Total number of days saved in the intervention group obtained by multiplying the total number of episodes in the intervention group by the days saved per patient
  • Relative rate of return to work
  1. 1.Daily differences in the percentage of return to work between groups ([percentage of return to work in intervention group]  – [percentage of return to work in control group] each day)
  2. Time of maximum programme effect – the period of time where the difference in the percentage of return to work between the intervention group and control group was maximal

Fit for Work Global Alliance is led by The Work Foundation and supported by AbbVie.

Toolkit partners:

Toolkit sponsor:

Fit for Work Global Alliance is a multi-stakeholder initiative, driving policy and practice change across the work and health agendas in Europe and worldwide (over 35 countries). The vision is to raise awareness of the facts of MSKs and make the case for more investment in sustainable healthcare by promoting and supporting the implementation of early intervention practices. Fit for Work is led by The Work Foundation – Lancaster University, which is also providing the Secretariat. AbbVie is founding sponsor since 2008. All the research is produced independently by The Work Foundation, with full editorial control resting with the think-thank alone.

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