Comparison of risk factors predicting return to work between patients with subacute and chronic non-specific low back pain: systematic review

Physiotherapeutic and non-conventional approaches in patients with chronic low-back pain: a level I Bayesian network meta-analysis

Chronic low back pain (cLBP) is a major cause of disability and healthcare expenditure worldwide. Its prevalence is increasing globally from somatic and psychosocial factors. While non-pharmacological management, and in particular physiotherapy, has been recommended as a first-line treatment for cLBP, it is not clear what type of physiotherapeutic approach is the most effective in terms of pain reduction and function improvement. This analysis is rendered more difficult by the vast number of available therapies and a lack of a widely accepted classification that can effectively highlight the differences in the outcomes of different management options. This study was conducted according to the PRISMA guidelines. In January 2024, the following databases were accessed: PubMed, Web of Science, Google Scholar, and Embase. All the randomised controlled trials (RCTs) which compared the efficacy of physiotherapy programs in patients with cLBP were accessed. Studies reporting on non-specific or mechanical cLPB were included. Data concerning the Visual Analogic Scale (VAS) or numeric rating scale (NRS), Roland Morris Disability Questionnaire (RMQ) and Oswestry Disability Index (ODI). Data from 12,773 patients were collected. The mean symptom duration was 61.2 ± 51.0 months and the mean follow-up was 4.3 ± 5.9 months. The mean age was 44.5 ± 9.4 years. The mean BMI was 25.8 ± 2.9 kg/m2. The Adapted Physical Exercise group evidenced the lowest pain score, followed by Multidisciplinary and Adapted Training Exercise/Complementary Medicine. The Adapted Physical Exercise group evidenced the lowest RMQ score followed by Therapeutic Exercises and Multidisciplinary. The Multidisciplinary group evidenced the lowest ODI score, followed by Adapted Physical Exercise and Physical Agent modalities. Within the considered physiotherapeutic and non-conventional approaches to manage nonspecific and/or mechanic cLBP, adapted physical exercise, physical agent modalities, and a multidisciplinary approach might represent the most effective strategy to reduce pain and disability.

Economic analysis of patient-related effects of an interdisciplinary pain self-management program

ABSTRACT

Active Day Patient Treatment (ADAPT) is a well-established 3 week intensive cognitive-behavioural, interdisciplinary pain management program for patients with disabling chronic pain. The aim of this analysis was to conduct an economic analysis of patient-related effects of ADAPT using hospital administrative data, specifically, to compare the costs and health outcomes for patients 1 month after participating in the program, with the preprogram period when they were receiving standard care. This retrospective cohort study included 230 patients who completed ADAPT (including follow-ups) between 2014 and 17 at the Pain Management and Research Centre at the Royal North Shore Hospital in Sydney, Australia. Data on pain-related healthcare utilization and costs before and after the program were assessed. Primary outcome measures were labour force participation for patients' average weekly earnings and cost per clinically meaningful change in Pain Self-efficacy Questionnaire, Brief Pain Inventory (BPI) Severity, and BPI interference scores (n = 224). We estimated patients, on average, earned $59 more each week at 1 month follow-up compared with baseline. The cost per clinically meaningful change in pain severity and interference score based on the BPI severity and BPI interference were AU$9452.32 (95% CI: $7031.76-$12,930.40) and AU$3446.62 (95% CI: $2851.67-$4126.46), respectively. The cost per point improvement and per clinically meaningful change in the Pain Self-efficacy Questionnaire were $483 (95% CI: $411.289-$568.606) and $3381.02, respectively. Our analysis showed a better health outcome, reduced healthcare services' cost, and reduced number of medications taken 1 month after participating in ADAPT.

Non-Specific Low Back Pain: An Inductive Exploratory Analysis through Factor Analysis and Deep Learning for Better Clustering

Non-specific low back pain (NSLBP) is a significant and pervasive public health issue in contemporary society. Despite the widespread prevalence of NSLBP, our understanding of its underlying causes, as well as our capacity to provide effective treatments, remains limited due to the high diversity in the population that does not respond to generic treatments. Clustering the NSLBP population based on shared characteristics offers a potential solution for developing personalized interventions. However, the complexity of NSLBP and the reliance on subjective categorical data in previous attempts present challenges in achieving reliable and clinically meaningful clusters. This study aims to explore the influence and importance of objective, continuous variables related to NSLBP and how to use these variables effectively to facilitate the clustering of NSLBP patients into meaningful subgroups. Data were acquired from 46 subjects who performed six simple movement tasks (back extension, back flexion, lateral trunk flexion right, lateral trunk flexion left, trunk rotation right, and trunk rotation left) at two different speeds (maximum and preferred). High-density electromyography (HD EMG) data from the lower back region were acquired, jointly with motion capture data, using passive reflective markers on the subject's body and clusters of markers on the subject's spine. An exploratory analysis was conducted using a deep neural network and factor analysis. Based on selected variables, various models were trained to classify individuals as healthy or having NSLBP in order to assess the importance of different variables. The models were trained using different subsets of data, including all variables, only anthropometric data (e.g., age, BMI, height, weight, and sex), only biomechanical data (e.g., shoulder and lower back movement), only neuromuscular data (e.g., HD EMG activity), or only balance-related data. The models achieved high accuracy in categorizing individuals as healthy or having NSLBP (full model: 93.30%, anthropometric model: 94.40%, biomechanical model: 84.47%, neuromuscular model: 88.07%, and balance model: 74.73%). Factor analysis revealed that individuals with NSLBP exhibited different movement patterns to healthy individuals, characterized by slower and more rigid movements. Anthropometric variables (age, sex, and BMI) were significantly correlated with NSLBP components. In conclusion, different data types, such as body measurements, movement patterns, and neuromuscular activity, can provide valuable information for identifying individuals with NSLBP. To gain a comprehensive understanding of NSLBP, it is crucial to investigate the main domains influencing its prognosis as a cohesive unit rather than studying them in isolation. Simplifying the conditions for acquiring dynamic data is recommended to reduce data complexity, and using back flexion and trunk rotation as effective options should be further explored.

Exercise treatments for chronic low back pain: a network meta‐analysis

This is a protocol for a Cochrane Review (intervention). The objectives are as follows:

The objectives of this systematic review, conducted using a collaborative review model, are to:

Assess the effectiveness of exercise treatment (overall) in adults with chronic non‐specific low back pain on important individual health outcomes: pain, functional limitations, health‐related quality of life, depression, and adverse effects versus comparison treatments: (a) placebo, sham, or attention control, (b) no trial treatment (including waiting lists, control groups described as having no treatment provided, usual/normal care not controlled by the trial available to all treatment groups, or when the exercise and comparison groups receive the same co‐interventions, allowing the effect of exercise treatment to be isolated), and (c) other conservative treatments (eight categories).  Estimate the treatment effects and associated uncertainty for comparisons of different specific types of exercise treatment in adults with chronic non‐specific low back pain to each other, and to each comparison treatment, using direct and indirect evidence with network meta‐analysis. Estimate the treatment effects and associated uncertainty for comparisons of treatments composed of different exercise type categories, design, delivery, dose, and additional treatment components, and their combinations, using direct and indirect evidence with component network meta‐analysis. 

