Predicting return to work after low back injury using the Psychosocial Risk for Occupational Disability Instrument: a validation study

Injured worker participation in assessment during the acute phase of workers compensation rehabilitation: a scoping review

PURPOSE

Rates of return to work (RTW) are declining in the Australian workers compensation system alongside significant economic and social costs, disputes, and secondary psychological injury. Non-medical assessment of workplace injuries now considers psychosocial and workplace factors, and worker participation in the assessment process is limited. This scoping review examines studies regarding non-medical assessment during the acute phase of rehabilitation in terms of costs, disputes, secondary psychological injury, and worker participation.

METHOD

An electronic and manual search of relevant articles across four databases was conducted using PRISMA guidelines, followed by quality assessment.

RESULTS

Of the 1,630 studies retrieved, 12 met the inclusion criteria with most focused on assessment for risk of obstructed or delayed RTW.

CONCLUSIONS

Non-medical assessment in the acute stage of rehabilitation identifies risk for delayed or complicated RTW, overlooking potential for the process of assessment to contribute to disputes and development of secondary psychological injury. Doubt around the capacity of workers to participate objectively in assessment persists. These are aspects of assessment worthy of further exploration for their impact on RTW outcomes.

Recommended approaches to assessing and managing physiotherapy clients experiencing psychological distress: a systematic mapping review

BACKGROUND

Some physiotherapists find assessing and managing clients experiencing psychological distress challenging and are uncertain regarding the boundaries of the profession's scope.

OBJECTIVE

To map the approaches recommended for physiotherapists in scholarly literature, with respect to the assessment and management of clients experiencing psychological distress.

METHODS

A systematic mapping review was conducted. CINAHL, APA PsycINFO, Embase, and Medline ALL databases were systematically searched for secondary and tertiary literature relevant to the research objective. Recommended approaches were extracted from each article and analyzed descriptively and thematically.

RESULTS

3884 records were identified with 40 articles meeting the inclusion/exclusion criteria. Most recommendations related to identifying, assessing, and managing pain-related distress, with depression screening and referral also receiving some attention. Three approaches to detecting and assessing psychological distress were identified: 1) brief depression screen; 2) integrated suicide/nonsuicidal self-harm and depression screen; and 3) multidimensional screen and health-related distress assessment. Regarding the management of psychological distress the main approaches identified were: 1) education and reassurance; 2) cognitive-behavioral approaches; 3) mindfulness; and 4) case management.

CONCLUSION

While assessment and management of health-related distress by physiotherapists is commonly recommended, further guidance is needed to differentiate various forms of distress.

Recovery expectations can be assessed with single-item measures: findings of a systematic review and meta-analysis on the role of recovery expectations on return-to-work outcomes after musculoskeletal pain conditions

ABSTRACT

The objective of this systematic review is to quantify the association between recovery expectations and return-to-work outcomes in adults with musculoskeletal pain conditions. In addition, this review has the second objective to compare the predictive utility of single-item and multi-item recovery expectation scales on return-to-work outcomes. Relevant articles were selected from Embase, PsycINFO, PubMed, Cochrane, and manual searches. Studies that assessed recovery expectations as predictors of return-to-work outcomes in adults with musculoskeletal pain conditions were eligible. Data were extracted on study characteristics, recovery expectations, return-to-work outcomes, and the quantitative association between recovery expectations and return-to-work outcomes. Risk of bias was assessed using the Effective Public Health Practice Project. Odds ratios were pooled to examine the effects of recovery expectations on return-to-work outcomes. Chi-square analyses compared the predictive utility of single-item and multi-item recovery expectation scales on return-to-work outcomes. Thirty studies on a total of 28,741 individuals with musculoskeletal pain conditions were included in this review. The odds of being work disabled at follow-up were twice as high in individuals with low recovery expectations (OR = 2.06 [95% CI 1.20-2.92] P < 0.001). Analyses also revealed no significant differences in the predictive value of validated and nonvalidated single-item measures of recovery expectations on work disability (χ 2 = 1.68, P = 0.19). There is strong evidence that recovery expectations are associated with return-to-work outcomes. The results suggest that single-item measures of recovery expectations can validly be used to predict return-to-work outcomes in individuals with musculoskeletal pain conditions.

