Journal of Occupational Rehabilitation 2017 (Sep); 27 (3): 382–392 ~ FULL TEXT
Marc-André Blanchette, Michèle Rivard, Clermont E. Dionne, Sheilah Hogg-Johnson, Ivan Steenstra
Public Health PhD Program,
School of Public Health,
University of Montreal,
Montreal, QC, Canada.
Objective To compare the duration of financial compensation and the occurrence of a second episode of compensation of workers with occupational back pain who first sought three types of healthcare providers.
Methods We analyzed data from a cohort of 5,511 workers who received compensation from the Workplace Safety and Insurance Board for back pain in 2005. Multivariable Cox models controlling for relevant covariables were performed to compare the duration of financial compensation for the patients of each of the three types of first healthcare providers. Logistic regression was used to compare the occurrence of a second episode of compensation over the 2–year follow-up period.
Results Compared with the workers who first saw a physician (reference), those who first saw a chiropractor experienced shorter first episodes of 100 % wage compensation (adjusted hazard ratio [HR] = 1.20 [1.10–1.31], P value < 0.001), and the workers who first saw a physiotherapist experienced a longer episode of 100 % compensation (adjusted HR = 0.84 [0.71–0.98], P value = 0.028) during the first 149 days of compensation. The odds of having a second episode of financial compensation were higher among the workers who first consulted a physiotherapist (OR = 1.49 [1.02–2.19], P value = 0.040) rather than a physician (reference).
Conclusion The type of healthcare provider first visited for back pain is a determinant of the duration of financial compensation during the first 5 months. Chiropractic patients experience the shortest duration of compensation, and physiotherapy patients experience the longest. These differences raise concerns regarding the use of physiotherapists as gatekeepers for the worker's compensation system. Further investigation is required to understand the between-provider differences.
KEYWORDS: Back pain; Chiropractic; Compensation duration; Healthcare provider; Medicine; Occupational; Physiotherapy
From the FULL TEXT Article:
According to the 2010 Global Burden of Disease study,
back pain causes more years of life with disability (YLD)
than any of the other 291 conditions studied.  It also
ranks sixth for the overall burden.  The point prevalence
of back pain is estimated at approximately 9 %, and its
lifetime prevalence is near 85 %. [2, 3] Back pain is the
most common occupational injury in Canada and the
United States. [4, 5] The Workplace Safety and Insurance
Board (WSIB) of Ontario considers low back pain a highimpact
claim responsible for 20 % of all lost time claims , and the Quebec’s Commission de la Sante´ et de la
Se´curite´ du Travail paid approximately $540.5 million for
vertebral conditions in 2008. 
In Canada, the provincial workers’ compensation boards
provide financial support, medical assistance and rehabilitation
to workers suffering from occupational injuries.
Most provincial boards provide direct access to physicians
and chiropractors. The exception is Quebec, where physicians
are the sole gatekeepers of the workers’ compensation
system.  In January 2004, the WSIB expanded
direct access to physiotherapists and registered nurses
(extended class). 
The Regulated Health Profession Act in Ontario (and the
Physiotherapy Act) has allowed physiotherapists (outside
of a public hospital) to assess and treat patients without a
referral from a physician since 1991. Even after those
policy changes went into effect, many private and quasipublic
insurers continued to require a physician referral. A
previous study concluded that delayed access to physiotherapy
was a predictor of an increased duration of WSIB
benefits  and that direct access to physiotherapy was
associated with positive patient outcomes.  The evaluation
of the WSIB Acute Low Back Injury Program of
Care (ALBI) revealed that physiotherapists saw patients at
a much later date after their injury than physicians or
chiropractors did ; often, the first visit was so late that
the patient was not eligible for treatment within the ALBI
recommendation (at the time, patients were required to
access care within 28 days after their injury). Those findings
influenced the WSIB policy change.
The diagnostic and therapeutic tools for back pain differ
among healthcare providers: physicians can prescribe
medication and diagnostic imaging; chiropractors can
prescribe X-rays but no medication; and physiotherapists
cannot prescribe diagnostic imaging or medication.