Depression symptoms reducing return to work: a meta-analysis of prospective studies

Objectives. This study was conducted to estimate the risk of return to work for people who experience symptoms of depression based on the pool of prospective data. Methods. All online articles in PubMed and Scopus which were accessible before November 2019 were searched. The odds ratios of each of the studies were pooled together to obtain an overall odds ratio. The pool of studies was with random effects. The analysis was performed based on the depression symptoms scale, type of disease and duration of follow-up. Two other aspects were examined in the analysis, one being the bias in the publication of studies and the other being the level of heterogeneity that was examined. Results. Thirty-five studies were selected for the meta-analysis. The pooled odds ratio indicates that the odds of return to work in people with depressive symptoms is 31% lower than in those without depressive symptoms. The funnel plot shows that there is asymmetry. The Egger test result was significant (p < 0.001) and there is publication bias. Conclusion. Depression symptoms after sick leave due to physical illness is a risk factor for not returning to work.

Spinal cord stimulation and return to work of patients with failed back surgery syndrome

OBJECTIVES

Chronic pain has a substantial negative impact on work-related outcomes, which underlines the importance of interventions to reduce the burden. Spinal cord stimulation (SCS) efficiently relieves pain in specific chronic pain syndromes and is recommended for treating failed back surgery syndrome (FBSS) or post-surgical chronic back pain that is refractory to other treatments. To examine the impact of SCS in patients with FBSS on the return to work (RTW), we determined the RTW rate and the factors positively associated with the RTW.

MATERIALS AND METHODS

Among 106 patients with FBSS who benefitted from SCS at a single institution in France between September 1999 and March 2010, we retrospectively included 59 who had stopped work at the time of SCS because of disability or sick leave and evaluated the RTW (rate and predictors, estimating odds ratios [ORs] and 95% confidence intervals [CIs]).

RESULTS

The mean (SD) post-surgery follow-up for the 59 patients (34 men; mean [SD] age 46.9 [7.4] years) was 7.5 (3.6) years (range 5-15). The RTW rate was 30.5%, with a median [IQR] recovery time of 5.5 months [3-8.5]. RTW was improved with functional improvement evolution (OR 1.1, 95% CI [1.01-1.1], p = 0.02) and was reduced with unemployment > 3 years (OR 0.1, 95% CI [0.01-0.7], p = 0.02).

CONCLUSIONS

Our protocol for SCS for patients with FBSS, including a strict selection of patients and a multidisciplinary approach, led to good results, especially for the RTW. RTW should be a therapeutic goal, directly affecting indirect costs related to FBSS.

A Scoping Review on the Epidemiology of Chronic Low Back Pain among Adults in Sub-Saharan Africa

BACKGROUND

The global burden of chronic low back pain (CLBP) is a major concern in public health. Several CLBP epidemiological studies have been conducted in high-income-countries (HICs) with little known in low-and-middle-income-countries (LMICs) due to other competing priorities of communicable diseases. The extrapolation of results of studies from HICs for use in LMICs is difficult due to differences in social norms, healthcare systems, and legislations, yet there is urgent need to address this growing burden. It is against this backdrop that we conducted this review to map the current evidence on the distribution of CLBP in Sub-Saharan Africa (SSA).

METHODS

A comprehensive literature search was conducted from the following databases: PubMed, Google Scholar, Science Direct databases, World Health Organizations library databases, EMBASE, EBSCOhost by searching the following databases within the platform; academic search complete, CINAHL with full text, health sources: nursing/academic and MEDLINE. The title, abstract and the full text screening phases were performed by two independent reviewers with the third reviewer employed to adjudicate discrepancies. The reference list of all included articles was also searched for eligible articles. This scoping review was reported in accordance with the PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation, as well as guided by Arksey and O'Malley's scoping review framework. A thematic content analysis was used to give a narrative account of the review.

RESULTS

The electronic search strategy retrieved 21,189 articles. Title/abstract and full text screening only identified 11 articles, which were included in this review. The prevalence of CLBP among the general population ranged from 18.1% to 28.2% and from 22.2% to 59.1% among LBP patients. The prevalence of occupation based CLBP ranged from 30.1% to 55.5%. Identified risk factors for CLBP are multifactorial and included biomechanical, psychological, socioeconomic and lifestyle factors, with psychosocial factors playing a significant role. Hypertension, diabetes mellitus, peptic ulcer disease were the most common comorbidities identified. CLBP disability was significantly associated with psychosocial factors. The management of CLBP in primary care follows the traditional biomedical paradigm and primarily involves pain medication and inconsistent with guidelines.

CONCLUSIONS

There are limited epidemiological data on CLBP in SSA, however, this study concluded that the prevalence and risk factors of CLBP in SSA are comparable to reports in HICs. Considering the projected increase in the burden of CLBP in LMICs extensive research effort is needed to close this knowledge gap.

Professional Status of Persistent Spinal Pain Syndrome Patients after Spinal Surgery (PSPS-T2): What Really Matters? A Prospective Study Introducing the Concept of "Adapted Professional Activity" Inferred from Clinical, Psychological and Social Influence

Persistent Spinal Pain Syndrome Type 2 (PSPS-T2) represents a main cause of work disruption. Beyond its societal consequences, occupational inactivity is responsible for a major decrease in physical/mental health in individuals but remains poorly analyzed. We designed a study to prospectively examine Professional Status (PS) evolution and its association with key bio-psychological markers. Data from 151 consecutively included working-age PSPS-T2 patients were analyzed to determine the proportion of professional inactivity and the relationships between PS and Social Gradient of Health (SGH), Numeric Pain Rating Scale (NPRS), EuroQol 5-Dimensional 5-Level (EQ-5D-5L), Oswestry Disability Index (ODI), Hospital Anxiety and Depression Scale (HADS), and Fear-Avoidance Belief Questionnaire work subscale (FABQ-W). Despite optimized medical management, 73.5% of PSPS-T2 patients remained inactive after 1 year of follow-up/p = 0.18. Inactive patients presented a low SGH/p = 0.002, higher NPRS/p = 0.048, lower EQ-5D-5L/p < 0.001, higher ODI/p = 0.018, higher HADS-D/p = 0.019 and higher FABQ-W/p < 0.001. No significant mediation effect of FABQ-W on SGH consequences regarding PS was observed in our structural model/p = 0.057. The link between unemployment and bio-psycho-social pain dimensions appears bidirectional and justifies intense collaboration with social workers. Optimizing therapeutical sequencing towards personalized professional plans implies restoring "Adapted Physical Function" as an initial goal, and tailoring an "Adapted Professional Activity", matching with patient expectations and capabilities, as a final objective.