Disability and return to work after a multidisciplinary intervention for (sub)acute low back pain: A systematic review

Objective

This systematic review aimed to examine pain, functional status and return to work after a multidisciplinary intervention, with or without additional workplace intervention, for (sub)acute low back pain among adults.

Data sources

A comprehensive search was completed (November 2022) in six electronic databases (Embase, MEDLINE, Web of Science, Cochrane, CENTRAL and Scopus) and in the reference list of all identified studies.

Review methods

The search results were screened against predefined eligibility criteria by two independent researchers. Included articles were systematic reviews or randomized controlled trials examining the effect of a multidisciplinary intervention, with or without workplace intervention, in working adults with (sub)acute low back pain. Relevant information was summarized and clustered, and the methodological quality and certainty of evidence were assessed respectively using the RoB 2-tool, the ROBIS tool and the GRADE criteria.

Results

The search resulted in a total of 3020 articles. After the screening process, 12 studies remained (11 randomized controlled trials and 1 systematic review), which studied overall 2751 patients, with a follow-up period of at least 12 months.

Conclusions

A multidisciplinary intervention is favorable compared to usual care for pain intensity and functional status but this is less clear for return to work. Comparable work-related effects were found when comparing a multidisciplinary intervention with a less extensive intervention, whereas uncertainties exist regarding outcomes of pain intensity and functional status. Furthermore, adding a workplace intervention to usual care and subdividing patients based on work-related characteristics seems beneficial for return to work.

Expectations for Return to Work Predict Return to Work in Workers with Low Back Pain: An Individual Participant Data (IPD) Meta-Analysis

Purpose Low back pain is associated with disability and lost productivity due to inability of workers to return to work. Personal recovery expectation beliefs may be associated with return to work outcomes in those with low back pain at high risk for chronic disability. We aimed to (1) assess whether workers' expectations for return to work, following a low back pain episode, are associated with subsequent return to work; and (2) explore the relationships between return to work expectations and other prognostic factors in their association with work outcomes.Methods We conducted an Individual Participant Data (IPD) meta-analysis using data from five prospective cohort studies identified by a Cochrane prognostic factor review. A one-stage IPD meta-analysis approach was applied. Multi-level mixed effects models were used to determine the unadjusted and adjusted associations between expectations and return to work (logistic regression) and time to return to work (parametric survival models with Weibull distribution).Results The final dataset included 2302 participants. Positive expectations for return to work were associated with return to work at follow-up in both unadjusted (Odds Ratio (OR) 2.95; 95% Confidence Interval (CI) 2.21, 3.95) (n = 2071) and comprehensively adjusted (OR 2.01; 95% CI 1.46, 2.77) (n = 1109) models. Similar findings were identified for shorter length of time to return to work in both unadjusted (HR 2.40; 95% CI 2.09, 2.75) (n = 1156) and minimally adjusted (HR 2.43; 95% CI 2.12, 2.79) (n = 1154) models.Conclusions Results suggest workers with low expectations for return to work are at increased risk for long-term work disability.

Health screening questionnaires used in the management of mental distress acquired during an injured worker’s return to work: A scoping review

BACKGROUND: Mental distress is often endured by injured workers participating in the rehabilitation or return to work process following a physical injury. Delays in detecting the onset and treating mental distress can lead to a diverse range of cognitive and behavioural changes that may precipitate psychological distress such as anxiety, depression, and posttraumatic stress. OBJECTIVE: The objective of this scoping review was to provide an overview of existing health questionnaires utilised by health care providers and affiliated researchers. It reviewed their effectiveness and suitability to detect mental distress endured by injured workers engaged in the return to work process. METHODS: A scoping review methodology was conducted using the Arksey and O’Malley framework which examined peer-reviewed articles published between 2000 and March 2020 comprising health questionnaires. Database searches included Medline, CINAHL, EMBASE and PsycINFO combining specific MeSH terms and key words. RESULTS: The full search identified 3168 articles. Following full screening a total of 164 articles reviewed the use of health questionnaires and specific criteria to determine their suitability. Most of the health questionnaires reviewed were used as screening measures for identifying both work and non-work-related psychological hazards. However, they were found to be limited in their application when considering all potential predictors of delayed return to work such as poor or stressful interactions with stakeholders, financial stress and the injured workers experience of the RTW process. CONCLUSION: Earlier identification of mental distress using an optimal MHSQ followed by appropriate intervention will reduce the risk of psychological injury becoming cumulative on a physical workplace injury. Without such complications, early return to work can be achieved with significant cost saving to the economy.