Therefore, it is possible that a patient who initially consults
a physiotherapist or a chiropractor will be referred to a
medical environment for complementary imaging or drug
prescriptions. This situation could lead to a duplication of
consultations, which could prolong the rehabilitation process.
To develop the best first-line care possible, it is
important to investigate whether these new providers have
an impact on the return to work after an injury. In Washington,
nurse practitioners as attending providers had disability
and cost outcomes similar to those of physicians , and workers who first saw a chiropractor were less
likely to become chronically work disabled.  The
objective of the current study was to compare the duration
of financial compensation and the occurrence of a second
episode of compensation for back pain among patients seen
by three types of first healthcare providers (physicians,
chiropractors, and physiotherapist) in the context of the
Ontario workers’ compensation board.
The study analyzed data of a cohort of Ontarian workers
who received at least 1 day of financial compensation from
the Workplace Safety and Insurance Board (WSIB)
between January 1 and June 30, 2005, for uncomplicated
back pain, based on historical WSIB records. Each worker
had a 2–year follow-up after the accident date. This historical
cohort was initially assembled to build a prediction
model for time on benefits. [15, 16] The recruitment period
was chosen to match that of a smaller prospective cohort
(the readiness to return to work (R-RTW) cohort [16, 17])
used to investigate the predictors of return to work status
for musculoskeletal disorders. The University of Montreal
Health Research Ethics Board approved this study (12-129-
A simple random sample of 6500 out of a total of 18,974
claims was selected from all of the lost-time claims related
to uncomplicated back pain that had an accident date
during the recruitment period. We added 157 back pain
subjects from the R-RTW cohort who were not randomly
selected. We then excluded 1146 subjects because they did
not have the main outcome of interest (100 % wage compensation;
n = 413) or they had missing (n = 420) or
aberrant data (n = 304) for the main independent variable.
We excluded workers who initially sought treatment from a
nurse because of their low number (n = 9). Our final
sample comprised 5511 injured workers. More details
regarding the selection process were reported in a previous
Source of Data
Following a work injury, the employer must report the
injury to the WSIB within 3 days via their form containing:
worker identification, details of the injury, earnings details,
and claim information. The healthcare provider must
complete their form when a patient’s injury is related to
work, and workers may submit their form if they are
concerned that the employer did not send theirs or if they
incur expenses related to the injury. The worker form
includes general information and the injury details while
the healthcare provider form contains the following sections:
patient and employer information, billing, incident
dates and details sections, clinical information, treatment
plan and return to work information. The WSIB cannot
adjudicate the claim if too much information is missing;
consequently, form submission rates are high
(worker = 76.8 %, employer = 99.1 % and healthcare
provider = 90.9 %), and the rate of missing information is
low. In order to complete this project, relevant WSIB data
from the claim file; the healthcare billing database; and the
imaged files of the forms completed by the employers,
workers and healthcare providers were extracted and
assembled by an experienced programmer-analyst at the
Institute for Work and Health (IWH). Information from the
forms for the first 100 claims was independently collected
from the imaged files by two extractors, and their agreement
was high (98 %).  Therefore, only one extractor
per claim was used for the remaining claims. When the
employer and the worker provided divergent information,
the worker’s information was prioritized.
Description of the Study Variables
The type of first healthcare provider seen was determined
using data from the healthcare billing database and the
healthcare provider form(s). We selected the first billing
associated with a chiropractor (DC), a physician (MD,
regardless of specialty), or a physiotherapist (PT) for each
claim. When the date of the service provided was prior to
the accident (n = 283), we either chose to correct an
obvious data transcription error (i.e., the inversion of day
and month) or to select the first billing after the accident
date. We selected the first date on the first healthcare
provider form for each claim. Dates preceding the accident
(n = 287) were replaced with another date from the same
form (the assessment, treatment or signature date) when
available or were marked as missing. The first date and the
associated provider from either the billing or the form were
then selected. If two different providers were recorded on
the same day (n = 96), the one who completed the
healthcare provider form was considered the first healthcare
Three outcomes were analyzed: the duration of the first
episode of 100 % wage compensation, the duration of the
first episode of any wage compensation (full or partial) and
the occurrence of a second episode of compensation for the
same claim during the follow-up period. We considered
that a second episode of compensation occurred when the
worker received income compensation (full or partial) after
the end of the first episode of any wage compensation. The
outcomes were obtained from the compensation administrative
database for 2 years after the accident date.