Exercise therapy for chronic low back pain

BACKGROUND

Low back pain has been the leading cause of disability globally for at least the past three decades and results in enormous direct healthcare and lost productivity costs.

OBJECTIVES

The primary objective of this systematic review is to assess the impact of exercise treatment on pain and functional limitations in adults with chronic non-specific low back pain compared to no treatment, usual care, placebo and other conservative treatments.

SEARCH METHODS

We searched CENTRAL (which includes the Cochrane Back and Neck trials register), MEDLINE, Embase, CINAHL, PsycINFO, PEDro, SPORTDiscus, and trials registries (ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform), and conducted citation searching of relevant systematic reviews to identify additional studies. The review includes data for trials identified in searches up to 27 April 2018. All eligible trials have been identified through searches to 7 December 2020, but have not yet been extracted; these trials will be integrated in the next update.

SELECTION CRITERIA

We included randomised controlled trials that assessed exercise treatment compared to no treatment, usual care, placebo or other conservative treatment on the outcomes of pain or functional limitations for a population of adult participants with chronic non-specific low back pain of more than 12 weeks' duration.

DATA COLLECTION AND ANALYSIS

Two authors screened and assessed studies independently, with consensus. We extracted outcome data using electronic databases; pain and functional limitations outcomes were re-scaled to 0 to 100 points for meta-analyses where 0 is no pain or functional limitations. We assessed risk of bias using the Cochrane risk of bias (RoB) tool and used GRADE to evaluate the overall certainty of the evidence. When required, we contacted study authors to obtain missing data. To interpret meta-analysis results, we considered a 15-point difference in pain and a 10-point difference in functional limitations outcomes to be clinically important for the primary comparison of exercise versus no treatment, usual care or placebo.

MAIN RESULTS

We included 249 trials of exercise treatment, including studies conducted in Europe (122 studies), Asia (38 studies), North America (33 studies), and the Middle East (24 studies). Sixty-one per cent of studies (151 trials) examined the effectiveness of two or more different types of exercise treatment, and 57% (142 trials) compared exercise treatment to a non-exercise comparison treatment. Study participants had a mean age of 43.7 years and, on average, 59% of study populations were female. Most of the trials were judged to be at risk of bias, including 79% at risk of performance bias due to difficulty blinding exercise treatments. We found moderate-certainty evidence that exercise treatment is more effective for treatment of chronic low back pain compared to no treatment, usual care or placebo comparisons for pain outcomes at earliest follow-up (MD -15.2, 95% CI -18.3 to -12.2), a clinically important difference. Certainty of evidence was downgraded mainly due to heterogeneity. For the same comparison, there was moderate-certainty evidence for functional limitations outcomes (MD -6.8 (95% CI -8.3 to -5.3); this finding did not meet our prespecified threshold for minimal clinically important difference. Certainty of evidence was downgraded mainly due to some evidence of publication bias.  Compared to all other investigated conservative treatments, exercise treatment was found to have improved pain (MD -9.1, 95% CI -12.6 to -5.6) and functional limitations outcomes (MD -4.1, 95% CI -6.0 to -2.2). These effects did not meet our prespecified threshold for clinically important difference. Subgroup analysis of pain outcomes suggested that exercise treatment is probably more effective than education alone (MD -12.2, 95% CI -19.4 to -5.0) or non-exercise physical therapy (MD -10.4, 95% CI -15.2 to -5.6), but with no differences observed for manual therapy (MD 1.0, 95% CI -3.1 to 5.1). In studies that reported adverse effects (86 studies), one or more adverse effects were reported in 37 of 112 exercise groups (33%) and 12 of 42 comparison groups (29%). Twelve included studies reported measuring adverse effects in a systematic way, with a median of 0.14 (IQR 0.01 to 0.57) per participant in the exercise groups (mostly minor harms, e.g. muscle soreness), and 0.12 (IQR 0.02 to 0.32) in comparison groups.

AUTHORS' CONCLUSIONS

We found moderate-certainty evidence that exercise is probably effective for treatment of chronic low back pain compared to no treatment, usual care or placebo for pain. The observed treatment effect for the exercise compared to no treatment, usual care or placebo comparisons is small for functional limitations, not meeting our threshold for minimal clinically important difference. We also found exercise to have improved pain (low-certainty evidence) and functional limitations outcomes (moderate-certainty evidence) compared to other conservative treatments; however, these effects were small and not clinically important when considering all comparisons together. Subgroup analysis suggested that exercise treatment is probably more effective than advice or education alone, or electrotherapy, but with no differences observed for manual therapy treatments.

Prognostic factors for pain chronicity in low back pain: a systematic review

Supplemental Digital Content is Available in the Text.

Several prognostic factors are related to low back pain chronicity, and these should be taken into account when planning more comprehensive models in its prevention.

Low back pain is the leading cause for years lived in disability. Most people with acute low back pain improve rapidly, but 4% to 25% of patients become chronic. Since the previous systematic reviews on the subject, a large number of new studies have been conducted. The objective of this article was to review the evidence of the prognostic factors behind nonspecific chronic low back pain. A systematic literature search was performed without date limitation from the MEDLINE, Cochrane library, and Medic databases. Specific inclusion criteria were used, and risk factors before the onset of chronic symptoms were searched. Study quality was assessed by 2 independent reviewers. One hundred eleven full articles were read for potential inclusion, and 25 articles met all the inclusion criteria. One study was rated as good quality, 19 studies were rated as fair quality, and 5 articles were rated as poor quality. Higher pain intensity, higher body weight, carrying heavy loads at work, difficult working positions, and depression were the most frequently observed risk factors for chronic low back pain. Maladaptive behavior strategies, general anxiety, functional limitation during the episode, smoking, and particularly physical work were also explicitly predictive of chronicity. According to this systematic review, several prognostic factors from the biomechanical, psychological and psychosocial point of view are significant for chronicity in low back pain.

Determination of Biodex Balance System Cutoff Scores in Older People With Nonspecific Back Pain: A Cross-sectional Study

OBJECTIVE

The purpose of this study was to determine cutoff scores for the Biodex Balance System (BBS) and verify if they could be used to discriminate older people with nonspecific low back pain (NSLBP) with poor postural performance from those with good postural performance.

METHODS

This cross-sectional study included 52 participants with NSLBP older than 65 years. One level of stability (level 5; intraclass correlation ≥0.70) and 2 conditions (eyes open and eyes closed) were selected for the testing procedure. Anterior-posterior stability index (APSI), medial-lateral stability index (MLSI), and overall stability index (OSI) scores were calculated. The participants were classified into 2 groups: high risk of falling and low risk of falling. Both the receiver operating characteristic and the area under the curve were used to determine the best BBS cutoff values. Binary logistic regression analysis was used to investigate the ability of BBS scores to predict risk of falling.