Clinical Guidance to Optimize Work Participation After Injury or Illness: The Role of Physical Therapists

Work rehabilitation refers to the process of assisting workers to remain at work or return to work (RTW) in a safe and productive manner, while limiting the negative impact of restricted work, unemployment, and work disability. The primary purpose of this clinical practice guideline (CPG) is to systematically review available scientific evidence and provide a set of evidence-based recommendations for effective physical therapy evaluation, treatment, and management of individuals experiencing limitations in the ability to participate in work following injury or illness. J Orthop Sports Phys Ther 2021;51(8):CPG1-CPG102. doi:10.2519/jospt.2021.0303.

ANALYSIS OF MUSCLE STRENGTH EFFECTS ON EXERCISE PERFORMANCE USING DYNAMIC STABILIZATION EXERCISE DEVICE

Muscle strength may vary depending on the pathological issues and static life habits. These conditions lead to abnormal spinal loads and change muscle strength as well as activation patterns, thereby causing spinal disorders. In this study, the effects of muscle strength on the spine stabilization exercise were analyzed using a whole-body tilt device. Musculoskeletal modeling was performed and the results were validated through a comparison with the electromyography (EMG) analysis results. Based on the validated basic model, modeling was performed for the whole-body tilt device. To examine the exercise effect and muscle activation while the maximum muscle force capacity (MFC) was varied from 30[Formula: see text]N/cm2 to 60[Formula: see text]N/cm2 and 90[Formula: see text]N/cm2, the muscle force was predicted through inverse dynamics analysis. When MFC was 30[Formula: see text]N/cm2, the posterior direction of the tilt could not be analyzed (no solution found). When MFC was 60[Formula: see text]N/cm2, it could be analyzed, but the muscle force was predicted to be higher compared to when MFC was 90[Formula: see text]N/cm2. It was confirmed that muscle strength is a very important element for maintaining postural activities and performing exercise. Therefore, for rehabilitation patients and elderly people with weak muscle strength, hard or extreme exercise may cause musculoskeletal injuries.

Screening Tools to Predict the Development of Chronic Low Back Pain: An Integrative Review of the Literature

OBJECTIVE

To identify and describe available instruments that can be used to screen patients with acute or subacute low back pain for a chronic low back pain trajectory.

DESIGN

Integrative literature review.

METHODS

An electronic search of PubMed/MEDLINE, CINAHL, Cochrane Database of Systematic Reviews, and PsychINFO databases took place from May through July of 2014 using systematic search strategies to identify screening instruments developed to identify people at risk of chronic low back pain. After screening for inclusion and exclusion criteria as well as quality indicators, the identified studies were categorized based on whether the instrument measured psychological, clinical, or functional measures to predict chronic low back pain.

RESULTS

Initial searches identified 2,274 potential articles. After assessing for duplicates, title, and abstract content, there were 129 remaining articles. Articles were further excluded after analysis of the text, for a total of 42 studies reviewed. Most instruments reviewed were unable to provide evidence of predictive power for developing chronic low back pain.

CONCLUSIONS

This review identified numerous instruments developed to assess the likelihood of chronic low back pain in acute and subacute low back pain populations. Of the instruments reviewed, the STarT Back Screening Tool and the Örebro Musculoskeletal Pain Questionnaire demonstrated superior predictive power compared with other instruments. Both screening tools offer evidence of validation, translation into different languages and international application, and usage in various health care settings and provide data on predictive power.