age at time of injury, sex and
annual gross income were extracted from the claim file.
The preferred language of communication was obtained
from the employer and/or worker form (% of agreement
= 100 %). The French and English languages were
combined as they demonstrated a similar association with
our dependent variables. The postal code from the claim
file was converted into the community size and the urban/
rural indicator using the postal code conversion file. 
we used information from the
claim file to determine the job tenure, national occupational
code (NOC), the sector of economic activity (Statistics
Canada 1980 Standard Industrial Classification [SIC-80] ) and the number of employees in the company. The
number of employees was dichotomized into 20 or fewer
and more than 20 employees because small companies do
not have the same re-employment obligations as larger
ones.  The NOC from the claim file was converted into
the physical demands of the job (manual, non-manual and
mixed work) using an exposure matrix. [22, 23] The
employer and worker’s forms contained information about
union membership (% of agreement = 96.3 %). The
employer also specified the availability of early return to
work programs on their form and whether they doubted
that the injury was related to work. We considered this
answer as an indicator of an adversarial relationship with
the claim file contained information
about previous lost time claim(s), the part of the
body affected and the nature of the injury. We categorized
the affected body part into four anatomical regions and the
nature of the injury into least-severe cases (non-specific
backache) and more-severe case (disc disorders, sciatica,
herniated lumbar disc, radiculitis) based on a previously
used classification. [24, 25] The worker’s and employer’s
forms specifically asked whether the worker had had a
similar injury in the past (% of agreement = 78.4 %). The
healthcare provider form contained information about task
limitations. Because different versions of the healthcare
provider form were used during the study period, we
grouped the ability to use public transportation, the ability
to operate a motor vehicle and other specified task limitations
together under ‘‘any task limitations’’ to combine
the information from the different versions of the form.
More details regarding the construction of these variables
have been reported elsewhere. 
Use of health services:
the number of days between the
accident date and the first healthcare consultation was
calculated to control for the timing of the first consultation.
Most of the covariables had low levels (\5 %) of missing
data, and only 3.5 % of all values were missing. Only, the
following variables had more than 5 % of missing values:
job tenure (28.5 %), sector of economic activity (19.0 %),
employer’s doubt that the injury was work-related
(13.3 %), restricted use of public transportation (11.8 %)
or a motor vehicle (11.3 %), any task limitations (10.2 %),
and the availability of an early return to work program
(6.9 %). We assumed that data were missing at random
because Little’s missing completely at random test was
significant (Chi squared = 44.5, df = 27, P = 0.018) and
because we did not find a clear pattern of missing values.
To fill in the variables with missing values we applied
multiple imputations by using Markov Chain Monte Carlo
simulations. We generated twenty different imputed data
sets. In order to respect the 100–parameter limit in SPSS,
the sector of economic activity and the community size
were not used as predictors. The imputation used all the
others available variables as predictors. The analysis were
performed in every imputed data sets and the pooled estimates
were generated by using Rubin’s algorithms. 
We conducted two models of multivariable survival
analyses (Cox model) to compare the duration of financial
compensation for back pain (dependent variable) for the
three types of first healthcare providers (independent
variable). We created a multivariable logistic regression
model to compare the occurrence of a second episode of
compensation (dependent variable) between the three types
of first healthcare providers (independent variable).