RESULTS

BBS cutoff scores in the eyes-open condition (APSI = 2.60, MLSI = 1.95, OSI = 2.95) and eyes-closed condition (APSI = 3.05, MLSI = 2.17, OSI = 3.25) were found to be sensitive and specific in determining postural performance. Participants with index values lower than the cutoff scores had, respectively, 6.42, 4.20, and 3.72 times lower risk of falling in the eyes-open condition and 3.33, 5.50, and 3.00 times lower risk of falling in the eyes-closed condition. The predictive characteristics of the models for risk analysis were excellent and good to excellent.

CONCLUSION

Our study shows that BBS cutoff scores are sensitive and specific in distinguishing between poor and good postural performance in older people with NSLBP.

Association of thoraco-lumbar fascia length in individuals with non-specific low back pain - an observational study

OBJECTIVE

The purpose of the study was to assess the length of TLF and to evaluate the strength of muscles attached to it in subjects with and without nonspecific low back pain (NSLBP).

METHODS

31 patients with NSLBP and 31 healthy individuals were included in the study. In each subject the TLF length was assessed by quantifying lumbar rotation using Back range of motion (BROM-II) instrument. The endurance of transverses abdominis was assessed using the pressure biofeedback unit while the strength of Latissimus dorsi, internal and external oblique's were assessed using MMT. Outcome measure such as Range of Motion (ROM) was compared across the group using independent sample T-test. While the muscle strength of Latissimus dorsi and oblique's were compared across the group using Man-whitney U- test. Transverse abdominis endurance was tested using chi-square test.

RESULTS

There was statistically significant difference in the length of TLF of subjects with NSLBP when compared with subjects without NSLBP. When the strength of Latissimus dorsi muscle, transverses abdominis muscle and internal and external oblique's muscle was assessed no significant (p value > 0.05) difference was found in either group.

CONCLUSIONS

There was statistically significant reduction in length of TLF but there was no difference in the strength of Latissimus dorsi, internal and external oblique's or endurance of transverses abdominus attached to the TLF in individuals with NSLBP and without low back pain. This study will help in determining the inclusion of TLF and the associated structures in evaluation and management of subjects with NSLBP.

Long-term effects on function, health-related quality of life and work ability after structured physiotherapy including a workplace intervention. A secondary analysis of a randomised controlled trial (WorkUp) in primary care for patients with neck and/or back pain

Objective: To study the long-term effects of a workplace intervention in addition to structured physiotherapy regarding self-reported measures in patients with acute/subacute neck and/or back pain.Design: WorkUp - a cluster-randomised controlled trial in 32 primary care centers in Sweden, from January 2013 through December 2014 (ClinicalTrials.gov ID: NCT02609750).Intervention: Structured physiotherapy with the workplace dialogue 'Convergence Dialogue Meeting' (CDM), conducted by the treating physiotherapist as an add-on. Reference group received structured physiotherapy.Subjects: Adults, 18-67 years (mean 43.7, standard deviation (SD) 12.2), 65.3% women with acute/subacute neck and/or back pain who had worked ≥4 weeks past year, considered at risk of sick leave or were on short-term sick leave (≤60 days) were included (n = 352).Outcome measures: Self-reported function, functional rating index (FRI), health-related quality of life (EQ-5D-3L) and work ability (Work Ability Score, WAS) at 12 months follow-up.Results: The mean differences in outcomes between intervention and reference group were; -0.76 (95% confidence interval (CI): -2.39, 0.88; FRI), 0.02 (95% CI: -0.04, 0.08; EQ-5D-3L) and -0.05 (95% CI: -0.63, 0.53; WAS). From baseline to 12 months, the intervention group improved function from 46.5 (SD 19.7) to 10.5 (SD 7.3) on FRI; health-related quality of life from 0.53 (SD 0.29) to 0.74 (SD 0.20) on EQ-5D and work ability from 5.7 (SD 2.6) to 7.6 (SD 2.1) on WAS.Conclusion: Despite a clinically relevant improvement over time, there were no significant differences in improvement between groups, thus we conclude that CDM had no effect on self-reported measures in this study.Key pointsIn earlier analysis of the primary outcome (work ability measured by absenteeism) in this trial, a positive effect was found when the workplace intervention 'Convergence Dialogue Meeting' (CDM) was added to structured physiotherapy for patients with neck or back pain.By contrast, in this new analysis of secondary outcomes (self-reported function, health and perceived work ability), there was no added effect of CDM above structured physiotherapy alone, although patients in both the intervention and reference group improved over time.The addition of CDM to physiotherapy is therefore justified by its specific effect on behavior (work absence) rather than any effect on clinical outcomes.

[Obstacles to return to work: Translation and cross-cultural adaptation of the questionnaire to the Brazilian context]

The few existing questionnaires addressing return to work in Brazil are medical and/or psychological and do not examine work environment-related issues. The Obstacles to Return-to-Work Questionnaire (ORTWQ) is multidimensional, including biopsychosocial and environmental factors, and has proven useful in the return to work issue. The scope of this study is to describe the translation and cultural adaptation process of ORTWQ for use in the Brazilian context. It also discusses aspects related to work and the importance for health professionals to identify obstacles to return to work for occupational health vigilance. For the cultural adaptation process, there were five steps: translation, synthesis, back translation, evaluation by an expert committee and the pre-test process. Before the pre-test phase, the Content Validity Index was checked and was considered adequate when it was ≥ 0.8. The expression "increase working hours" was withdrawn from the questionnaire, since the partial returnto-work regime is rare in Brazil. The sample for the pre-test involved 40 individuals. The average time for completing ORTWQ was 14 minutes and the Brazilian version of ORTWQ proved to be adequate. Further studies should assess psychometric qualities of the questionnaire.

Return to work following surgery for lumbar radiculopathy: a systematic review

BACKGROUND CONTEXT

Informing patients about postoperative return to work (RTW) expectations is of utmost importance because of the influence of realistic expectations on RTW outcomes.

PURPOSE

We aimed to give an overview of the duration of sick leave and RTW rates after surgery for lumbar radiculopathy and to list predictors of and factors related to RTW.

STUDY DESIGN

A systematic review was carried out.

METHODS

A systematic literature search was conducted in PubMed, Web of Science, EMBASE, and SCOPUS. Full-text articles on RTW following surgery for lumbar radiculopathy were included through double-blind screening. Risk of bias was assessed using a modified version of the Downs and Black checklist.

RESULTS

Sixty-three full-text articles (total sample size: 7,100 patients) were included. Risk of bias was scored low to high. Mean duration of sick leave ranged from 0.8 to 20 weeks. Within 0.1-240 months post surgery, 3%-100% of patients resumed work. Most important predictors for work resumption were preoperative work status, presence of comorbidities, age, sex and duration of preoperative symptoms. Duration of sick leave can be predicted by the preoperative level of pain or disability and presence of symptoms of depression, occupational mental stress, and lateral disc prolapse. Furthermore, less invasive surgical techniques were found to result in better RTW outcomes compared with more invasive techniques.