Individual recovery expectations and prognosis of outcomes in non-specific low back pain: prognostic factor review

BACKGROUND

Low back pain is costly and disabling. Prognostic factor evidence can help healthcare providers and patients understand likely prognosis, inform the development of prediction models to identify subgroups, and may inform new treatment strategies. Recent studies have suggested that people who have poor expectations for recovery experience more back pain disability, but study results have differed.

OBJECTIVES

To synthesise evidence on the association between recovery expectations and disability outcomes in adults with low back pain, and explore sources of heterogeneity.

SEARCH METHODS

The search strategy included broad and focused electronic searches of MEDLINE, Embase, CINAHL, and PsycINFO to 12 March 2019, reference list searches of relevant reviews and included studies, and citation searches of relevant expectation measurement tools.

SELECTION CRITERIA

We included low back pain prognosis studies from any setting assessing general, self-efficacy, and treatment expectations (measured dichotomously and continuously on a 0 - 10 scale), and their association with work participation, clinically important recovery, functional limitations, or pain intensity outcomes at short (3 months), medium (6 months), long (12 months), and very long (> 16 months) follow-up.

DATA COLLECTION AND ANALYSIS

We extracted study characteristics and all reported estimates of unadjusted and adjusted associations between expectations and related outcomes. Two review authors independently assessed risks of bias using the Quality in Prognosis Studies (QUIPS) tool. We conducted narrative syntheses and meta-analyses when appropriate unadjusted or adjusted estimates were available. Two review authors independently graded and reported the overall quality of evidence.

MAIN RESULTS

We screened 4635 unique citations to include 60 studies (30,530 participants). Thirty-five studies were conducted in Europe, 21 in North America, and four in Australia. Study populations were mostly chronic (37%), from healthcare (62%) or occupational settings (26%). General expectation was the most common type of recovery expectation measured (70%); 16 studies measured more than one type of expectation. Usable data for syntheses were available for 52 studies (87% of studies; 28,885 participants). We found moderate-quality evidence that positive recovery expectations are strongly associated with better work participation (narrative synthesis: 21 studies; meta-analysis: 12 studies, 4777 participants: odds ratio (OR) 2.43, 95% confidence interval (CI) 1.64 to 3.62), and low-quality evidence for clinically important recovery outcomes (narrative synthesis: 12 studies; meta-analysis: 5 studies, 1820 participants: OR 1.89, 95% CI 1.49 to 2.41), both at follow-up times closest to 12 months, using adjusted data. The association of recovery expectations with other outcomes of interest, including functional limitations (narrative synthesis: 10 studies; meta-analysis: 3 studies, 1435 participants: OR 1.40, 95% CI 0.85 to 2.31) and pain intensity (narrative synthesis: 9 studies; meta-analysis: 3 studies, 1555 participants: OR 1.15, 95% CI 1.08 to 1.23) outcomes at follow-up times closest to 12 months using adjusted data, is less certain, achieving very low- and low-quality evidence, respectively. No studies reported statistically significant or clinically important negative associations between recovery expectations and any low back pain outcome.

AUTHORS' CONCLUSIONS

We found that individual recovery expectations are probably strongly associated with future work participation (moderate-quality evidence) and may be associated with clinically important recovery outcomes (low-quality evidence). The association of recovery expectations with other outcomes of interest is less certain. Our findings suggest that recovery expectations should be considered in future studies, to improve prognosis and management of low back pain.

Multidimensional screening for predicting pain problems in adults: a systematic review of screening tools and validation studies

Screening tools allowing to predict poor pain outcomes are widely used. Often these screening tools contain psychosocial risk factors. This review (1) identifies multidimensional screening tools that include psychosocial risk factors for the development or maintenance of pain, pain-related distress, and pain-related disability across pain problems in adults, (2) evaluates the quality of the validation studies using Prediction model Risk Of Bias ASsessment Tool (PROBAST), and (3) synthesizes methodological concerns. We identified 32 articles, across 42 study samples, validating 7 screening tools. All tools were developed in the context of musculoskeletal pain, most often back pain, and aimed to predict the maintenance of pain or pain-related disability, not pain-related distress. Although more recent studies design, conduct, analyze, and report according to best practices in prognosis research, risk of bias was most often moderate. Common methodological concerns were identified, related to participant selection (eg, mixed populations), predictors (eg, predictors were administered differently to predictors in the development study), outcomes (eg, overlap between predictors and outcomes), sample size and participant flow (eg, unknown or inappropriate handling of missing data), and analysis (eg, wide variety of performance measures). Recommendations for future research are provided.