Bivariable analyses (survival analysis or logistic regression)
between the dependent variables and all the other
variables were conducted prior to data imputation. To
control for confounding variables, an initial model was
built that included all of the individual characteristics and
health behaviors with a P\0.25 or less in the bivariable
analysis.  We formed a reduced model by removing the
covariates with the largest P values one by one until all of
the variables had a P\0.25 according to the Wald test
(confirmed with the likelihood ratio test).
Excluded or nonincluded
variables were reintroduced one at a time. Variables
were left in the model if they were significant
(P\0.25) or if they caused a change of 15 % or more in
the main regression coefficient. The linearity assumption of
continuous variables was assessed graphically and
collinearity was assessed by using variance inflation factor.
Assumptions of non-informative censoring were found
satisfactory. We tested the proportional hazard assumption
by introducing an interaction term with a time-dependent
covariate and found that the hazards of the three healthcare
providers were not proportional. After analyzing the
Kaplan–Meier survival curves for the three types of
healthcare providers (Figs. 1, 2), we decided to treat the
type of first healthcare provider as a time-dependent variable.
Therefore, we created two Heaviside functions for the
effect of the first healthcare provider (0–149 and
We excluded the 163 subjects that did not ended their
first episodes of compensation by the end of the follow-up
period prior to building the logistic regression model that
compared the occurrence of a second episode of income
compensation for the same claim (dependent variable)
across the three types of first healthcare providers (independent
variable) using the same modeling strategy to
control for confounding. The linearity assumption of continuous
variables was assessed graphically. All comparisons
were considered statistically significant at P\0.05.
We performed all analyses using SPSS for Mac (version
22.0, IBM Corporation, Armonk, NY, USA).
Of the 5511 compensated workers included in the sample,
85.3 % first saw a medical doctor (n = 4710), 11.4 %
(n = 627) first saw a chiropractor, and 3.2 % (n = 174)
first saw a physiotherapist. The median numbers of days of
the first episode of full wage compensation were 7.0 (95 %
confidence interval (CI) 5.8–8.2), 8.0 (95 % CI 7.5–8.5)
and 19.0 (95 % CI 15.5–22.5) for the workers who first
consulted chiropractors, physicians and physiotherapists,
respectively. When the partial wage compensation associated
with a gradual return to work was included, the
median number of days of the first episode of any wage
compensation were 8.0 (95 % CI 6.6–9.4), 10.0 (95 % CI
9.5–10.0) and 25.0 (95 % CI 20.3–29.7) for the workers
who first consulted chiropractors, physicians and
physiotherapists, respectively. Among the workers who
completed their first episode of any wage compensation
during the follow-up, 15.0 % (n = 92) of the chiropractic
care seekers, 16.2 % (n = 738) of the physician care
seekers and 23.7 % (n = 40) of the physiotherapist care
seekers had a second compensation episode. The complete
characteristics of the analyzed sample are reported elsewhere. 
The results of the bivariable analyses between the workers’
characteristics and the study outcomes are presented
in Tables 1 and 2.
Kaplan–Meier Survival Curves
The Kaplan–Meier survival curves for the duration of the
first episode of 100 % wage compensation and the duration
of the first episode of any wage compensation according to
the three types of healthcare providers are presented in
Figs. 1 and 2. Up to 150 days post-injury, the curves are
regular and distinct in both figures. Physiotherapists
showed the longest duration of compensation, and chiropractors
showed the shortest. After 150 days, the three
curves cross and demonstrate a similar trajectory until the
end of the follow-up period (730 days). Few events
occurred after 150 days among the chiropractic (n = 20)
and physiotherapy (n = 10) groups.
Our three final multivariable models are presented in
Tables 1 and 2. We report the pooled estimates from the
multiple imputations. All the HRs and ORs obtained from
the listwise analysis (not reported) were within 10 % of the
variation of the reported pooled estimates.