CONCLUSIONS

Diverse results were found for RTW rates and duration of sick leave. Preoperative work status, presence of comorbidities, and several demographic factors were retrieved as predictors of RTW and duration of sick leave.

A scoping review of biopsychosocial risk factors and co-morbidities for common spinal disorders

OBJECTIVE

The purpose of this review was to identify risk factors, prognostic factors, and comorbidities associated with common spinal disorders.

METHODS

A scoping review of the literature of common spinal disorders was performed through September 2016. To identify search terms, we developed 3 terminology groups for case definitions: 1) spinal pain of unknown origin, 2) spinal syndromes, and 3) spinal pathology. We used a comprehensive strategy to search PubMed for meta-analyses and systematic reviews of case-control studies, cohort studies, and randomized controlled trials for risk and prognostic factors and cross-sectional studies describing associations and comorbidities.

RESULTS

Of 3,453 candidate papers, 145 met study criteria and were included in this review. Risk factors were reported for group 1: non-specific low back pain (smoking, overweight/obesity, negative recovery expectations), non-specific neck pain (high job demands, monotonous work); group 2: degenerative spinal disease (workers' compensation claim, degenerative scoliosis), and group 3: spinal tuberculosis (age, imprisonment, previous history of tuberculosis), spinal cord injury (age, accidental injury), vertebral fracture from osteoporosis (type 1 diabetes, certain medications, smoking), and neural tube defects (folic acid deficit, anti-convulsant medications, chlorine, influenza, maternal obesity). A range of comorbidities was identified for spinal disorders.

CONCLUSION

Many associated factors for common spinal disorders identified in this study are modifiable. The most common spinal disorders are co-morbid with general health conditions, but there is a lack of clarity in the literature differentiating which conditions are merely comorbid versus ones that are risk factors. Modifiable risk factors present opportunities for policy, research, and public health prevention efforts on both the individual patient and community levels. Further research into prevention interventions for spinal disorders is needed to address this gap in the literature.

Whole-body vibration training as a workplace-based sports activity for employees with chronic low-back pain

The goal of this randomized and controlled study was to examine whether whole-body vibration (WBV) training is able to reduce back pain and physical disability in seated working office employees with chronic low-back pain in a real-world setting. A total of 41 subjects (68.3% female/mean age 45.5±9.1 years/mean BMI 26.6±5.2) were randomly allocated to an intervention group (INT [n=21]) or a control group (CON [n=20]). The INT participated in WBV training 2.5 times per week for 3 months. The primary outcome was the change in the Roland and Morris disability questionnaire (RMQ) score over the study period. In addition, secondary outcomes included changes in the Oswestry Disability Index (ODI), the Work Ability Index Questionnaire, the quality of life questionnaire SF-36, the Freiburger activity questionnaire, and an isokinetic test of the musculature of the trunk. Compliance with the intervention in the INT reached a mean of 81.1%±31.2% with no long-lasting unwanted side effects. We found significant positive effects of 3 months of WBV training in the INT compared to the CON regarding the RMQ (P=.027), the ODI (P=.002), the SF-36 (P=.013), the Freiburger activity questionnaire (P=.022), the post-interventional sick-leave in the INT (P=.008), and trends regarding a positive effect of the intervention on the muscular capacity of the muscles of the trunk in flexion. WBV training seems to be an effective, safe, and suitable intervention for seated working employees with chronic low-back pain.

Pain and functional outcomes after outpatient physiotherapy in patients with low back pain

BACKGROUND

Physiotherapy treatment programs are recommended in the rehabilitation of low back pain (LBP). Rehabilitation institutions are increasingly asked to demonstrate the outcomes of their intensive physiotherapy services.

AIM

To describe pain and functional outcome measures following a 6-month outpatient physiotherapy treatment program in patients with LBP.

METHODS

A total of 85 patients were analysed after being treated with a combination of physiotherapeutic treatment modalities 2-3 days weekly. Pain and disability were measured before, 3 and 6 months after the onset of treatment. Isometric trunk muscle strength for flexion and extension and flexibility of dorsal trunk and thigh structures were measured before and 6 months after treatment.

RESULTS

After 6 months, pain at rest decreased from a median of 4.0 to 0.0 (p < 0.01) and pain during activity from a median of 5.5 to 2.0 on the numeric rating scale (p < 0.001). The Roland-Morris Disability (RMDQ) score decreased from a median of 7.0 to 3.0 (p < 0.001). Mean trunk muscle flexion strength increased from 133.7 to 156.0 Nm and for extension from 235.5 to 278.3 Nm (p < 0.001). Flexibility was improved from a mean of -5.9 to -1.4 cm (p < 0.001). A moderate correlation between pain at rest and RMDQ score was found after 3 (r = 0.532, p < 0.01) and 6 months (r = 0.508, p < 0.01).

CONCLUSIONS

Patients with LBP who were treated with the physiotherapeutic treatment program showed a clinically relevant reduction of pain and disability with improved trunk muscle strength and flexibility. Reductions in pain and disability do not seem to correlate with increased trunk muscle strength and flexibility. No conclusions can be declared about long-term changes after the intervention.

Supervisors' perceptions of organizational policies are associated with their likelihood to accommodate back-injured workers

Background Low back pain (LBP) is a major concern among North American workplaces and little is known regarding a supervisor's decision to support job accommodation for workers with LBP. The extent to which supervisors are included in a company's effort to institute disability management policies and practices and workplace safety climate are two factors that may influence a supervisor's decision to accommodate workers with LBP. Objective Determine the association between supervisors' perceptions of disability management policies, corporate safety culture and their likelihood of supporting job accommodations for workers with LBP. Methods We conducted a cross-sectional study of supervisors (N=796) recruited from a non-random, convenience sample of 19 Canadian and US employers. The outcome was supervisors' likeliness to support job accommodation and the exposure was global work safety culture and disability management policies and practices. A multivariable generalized linear modelling strategy was used and final models for each exposure were obtained after assessing potential effect modifiers and confounders. Results In the study, 796 eligible supervisors from 19 employers participated. Disability management policies and practices were positively associated with supervisors' likeliness to accommodate (β=0.19; 95% CI: 0.13; 0.24) while no significant association was found between corporate safety culture (β= -0.084; 95% CI: -0.19; 0.027) and supervisors' likeliness to accommodate. Conclusions Employers should ensure that proactive disability management policies and practices are clearly communicated to supervisors in order to improve job modification and return to work efforts. Implications for Rehabilitation Low back pain (LBP) is a major workplace concern and little is known regarding what factors are associated with a supervisor's likelihood to support job accommodation for workers with LBP. The objective of this article was to determine the association between supervisors' perceptions of disability management policies and practices, corporate safety culture and their likelihood of support job accommodations for workers with LBP. Results suggest that disability management policies and practices are positively associated with supervisors' likelihood to accommodate while corporate safety culture is not. These results are important for employers as it suggests that employers should ensure that their disability management policies and practices are clearly communicated to supervisors in order to improve job accommodation and return to work efforts.