Presenteeism as a predictor of disability pension: A prospective study among nursing professionals and care assistants in Sweden

Objectives

The aim of the present study was to examine how presenteeism affects the risk of future disability pension among nursing professionals and care assistants (assistant nurses, hospital ward assistants, home‐based personal care workers, and child care assistants). A specific objective was to compare health and social care employees with all other occupations.

Methods

The study was based on a representative sample of working women and men (n = 43 682) aged 16‐64 years, who had been interviewed between 2001 and 2013 for the Swedish Work Environment Survey conducted every second year since 1989. Information on disability pension was obtained from the Social Insurance Agency's database (2002‐2014). The studied predictors were related to disability pension using Cox's proportional hazard regression with hazard ratios (HR) and 95% confidence interval (CI) and selected confounders were controlled for. The follow‐up period was 6.7 years (SD 4.2).

Results

Health and social care employees with frequent presenteeism showed a particularly elevated risk of future disability pension after adjusting for sex, sociodemographic variables, physical and psychosocial working conditions, and self‐rated health symptoms. In the amalgamated occupational group of nursing professionals and care assistants, the impact on disability pension of having engaged in presenteeism four times or more during the prior year remained significant (HR = 3.72, 95% CI = 2.43‐5.68).

Conclusions

The study suggests that frequent presenteeism contributes to an increased risk of disability pension among nursing professionals and care assistants as well as among all other occupations.

Long-Term Effects of Psychological Symptoms after Occupational Injury on Return to Work: A 6-Year Follow-Up

Psychological factors may compromise return to work among workers with occupational injuries, and little is known about the long-term consequences of psychological symptoms relating to return to work. The study examined the impact of psychological symptoms on return to work as well as exploring factors associated with return to work among injured workers. A total of 572 workers who experienced occupational injuries were recruited in this prospective cohort study. Surveys of the psychological symptoms using the 5-item Brief Symptom Rating Scale (BSRS-5) were conducted at 3 and 12 months after the injury. All of the workers were invited to join the study at year 6 after the injury. Sociodemographic factors, psychological symptoms, injury severity, and return-to-work status were collected. Approximately 10% of injured workers could not return to work even 6 years after the injury. Severe psychological symptoms within 1 year after the injury presented a significant risk factor for not returning to work 6 years after the injury (adjusted OR = 0.7, 95% CI: 0.5⁻0.8). Furthermore, age, education level, length of hospitalization, and injury-induced changes in appearance had significant independent influence on return to work as well. These findings highlight the importance of the effects of mental health within 1 year post injury on return to work, and support the concept of early screening, detection, and intervention in at-risk occupational injured workers with severe psychological symptoms.

Psychosocial Factors Impacting Workplace Injury Rehabilitation: Evaluation of a Concise Screening Tool

Purpose To determine whether the delayed recovery often observed in simple musculoskeletal injuries occurring at work is related to poor workplace and home social support. Method A four question psychosocial screening tool called the "How are you coping gauge?" (HCG) was developed. This tool was implemented as part of the initial assessment for all new musculoskeletal workplace injuries. Participants were excluded if they did not meet the strict criteria used to classify a musculoskeletal injury as simple. The HCG score was then compared to the participant's number of days until return to full capacity (DTFC). It was hypothesised that those workers indicating a poorer level of workplace and home support would take longer time to return to full capacity. Results A sample of 254 participants (316 excluded) were included in analysis. Significant correlation (p < 0.001) was observed between HCG scores for self-reported work and home support and DTFC thereby confirming the hypothesis. Path analysis found workplace support to be a significant moderate-to-strong predictor of DTFC (-0.46). Conclusion A correlation was observed between delayed workplace injury recovery and poor perceived workplace social support. The HCG may be an effective tool for identifying these factors in musculoskeletal workplace injuries of a minor pathophysiological nature. There may be merit in tailoring injury rehabilitation towards addressing psychosocial factors early in the injury recovery process to assist with a more expedient return to full work capacity following simple acute musculoskeletal injury.