Over the first 149 days, the workers who first sought
care from a chiropractor had a significantly greater hazard
of ending their compensation episode compared with the
workers who first consulted a physician (100 % wage
compensation: HR = 1.20 [1.10–1.31], P value B 0.001;
any wage HR = 1.19 [1.09–1.30], P value B 0.001) and
those who first consulted a physiotherapist had a significantly
lower hazard of ending their compensation episode
(100 % wage compensation: HR = 0.84 [0.71–0.98],
P value = 0.028; any wage HR = 0.79 [0.68–0.93],
P value = 0.005). From 150 to 730 days, few events
occurred among the chiropractic and physiotherapy groups,
and the type of first healthcare provider was not a significant
predictor of termination of the first compensation
episode during this time period. Both of our final multivariable
Cox models that assessed the duration of the first
episode of compensation controlled for sex, age, language,
job tenure, union membership, employer’s doubts regarding
the work-relatedness of the injury, the physical
demands of the job, gross earnings, the availability of an
early return to work program, number of employees at the
company, previous similar injury, any task limitations, the
nature of the injury, the body part affected and the time
interval between the accident and the first healthcare
The workers who first sought care from a physiotherapist
had significantly higher odds of having a second episode
of compensation compared with the workers who first
consulted a physician (OR = 1.49 [1.02–2.18],
P value = 0.038). The workers who first sought care from
a chiropractor did not have significantly different odds of
having a second episode of compensation compared with
the workers who first consulted a physician (OR = 0.83
[0.65–1.06], P value = 0.135). Our final multivariable
logistic regression model that assessed the occurrence of a
second compensation episode controlled for sex, age,
community size, language, union membership, employer’s
doubts regarding the work-relatedness of the injury, physical
demands, gross earnings, previous similar injury, previous
100 % wage compensation, the nature of the injury
and the body part affected.
Summary of Main Findings
The type of first healthcare provider was a significant
predictor of the duration of the first episode of compensation
only during the first 5 months of compensation.
When compared with medical doctors, chiropractors were
associated with shorter durations of compensation and
physiotherapists with longer ones. Physiotherapists were
also associated with higher odds of a second episode of
Consistency with the Findings of Other Studies
Several randomized controlled trials have compared the
effectiveness of medical, chiropractic and physiotherapy
care for back pain among the general population, and the
results did not clearly favor any type of care in terms of
pain and functional status. [28–35] Reviews and a recent
observational study of occupational back pain failed to
clarify whether one type of care was more effective or cost
effective. [36–38] Most of the previous studies considered
the main or exclusive healthcare provider. There is, however,
a distinction between the ‘‘main’’ healthcare provider
and the ‘‘first’’ provider. In fact, the first provider will not
be the main provider in approximately 50 % of cases. [39–42] Few studies have investigated the impact of the
first healthcare provider. The cohort study of American
workers with back pain conducted by Turner et al. 
found that the first healthcare provider was one of the main
predictors of work disability after a year. In accordance
with our findings, workers who first sought chiropractic
care were less likely to be work-disabled after 1 year
compared with workers who first sought other types of
medical care. 
Regarding physiotherapy care, a recent
review concluded that direct access to physiotherapy care
was associated with better patient outcomes compared with
referred physiotherapy care.  We did not retrieve any
study that directly compared physiotherapy care with other
types of first healthcare providers in the context of occupational
back pain, probably because most workers’ compensation
systems still require a referral for physiotherapy.
However, a study comparing primary physiotherapy care
with usual emergency department care concluded that
physiotherapy care leads to a prolonged time before
patients return to their usual activities. 
According to previous studies, back pain care provided
by physiotherapists and chiropractors adheres more closely
to guidelines (reduced use of diagnostic imaging, surgery
and opioids) than medical care does. [44–46] Our findings
partly support that finding because 75.9 % of the workers
seeking chiropractic care did not seek an additional type of
care within the first month.  However, 58.6 % of
workers who first consulted a physiotherapist also sought
medical care within the first month.  At the time of our
study, physiotherapists could not prescribe medication or
diagnostic imaging, which might explain this additional use
of medical services. Additionally, direct access to physiotherapy
for injured workers was only in place for a year at
the time of our study, and physiotherapists were probably
not familiar with the workers’ compensation system.