Do expectancies of return to work and Job satisfaction predict actual return to work in workers with long lasting LBP?

Background

Musculoskeletal disorders including low back pain have major individual and socioeconomic consequences as it often leads to disability and long-term sick leave and exclusion from working life. Predictors of disability and return to work often differ, and the dominant knowledge is on predictors for prolonged sick leave and disability. Therefore it is also important to identify key predictors for return to work. The aim of the study was to assess if overall job satisfaction and expectancies of return to work predicts actual return to work after 12 months, among employees with long lasting low back pain, and to assess if there were gender differences in the predictors.

Methods

Data from the Cognitive interventions and nutritional supplements trial (CINS Trial) was used. Predictors for return to work were examined in 574 employees that had been on sick leave 2–10 months for low back pain, before entering the trial. Data were analysed with multiple logistic regression models stratified by gender, and adjusted for potential confounders.

Results

Regardless of gender high expectancies were a strong and significant predictor of return to work at 12 months, while high levels of job satisfaction were not a significant predictor. There were no differences in the levels of expectancies or overall job satisfaction between men and women. However, men had in general higher odds of returning to work compared with women.

Conclusions

Among individuals with long lasting low back pain high expectancies of returning to work were strongly associated with successful return to work. We do not know what factors influence individual expectancies of return to work. Screening expectancies and giving individuals with low expectancies interventions with a goal to change expectancies of return to work, such as CBT or self-management interventions, may contribute to increase actual return to work.

Trial registration

http://www.clinicaltrials.gov/, with registration number NCT00463970. The trial was registered at the 18th of April 2007.

Contribution of occupational factors to the incidence and persistence of chronic low back pain among workers: results from the longitudinal VISAT study

OBJECTIVE

Among the aetiological factors of chronic low back pain (CLBP), occupational factors are often suspected, but their contribution remains to be ascertained. This study aimed to determine the impact of a wide range of occupational factors on the incidence and persistence of CLBP.

METHOD

From the VISAT (VIeillissement SAnté Travail) study, 1560 workers were examined at baseline and 5 years later. CLBP was defined as having low back pain or specific treatment for at least 6 months. Participants newly affected with CLBP and those with persistent CLBP at follow-up were distinguished. In addition to individual factors, a broad panel of occupational factors were analysed, covering employment, physical, organisational and psychosocial factors. Multivariate analyses were used to determine predictive factors of incidence and persistence of CLBP. Receiver operating characteristic (ROC) curves were performed to analyse the contribution of occupational factors.

RESULTS

22.6% of participants without any CLBP initially presented with CLBP 5 years later, while 53.7% of participants with CLBP at baseline had CLBP at the second collection. Carrying heavy loads, the lack of recognition of completed work and productivity-related income predicted a higher risk of incidence of CLBP. However, no significant association between occupational factors and the risk for persistence of CLBP was observed, while the risk was multiplied by two for history of depression and rheumatological events. ROC curves confirmed the significant contribution of occupational factors to incidence of CLBP.

CONCLUSIONS

Occupational factors played a pivotal role in the incidence of CLBP, while individual factors were the main determinants of persistence of CLBP.

Mood and anxiety disorders in patients with chronic low back and neck pain caused by disc herniation

OBJECTIVE

We investigated the prevalence of mood and anxiety disorders in patients with chronic low back and neck pain caused by disc herniation and the relationships between pain and mood, and anxiety disorders.

METHODS

In total, 149 patients with disc herniation and 60 healthy subjects were included. Disc herniation was diagnosed based on a physical examination and magnetic resonance imaging. Mood and anxiety disorders were diagnosed using the Structured Clinical Interview of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition/Clinical Version.

RESULTS

The mean age of the study subjects (n = 209) was 45.96 ± 11.45 years. Seventy (46.6%) patients with disc herniation met the criteria for at least one mood or anxiety disorder. The prevalence rates of mood and anxiety disorders were 16.6% and 35.8%, respectively. The most common specific diagnoses were major depression (n = 25, 16.9%) and generalised anxiety disorder (n = 19, 12.8%).

CONCLUSIONS

Mood and anxiety disorders were more commonly seen in patients with lumbar or cervical disc herniation than in those without herniation. No relationship was detected between pain severity and mood or anxiety disorders. However, mood and anxiety disorders were associated with neurological deficits.

Supervisor Autonomy and Considerate Leadership Style are Associated with Supervisors' Likelihood to Accommodate Back Injured Workers

PURPOSE

To determine the association between supervisors' leadership style and autonomy and supervisors' likelihood of supporting job accommodations for back-injured workers.

METHODS

A cross-sectional study of supervisors from Canadian and US employers was conducted using a web-based, self-report questionnaire that included a case vignette of a back-injured worker. Autonomy and two dimensions of leadership style (considerate and initiating structure) were included as exposures. The outcome, supervisors' likeliness to support job accommodation, was measured with the Job Accommodation Scale (JAS). We conducted univariate analyses of all variables and bivariate analyses of the JAS score with each exposure and potential confounding factor. We used multivariable generalized linear models to control for confounding factors.

RESULTS

A total of 796 supervisors participated. Considerate leadership style (β = .012; 95% CI .009-.016) and autonomy (β = .066; 95% CI .025-.11) were positively associated with supervisors' likelihood to accommodate after adjusting for appropriate confounding factors. An initiating structure leadership style was not significantly associated with supervisors' likelihood to accommodate (β = .0018; 95% CI -.0026 to .0061) after adjusting for appropriate confounders.

CONCLUSIONS

Autonomy and a considerate leadership style were positively associated with supervisors' likelihood to accommodate a back-injured worker. Providing supervisors with more autonomy over decisions of accommodation and developing their considerate leadership style may aid in increasing work accommodation for back-injured workers and preventing prolonged work disability.

Cost-utility of cognitive behavioral therapy for low back pain from the commercial payer perspective

STUDY DESIGN

Markov cost-utility model.

OBJECTIVE

To evaluate the cost-utility of cognitive behavioral therapy (CBT) for the treatment of persistent nonspecific low back pain (LBP) from the perspective of US commercial payers.

SUMMARY OF BACKGROUND DATA

CBT is widely deemed clinically effective for LBP treatment. The evidence is suggestive of cost-effectiveness.

METHODS

We constructed and validated a Markov intention-to-treat model to estimate the cost-utility of CBT, with 1-year and 10-year time horizons. We applied likelihood of improvement and utilities from a randomized controlled trial assessing CBT to treat LBP. The trial randomized subjects to treatment but subjects freely sought health care services. We derived the cost of equivalent rates and types of services from US commercial claims for LBP for a similar population. For the 10-year estimates, we derived recurrence rates from the literature. The base case included medical and pharmaceutical services and assumed gradual loss of skill in applying CBT techniques. Sensitivity analyses assessed the distribution of service utilization, utility values, and rate of LBP recurrence. We compared health plan designs. Results are based on 5000 iterations of each model and expressed as an incremental cost per quality-adjusted life-year.