Factors associated with return to work among people on work absence due to long-term neck or back pain: a narrative systematic review

OBJECTIVE

The purpose of this narrative systematic review was to summarise prognostic factors for return to work (RTW) among people with long-term neck/shoulder or back pain.

METHODS

A systematic literature search was performed through three databases (Medline, CINAHL and PsycINFO) for studies published until February 2016. Only observational studies of people on work absence (≥2 weeks) due to neck/shoulder or back pain were included. The methodological quality of the included studies was assessed using guidelines for assessing quality in prognostic studies on the basis of Framework of Potential Biases. Factors found in the included studies were grouped into categories based on similarities and then labelled according to the aspects covered by the factors in the category.

RESULTS

Nine longitudinal prospective cohort studies and one retrospective study fulfilled the inclusion criteria. From these, five categories of factors were extracted. Our findings indicate that recovery beliefs, health-related factors and work capacity are important for RTW among people with long-term neck or back pain. We did not find support for workplace factors and behaviour being predictive of RTW.

CONCLUSIONS

Our findings suggest that recovery beliefs, perceived health and work capacity may be important targets of intervention for people with long-term neck or back pain. However, more high-quality prospective studies are needed to confirm the results and improve our understanding of what is needed to facilitate RTW in this population.

Conceptualizing the driving forces for successful rehabilitation back to work

BACKGROUND

An earlier study states that the terms of desire, longing, and vanity carry with them ideas, emotions, and values that influence how individuals perceive themselves and their rehabilitation process. Our aim was (1) to use concept analysis to explore the meaning of the terms desire, longing, and vanity and (2) to investigate the potential role of these concepts in successful rehabilitation back to work.

METHODS

To achieve these two objectives, we used a model of concept analysis. The final step in the model is to define empirical references, for example, articles within the scientific literature, to determine the existence of a concept in a given situation.

RESULTS

The concept analysis resulted in 15 new searchable terms. All of these were accepted in the thesaurus system for the databases we used. We identified 59 scientific articles that were deemed relevant to the purposes of the study. Of these, only 20 was about emotions as driving forces in a rehabilitation process back to work.

CONCLUSION

The conclusion of the study is that the concepts of desire, longing, and vanity encompassed ideas, emotions, and values that influence how individuals perceived themselves and their situations. How individuals talk about and understand rehabilitation will undoubtedly play a role in how they respond to interventions, and thus, the success of the rehabilitation process back to work. Implications for rehabilitation Emotional energy often drives behavior and can provide significant motivation that potentially can mobilize vocational rehabilitation. The concepts of desire, longing and vanity encompass ideas, emotions, and values that influence individuals' self-perception and their view of their situation. To engage people in discussions on what they long for and desire could be a new way to connect with a person in a rehabilitation situation. It can be less provoking to talk about what a person desires or longs for than to ask them what they want or are motivated for. Feelings of meaningfulness are a basic driving force and a contributing factor in how health is experienced. By affirming the desire to do activities that are liked, this in turn generates motivation to be engaged in other activities. Individual confidence is generated through the experience of mastering a skill and this in turn can underpin a desire to return to work after long-term sick leave. Earlier experience of success can be an inspiration and create expectations for a forthcoming working-role. Emotions relating to work such as pride can generate motivation in a rehabilitation process. Vanity and the possibility of being "ashamed" in a certain situation can be an emotional driving force to re-establish one's self.

The importance, measurement and practical implications of worker's expectations for return to work

PURPOSE

Workers' own expectations for return to work consistently predict work status. To advance the understanding of the relationship between RTW expectations and outcomes, we reviewed existing measures to determine those which we felt were the most likely to capture the construct.

METHOD

A comprehensive search of the work-disability rehabilitation literature was undertaken. The review of the measures was conducted in three steps: first, a review of terminology; second, an examination of whether a time reference was included; third, an evaluation of ease of comprehension, and applicability across contexts.