Strengths and Limitations
The large sample size of this study enabled us to perform
our multivariable modeling with sufficient statistical power
during the first 150 days. Because few events occurred
after 150 days, our modeling of the impact of the first
healthcare provider during that period is less robust. The
addition of information from the employee, employer and
healthcare provider forms to the data routinely collected by
the WSIB provided us with many potential confounders to
consider. We combined the information from two different
sources (the healthcare billing database and the healthcare
provider form) to determine the type of first healthcare
provider, thus limiting misclassification.
The information that we used was collected by the
WSIB for administrative purposes; therefore, its psychometric
proprieties have not been assessed. When comparing
the outcomes of different types of healthcare providers
in an observational study, it is essential to consider the
possibility of confounding by indication. We used several
variables to determine the needs of the injured workers. We
specifically used two dichotomized variables to control for
the burden of back pain: injury severity and task limitations.
Without knowing how these variables compared to
established functional status questionnaires, it is impossible
to completely rule out confounding by indication. We
found that the workers who sought chiropractic care
experienced shorter durations of compensation. Most previous
studies found that medical patients had more severe
pain, disability, comorbidity and lower general health status
than chiropractic patients. [39, 44, 47–53]
If our analysis
contains residual confounding, the real difference
between the types of provider might be diminished. We
also found that the physiotherapy patients experienced
longer compensation durations and more second episodes
of compensation. In order to attenuate the associations we
measured, physiotherapy patients should experience more
severe back pain in a way that was not captured by our
analysis. While increased pain among physiotherapy
patients is always a possibility, we believe this is unlikely
because the physiotherapy patients experienced a longer
time interval between the injury and the first consultation.  Usually, patients with more severe injuries will seek
immediate medical care at an emergency room. 
Additionally, the physiotherapy patients were more likely
to seek an additional type of care, which has previously
been associated with longer compensation durations. [55, 56]
Since a relatively small percentage of workers who first
saw a physiotherapist (3.2 %) was included 1 year after the
policy change, it is possible that our analysis captured early
adopter of the new policy and that the association between
first consulting a physiotherapist and the compensation
duration now differ from the ones assessed in 2005. Generalizations
of our findings to other jurisdictions should be
performed with caution since it was hypothesized that the
compensation policy might have a greater influence than
the type of care sought. 
Recommendations for Futures Research
Further investigations should be conducted for a better
understanding of why patients who initially seek physiotherapy
care experience longer compensation durations.
The factors that influence the decision to seek physiotherapy
as the first source of care should be better understood.
The process of care that follows the initial type of care
should also be evaluated. Because a differential use of
additional health services was observed, the trajectory of
care might also be an important predictor of the compensation
The type of first healthcare provider sought for occupational
back pain was associated with the duration of compensation
over the first 5 months. The chiropractic patients
experienced the shortest compensation duration, and the
physiotherapy patients experienced the longest. The physiotherapy
patients were also more likely to experience a
second episode of compensation. Our results raised concerns
regarding the use of physiotherapists as gatekeepers
of Ontario’s worker’s compensation system. Further
investigations should be conducted to better understand the
reasons behind the observed differences between the three
types of first healthcare providers.
The authors thank Ashleigh Burnet and many
others from the WSIB for facilitating access to data. M. A. Blanchette
is currently supported by a Ph.D. fellowship from the Canadian
Institutes for Health Research (CIHR) and previously received Ph.D.
Grants from both the Quebec Chiropractic Foundation and the CIHR
strategic training program in transdisciplinary research on public
health intervention (4P). The data extraction was funded through a
grant from the WSIB Research Advisory Committee. Dr. Hogg-
Johnson reports grants from Workplace Safety & Insurance Board
Research Advisory Council, during the conduct of the study; grants
from Ontario Ministry of Labour, outside the submitted work.
Compliance with Ethical Standards
Conflict of interest The authors declare they have no other conflict
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