RESULTS

The incremental cost-utility of CBT was $7197 per quality-adjusted life-year in the first year and $5855 per quality-adjusted life-year over 10 years. The results are robust across numerous sensitivity analyses. No change of parameter estimate resulted in a difference of more than 7% from the base case for either time horizon. Including chiropractic and/or acupuncture care did not substantively affect cost-effectiveness. The model with medical but no pharmaceutical costs was more cost-effective ($5238 for 1 yr and $3849 for 10 yr).

CONCLUSION

CBT is a cost-effective approach to manage chronic LBP among commercial health plans members. Cost-effectiveness is demonstrated for multiple plan designs.

LEVEL OF EVIDENCE

2.

The Nijmegen decision tool for chronic low back pain. Development of a clinical decision tool for secondary or tertiary spine care specialists

BACKGROUND

In Western Europe, low back pain has the greatest burden of all diseases. When back pain persists, different medical specialists are involved and a lack of consensus exists among these specialists for medical decision-making in Chronic Low Back Pain (CLBP).

OBJECTIVE

To develop a decision tool for secondary or tertiary spine care specialists to decide which patients with CLBP should be seen by a spine surgeon or by other non-surgical medical specialists.

METHODS

A Delphi study was performed to identify indicators predicting the outcome of interventions. In the preparatory stage evidence from international guidelines and literature were summarized. Eligible studies were reviews and longitudinal studies. Inclusion criteria: surgical or non-surgical interventions and persistence of complaints, CLBP-patients aged 18-65 years, reported baseline measures of predictive indicators, and one or more reported outcomes had to assess functional status, quality of life, pain intensity, employment status or a composite score. Subsequently, a three-round Delphi procedure, to reach consensus on candidate indicators, was performed among a multidisciplinary panel of 29 CLBP-professionals (>five years CLBP-experience). The pre-set threshold for general agreement was ≥70%. The final indicator set was used to develop a clinical decision tool.

RESULTS

A draft list with 53 candidate indicators (38 with conclusive evidence and 15 with inconclusive evidence) was included for the Delphi study. Consensus was reached to include 47 indicators. A first version of the decision tool was developed, consisting of a web-based screening questionnaire and a provisional decision algorithm.

CONCLUSIONS

This is the first clinical decision tool based on current scientific evidence and formal multidisciplinary consensus that helps referring the patient for consultation to a spine surgeon or a non-surgical spine care specialist. We expect that this tool considerably helps in clinical decision-making spine care, thereby improving efficient use of scarce sources and the outcomes of spinal interventions.

Predictors for return to work for those with occupational respiratory disease: clinical and structural factors

BACKGROUND

Few occupational researchers have examined "return to work" among patients with work-related respiratory diseases. In addition, prior studies have emphasized individual patient characteristics rather than a more multi-dimensional approach that includes both clinical and structural factors.

METHODS

A retrospective chart review identified patients with occupational respiratory diseases in the Occupational Health Clinical Center, Syracuse, NY between 1991 and 2009. We assessed predictors of work status using an exploratory, sequential mixed methods research design, multinomial (n = 188) and Cox regressions (n = 130).

RESULTS

The findings suggest that patients with an increased number of diagnoses, non-union members, and those who took more than a year before clinical presentation had significantly poorer work status outcomes, after adjusting for age, education level, and relevant diagnoses.

CONCLUSIONS

Efforts to prevent slow return to work after developing occupational respiratory disease should recognize the importance of timely access to occupational health services, disease severity, union membership, and smoking status.

Absence from work and return to work in people with back pain: a systematic review and meta-analysis

Background

A considerable proportion of work absence is attributed to back pain, however prospective studies in working populations with back pain are variable in setting and design, and a quantitative summary of current evidence is lacking.

Objective

To investigate the extent to which differences in setting, country, sampling procedures and methods for data collection are responsible for variation in estimates of work absence and return to work.

Methods

Systematic searches of seven bibliographic databases. Inclusion criteria were: adults in paid employment, with back pain, work absence or return to work during follow-up had been reported. Random effects meta-analysis and meta-regression analysis was carried out to provide summary estimates of work absence and return to work rates.

Results

45 studies were identified for inclusion in the review; 34 were included in the meta-analysis. The pooled estimate for the occurrence of work absence in workers with back pain was 15.5% (95% CI 9.8% to 23.6%, n=17 studies, I² 98.1%) in studies with follow-up periods of ≤6 months. The pooled estimate for the proportion of people with back pain returning to work was 68.2% (95% CI 54.8% to 79.1%, n=13, I² 99.2%), 85.6% (95% CI 78.2% to 90.7%, n=13, I² 98.7%) and 93.3% (95% CI 84.0% to 94.7%, n=10, I² 99%), at 1 month, 1–6 months and ≥6 months, respectively. Differences in setting, risk of participation bias and method of assessing work absence explained some of the heterogeneity.

Conclusions

Pooled estimates suggest high return to work rates, with wide variation in estimates of return to work only partly explained by a priori defined study-level variables. The estimated 32% not back at work at 1 month are at a crucial point for intervention to prevent long term work absence.

Psychosocial work factors and sick leave, occupational accident, and disability pension: a cohort study of civil servants

OBJECTIVE

To study associations between psychosocial work factors (PWF) and sick leave, occupational accident, and disability pension.

METHODS

A random population of 967 civil servants participated in a survey on PWF and health. The median follow-up time was 7 years.

RESULTS

Frequent feedback from supervisor, good opportunities for mental growth, good team climate, and high appreciation were associated with a decrease in the risk of sickness absences and shift/period work, monotonous movements, and crowdedness of workplace were associated with an increase in the risk of sickness absences. Good communication at work was associated with a decrease in client violence and high work pressure was associated with an increased risk of occupational accidents. High work control and good team climate were associated with a decreased and shift/period work and client violence was associated with an increased risk of disability pensions.

CONCLUSIONS

Psychosocial work factors can predict health outcomes with economic impact.

The clinical manifestations of lumbar disease are correlated with self-rating depression scale scores

BACKGROUND

Depression can exacerbate symptoms of chronic pain and worsen disability. The symptoms of lumbar disease may be particularly sensitive to psychological state, but statistical associations between low back pain (LBP) severity and mental health status have not been established.

METHODS

Of the 151 patients with LBP, 122 completed questionnaires probing depressive symptoms, LBP severity, and degree of disability. In addition to completing self-report questionnaires, patients provided demographic and clinical information. A self-rating depression scale (SDS) was used to screen for depression. Pain and disability were assessed by the visual analog scale (VAS) and the Roland-Morris disability questionnaire (RDQ), respectively. Overall clinical severity was assessed using the Japanese Orthopaedic Association (JOA) score. Kendall's tau correlation coefficients were calculated to examine the relationships among these variables.