RESULTS

A total of 42 different measures were identified. One of the most striking findings was the inconsistency in terminology. Measures were also limited by not including a time reference. Problems were also identified with regards to ease of understanding, utility of response options, and applicability in a wide variety of research and applied settings.

CONCLUSIONS

Most previously used measures contain elements that potentially limit utility. However, it would seem that further development can overcome these, resulting in a tool that provides risk prediction information, and an opportunity to start a conversation to help identify problems that might negatively impact a worker's movement through the RTW process and the outcomes achieved. Implications for Rehabilitation Return to work is an integral part of workplace injury management. The capture of RTW expectations affords a way to identify the potential for less than optimal RTW processes and outcomes. A mismatch between an injured worker's expectations and what other stakeholders might expect suggests that efforts could be made to determine what is causing the injured worker's concerns. Once underling issues are identified, work can be put into resolving these so that the worker's return to the workplace is not impeded.

The Mediating Role of Recovery Expectancies on the Relation Between Depression and Return-to-Work

PURPOSE

Depressive symptoms have been identified as a significant risk factor for prolonged disability, however, little is known about the process by which depression impacts recovery following work-related musculoskeletal disorders (WRMDs). The primary objective of this study was to examine whether recovery expectancies mediate the relation between depression and return-to-work (RTW) status in individuals with WRMDs.

METHODS

A sample of 109 patients with WRMDs were recruited from 1 of 6 primary care physiotherapy clinics. Participants completed measures of pain severity, depression and recovery expectancies. RTW status was assessed by telephone interview 1 year after the initial assessment.

RESULTS

Consistent with previous research, more severe depressive symptoms and lower recovery expectancies were associated with a lower probability of RTW. Logistic regression analyses revealed that recovery expectancies completely mediated the relation between depression and RTW status at 1-year follow-up.

CONCLUSION

The results suggest that interventions specifically targeting recovery expectancies in individuals with WRMDs and depressive symptoms might improve RTW outcomes.

Measures of patients' expectations about recovery: a systematic review

INTRODUCTION

Patients' expectations regarding their prognosis has been shown to affect recovery. We completed a systematic review to identify measures that assess patients' expectations of recovery.

METHODS

Eligible studies explored the association between patients' expectations of recovery, and return to work or claim resolution. We searched electronic databases (MEDLINE and PSYCInfo) from inception to June 21, 2014, bibliographies of eligible studies, relevant systematic reviews and our personal files. Reviewers determined study eligibility and study quality, and completed data extraction.

RESULTS

Of 14,509 unique citations, 46 studies were eligible with majority of the studies (n = 27; 59 %) rated as low quality, primarily due to substantial missing data and inappropriate adjustment for age, gender and illness severity in their regression models. We identified 5 measures and 41 individual items assessing recovery expectations. Three of seven (43 %) studies using a measure to assess recovery expectations reported psychometric properties, with only one reporting both reliability and construct validity. Only two measures (Expectations of Recovery Scale and the Work-related Recovery Expectations Questionnaire) were externally validated in different populations. Overall, 44 (96 %) studies found that patient recovery expectations was a significant predictor of return to work or sick leave/disability claim resolution.

CONCLUSIONS

Very few studies assessing recovery expectations use a psychometrically valid measure. Current evidence suggests that patients with lower recovery expectations are less likely to resolve their disability claim or return to work versus patients with higher recovery expectations. Further validation of existing measures for assessing patient recovery expectations, or development of a new measure that addresses the limitations of existing ones, is required.

Returning to work following low back pain: towards a model of individual psychosocial factors

PURPOSE

The aim of this paper is to develop and test a model of direct and indirect relationships among individual psychosocial predictors of return-to-work (RTW) outcomes following the onset of low back pain (LBP).

METHODS

We utilize secondary analysis of a larger study of adults seeking treatment for work-related LBP with recent onset. In total, 241 participants who completed a baseline survey, a short follow-up survey, and a longer follow-up survey after 3 months were included in our analyses. The participants were required to have LBP with onset of less than 14 days, be 18 years or older, and be fluent in English or Spanish. The analyses utilized structural equation models to test the direct and indirect relationships among the variables and RTW outcomes at 3 months.

