1 INTRODUCTION

Presenteeism is defined as workers being present at their jobs and completing their working hours, but not being able to function optimally because of an underlying illness or medical condition.¹ The socioeconomic burden of presenteeism is estimated to be higher than absenteeism (loss of productivity that stems from being absent from work); per year the cost of absenteeism is $520 USD per person and of presenteeism is $3055 USD in Japan.² Although presenteeism is also a risk factor for future absenteeism, thus detrimental for companies and corporations,^3-5 it is not limited to office workers. Presenteeism is also rampant among healthcare workers, who are generally neglected because they are often thought to be immune to occupational hazards.⁶ Decreased workforce productivity due to high turnover, poor retention, presenteeism, and absenteeism has a significant economic impact on healthcare systems.^{7, 8}

Conditions such as musculoskeletal pain, mental illnesses, and headaches can aggravate the economic burden due to presenteeism,^{2, 9-11} and managing them is important to avoid loss of productivity. Lower back or neck pain in workers can be improved by exercise,¹² stretching¹³ and high-intensity training.¹⁴ However, a recent systematic review demonstrated that there is no strong evidence in favor of any intervention to treat or prevent lower back pain in medical workers,¹⁵ and neck-and-shoulder resistance exercises did not reduce absenteeism or improve the workability of office workers.¹⁶ Therefore, there is a knowledge gap where other interventions to reduce presenteeism need to be explored.

Pain neuroscience education (PNE) is an increasingly popular modality for managing musculoskeletal pain.¹⁷ It is an educational approach based on a biopsychosocial model that helps people change their pain-related beliefs, increase knowledge about pain, and transform their behaviors such that they perceive pain as a less threatening experience.¹⁸ A systematic review demonstrated that PNE can enhance pain reconceptualization.¹⁷ Although PNE alone is not effective enough, its benefits can increase when it is combined with exercise.^{19, 20} However, to date, no studies have investigated whether a combination of PNE and exercise are effective in reducing presenteeism and pain in healthcare workers.

To address this research gap, we aimed to examine whether a regimen of combined PNE and exercise tailored to individual healthcare workers was effective in reducing presenteeism.

2 MATERIALS AND METHODS

2.3 Randomization and blinding

The participants were randomized into two groups, the intervention group and control group (Figure 1), using computerized random numbers by a researcher not involved in any other aspect of the study. The evaluators and data analysts were blinded to the study hypothesis and the treatment allocation. They did not receive any information regarding the design or the interventions in terms of the control or experimental group. The patients were not blinded to the treatment method owing to the nature of the intervention.

3 RESULTS

We enrolled 117 participants in our study, of which 13 declined to participate (Figure 1). Therefore, we included 104 people in our analyses (intervention group = 51; control group = 53). The participants’ characteristics are summarized in Table 1. All participants had pain in some part of their body.

Table 2 presents a pre- and post-intervention comparison of our participants. In the two-way ANOVA, we found a significant group-time interaction in terms of absolute presenteeism (F = 12.87, P = .001, partial η² = 0.94), relative presenteeism (F = 4.37, P = .04, partial η² = 0.04), pain intensity (F = 11.0, P = .001, partial η² = 0.1), WPI (F = 4.89, P = .03, partial η² = 0.046), job stress (F = 7.91, P = .006, partial η² = 0.07), and physical stress (F = 8.23, P = .005, partial η² = 0.08) for both groups (P < .05). For the intervention group, we observed significant improvement in presenteeism, pain intensity, WPI, physical and psychological stress, and EQ5D-5L after the intervention (P < .05). In the control group, we noted a significant improvement only in job stress post intervention (P < .05). We observed significant between-group differences in presenteeism after the intervention (P < .05).

4 DISCUSSION

This study showed that healthcare workers of the intervention group who practiced a combined regimen of PNE and exercise for 6 months showed reduced presenteeism than the participants in the control group.