RESULTS

Ninety-four patients (77 %) were in a depressive state as indicated by SDS score ≥40, including mild depression group (47 patients, SDS score from 40 to 49) and depression group (47 patients, SDS score ≥50). There were only 28 patients in the no depression group (SDS score ≤39). There was no significant difference in both age and pain duration among the three groups. The mean VAS score in the depression group (70 ± 19 mm) was higher than both no depression (41 ± 24 mm) and mild depression groups (52 ± 21 mm). The mean JOA score in the no depression group (14 ± 5.0 points) was higher than both mild depression (12 ± 4.0 points) and depression groups (10 ± 6.0 points). The mean RDQ in the depression group (15.1 ± 6.0 points) was higher than both no depression (6.4 ± 5.0 points) and mild depression groups (10.9 ± 5.4 points). Factors significantly correlated with SDS score included VAS, JOA score, and RDQ score. In contrast, SDS did not correlate with patient age or pain duration.

CONCLUSIONS

The majority of chronic LBP patients examined were in a depressed state and the severity of depression correlated with pain severity, degree of self-rated disability, and clinical severity.

Overview of data-synthesis in systematic reviews of studies on outcome prediction models

Background

Many prognostic models have been developed. Different types of models, i.e. prognostic factor and outcome prediction studies, serve different purposes, which should be reflected in how the results are summarized in reviews. Therefore we set out to investigate how authors of reviews synthesize and report the results of primary outcome prediction studies.

Methods

Outcome prediction reviews published in MEDLINE between October 2005 and March 2011 were eligible and 127 Systematic reviews with the aim to summarize outcome prediction studies written in English were identified for inclusion.

Characteristics of the reviews and the primary studies that were included were independently assessed by 2 review authors, using standardized forms.

Results

After consensus meetings a total of 50 systematic reviews that met the inclusion criteria were included. The type of primary studies included (prognostic factor or outcome prediction) was unclear in two-thirds of the reviews. A minority of the reviews reported univariable or multivariable point estimates and measures of dispersion from the primary studies. Moreover, the variables considered for outcome prediction model development were often not reported, or were unclear. In most reviews there was no information about model performance. Quantitative analysis was performed in 10 reviews, and 49 reviews assessed the primary studies qualitatively. In both analyses types a range of different methods was used to present the results of the outcome prediction studies.

Conclusions

Different methods are applied to synthesize primary study results but quantitative analysis is rarely performed. The description of its objectives and of the primary studies is suboptimal and performance parameters of the outcome prediction models are rarely mentioned. The poor reporting and the wide variety of data synthesis strategies are prone to influence the conclusions of outcome prediction reviews. Therefore, there is much room for improvement in reviews of outcome prediction studies.

A systematic review of instruments for the assessment of work-related psychosocial factors (Blue Flags) in individuals with non-specific low back pain

In individuals with low back pain (LBP) psychosocial factors can act as obstacles to return to work. A coloured Flags Framework has been conceptualised, in which Blue Flags represent work-related psychosocial issues. This systematic review was conducted to appraise available instruments for the assessment of Blue Flags in working age adults with non-specific LBP. The Ovid versions of MEDLINE, EMBASE, PsycINFO, AMED and CINAHL databases were searched from inception until the first week of March 2010; additionally, experts and study authors were contacted. Two authors independently selected studies, extracted data and assessed methodological quality. Eight studies (recruiting 5630 participants) met the review inclusion criteria, reporting six instruments: the Back Disability Risk Questionnaire (BDRQ); Occupational Role Questionnaire (ORQ); Obstacles to Return to Work Questionnaire (ORTWQ); Psychosocial Aspects of Work Questionnaire (PAWQ); Vermont Disability Prediction Questionnaire (VDPQ); and Modified Work Adaptation, Partnership, Growth, Affection and Resolve. Limited psychometric testing had been performed on the instruments, and solely by the original developers. None of the instruments, in their current stage of development, can be recommended as Blue Flags assessment instruments. The ORTWQ was the only instrument that showed adequate psychometric properties but was not considered clinically feasible in its present format. Future research should focus on further psychometric development of the ORTWQ.

Using a psychosocial subgroup assignment to predict sickness absence in a working population with neck and back pain

Background

The overall objective was to evaluate the predictive validity of a subgroup classification based on the Swedish version of the MPI, the MPI-S, among gainfully employed workers with neck pain (NP) and/or low back pain (LBP) during a follow-up period of 18 and 36 months.

Methods

This is a prospective cohort study that is part of a larger longitudinal multi-centre study entitled Work and Health in the Process and Engineering Industries (AHA). The attempt was to classify individuals at risk for developing chronic disabling NP and LBP. This is the first study using the MPI-questionnaire in a working population with NP and LBP.

Results

Dysfunctional individuals (DYS) demonstrated more statistically significant sickness absence compared to adaptive copers (AC) after 36 months. DYS also had a threefold increase in the risk ratio of long-term sickness absence at 18 months. Interpersonally distressed (ID) subgroup showed overall more sickness absence compared to the AC subgroup at the 36-month follow-up and had a twofold increase in the risk ratio of long-term sickness absence at 18 months. There was a significant difference in bodily pain, mental and physical health for ID and DYS subgroups compared to the AC group at both follow-ups.

Conclusions

The present study shows that this multidimensional approach to the classification of individuals based on psychological and psychosocial characteristics can distinguish different groups in gainfully employed working population with NP/LBP. The results in this study confirm the predictive validity of the MPI-S subgroup classification system.

Predictive ability of a modified Örebro Musculoskeletal Pain Questionnaire in an acute/subacute low back pain working population

The original 'Örebro Musculoskeletal Pain Questionnaire' (original-ÖMPQ) has been shown to have limitations in practicality, factor structure, face and content validity. This study addressed these concerns by modifying its content producing the 'Örebro Musculoskeletal Screening Questionnaire' (ÖMSQ). The ÖMSQ and original-ÖMPQ were tested concurrently in acute/subacute low back pain working populations (pilot n = 44, main n = 106). The ÖMSQ showed improved face and content validity, which broadened potential application, and improved practicality with two-thirds less missing responses. High reliability (0.975, p < 0.05, ICC: 2.1), criterion validity (Spearman's r = 0.97) and internal consistency (α = 0.84) were achieved, as were predictive ability cut-off scores from ROC curves (112-120 ÖMSQ-points), statistically different ÖMSQ scores (p < 0.001) for each outcome trait, and a strong correlation with recovery time (Spearman's, r = 0.71). The six-component factor structure reflected the constructs originally proposed. The ÖMSQ can be substituted for the original-ÖMPQ in this population. Further research will assess its applicability in broader populations.