Exercise alone may improve absenteeism and presenteeism; for example, resistance training once a week¹⁴ or short exercises for 10 min a day, 3–4 times per week is known to reduce presenteeism,³² and yoga and stretching may also have a similar effect.³³ Pereira et al.¹² showed that an individualized neck-specific exercise intervention improved presenteeism in the workplace, and Justesen et al.¹⁴ found that a 1-year individualized exercise training at the workplace improved absenteeism and presenteeism. However, Blangsted et al.¹⁶ reported that office workers did not benefit from a 12-month neck-and-shoulder resistance training exercise program in the workplace and that the program did not improve absenteeism and post-intervention work ability. Considering these studies, we believed that an exercise-only training program tailored to each individual in this study could have been effective against presenteeism, but we wished to check the added positive influence of PNE as well. PNE is a cognitive-based intervention that helps individuals reconceptualize their approach to pain and changes their maladaptive belief toward it (fear of pain, catastrophizing).³⁴ Decreased productivity among workers in pain is associated with a fear of pain³⁴; therefore, we assumed that PNE may reprogram these fears and reduce presenteeism.

Compared to the control group, pain intensity and the number of painful body areas (calculated by the WPI) were not significantly reduced in the intervention group. Lower back or neck pain and presenteeism in office workers are known to be improved by stretching (ratio of pain reduction = 13.3%)³² and reducing the sitting time (ratio of pain reduction = 3.2%).³⁵ However, a recent systematic review concluded that there is no strong evidence in favor of any intervention in treating or preventing lower back pain.¹⁵ Peria et al.¹² used a therapist-created exercise program that included 1 weekly exercise session supervised by the therapist. This method was very similar to ours, but this approach and other previous studies only used exercise that was not supervised.^{14, 32, 36} Our study was different because we adopted an individualized approach, ensured therapist supervision, and combined exercise with PNE, which is known to be effective in reducing pain intensity.²¹ Subjects with chronic low back pain have experienced a significant reduction in pain intensity was after practicing a combined approach of PNE and exercise.^{37, 38} Although our study did not yield the results that we hypothesized, some improvement was indicated in the reduction of pain intensity and number of painful body areas.

Galan-Martin et al.³⁹ showed that patients with chronic pain showed improved CSI scores after PNE, while another study showed a significant reduction in CSI scores of similar patients at 6 months.⁴⁰ However, there was no significant difference in the CSI scores in our study. This could be because the CSI scores for many participants in our study were very low initially, and their average CSI score was lower than those of previous studies.^{39, 40}

This study has some limitations. First, owing to the nature of the intervention, the patients who received it could not be blinded. Second, this study is the absence of “only exercise” group, so we could not determine whether a combination of PNE and exercise is more effective than only exercise. Third, study participants were enrolled from a single medical corporation; therefore, findings from this study cannot be generalized for other settings or populations.

5 CONCLUSION

The present study demonstrated that a combination of PNE and exercise resulted in better patient outcomes, that is, reduced presenteeism, pain intensity, physical stress, and an improved psychological state and quality of life among health care workers. Our findings will help physical therapists anticipate outcomes in their patients and will assist healthcare facilities in carrying out better employee management to ensure optimal productivity.

DECLARATIONS

Approval of the research protocol: Ethical approval was obtained from the Institutional Ethics Committee of Konan Women's University. Informed Consent: We explained the purpose and protocol of the study to all the participants and obtained their written informed consent. Registry and the Registration: The study (ID: 2020019) was registered in the UMIN Clinical Trials Registry (UMINID:000040122). Animal Studies: N/A.

CONFLICT OF INTEREST

We have no conflicts of interest to declare.

AUTHORS’ CONTRIBUTIONS

All the authors developed the study concept. R.I., T.N., and T.K. designed experiments; T.K. collected the data. R.I. analyzed the data with support from T.N.; R.I. wrote the manuscript with support from T.N., A.M., K.T. All authors reviewed the manuscript and approved the final version of the manuscript for submission.