RESULTS

Our results indicated a good fit for our model (χ2 = 69.59, df = 45, p < .05; RMSEA = .05; CFI = .95; WRMR = .61). Pain, catastrophizing, fear-avoidance beliefs, organizational support, and RTW confidence were all found to have indirect relationships with the outcomes. RTW confidence and RTW expectations were found to have direct relationships with the outcomes.

CONCLUSIONS

The process of returning to work after an episode of LBP is a complex process involving many interrelated factors. Understanding the relationships among critical individual factors in the RTW process may be important for the treatment and rehabilitation of those with LBP. Results suggest that if injured workers are struggling with fear avoidance, pain catastrophizing and confidence issues, they might benefit from the application of cognitive behavioral therapy techniques.

ANALYSIS OF THE EFFECTS OF SPINE STABILIZATION EXERCISES USING A WHOLE BODY TILT DEVICE ON MUSCLE FORCES IN THE SPINE

The objective of the study was to investigate the effects of 3D stabilization exercises using a whole body tilt device on forces in the trunk, such as individual muscle forces and activation patterns, maximum muscle activities and spine loads. For this sake, a musculoskeletal (MS) model of the whole body was developed, and an inverse dynamics analysis was performed to predict the forces on the spine. An EMG measurement experiment was conducted to validate the muscle forces and activation patterns. The MS model was rotated and tilted in eight different directions: anterior (A), posterior (P), anterior right (AR), posterior right (PR), anterior left (AL), posterior left (PL), right (R) and left (L), replicating the directions of the 3D spine balance exercise device, as performed in the experiment. The anterior directions of the tilt primarily induced the activation of long and superficial back muscles and the posterior directions activated the front muscles. However, deep muscles, such as short muscles and multifidi, were activated in all directions of the tilt. The resultant joint forces in the right and left directions of the tilt were the least among the directions, but higher muscle activations and more diverse muscle recruitments than other positions were observed. Therefore, these directions of tilt may be suitable for the elderly and rehabilitation patients who require muscle strengthening with less spinal loads. In the present investigation, it was shown that 3D stabilization exercises could provide considerable muscle exercise effects with a minimum perturbation of structure. The results of this study can be used to provide safety guidelines for muscle exercises using this type of tilting device. Therefore, the proposed direction of tilt can be used to strengthen targeted muscles, depending on the patients' muscular condition.

Topics and trends in research on non-clinical interventions aimed at preventing prolonged work disability in workers compensated for work-related musculoskeletal disorders (WRMSDs): a systematic, comprehensive literature review

PURPOSE

This study sought to provide an overview of the main topics and trends in contemporary research on successful non-clinical interventions for preventing prolonged work disability in workers compensated for work-related musculoskeletal disorders (WRMSDs).

METHODS

A systematic electronic search (English and French) was performed in ten scientific databases using keywords and descriptors. After screening the identified titles and abstracts using specific sets of criteria, categorical and thematic analyses were performed on the retained articles.

RESULTS

Five main topics appear to dominate the research: (1) risk factors and determinants; (2) effectiveness of interventions (programmes, specific components, strategies and policies); (3) viewpoints, experiences and perceptions of specific actors involved in the intervention process; (4) compensation issues; and (5) measurement issues. A currently widespread trend is early screening to identify risks factors for appropriate intervention and multidisciplinary, multimodal approaches. Morover, workplace-related psychosocial and ergonomic factors are considered vital to the success and sustainability of return-to-work (RTW) interventions. Finally, involving workplace actors, and more specifically, affected workers, in the RTW process appears to be a powerful force in improving the chances of moving workers away from disabled status.

CONCLUSIONS

The findings of this literature review provide with information about the main topics and trends in research on rehabilitation interventions, revealing some successful modalities of intervention aimed at preventing prolonged work disability.

IMPLICATIONS FOR REHABILITATION

Successful intervention for preventing prolonged work disability in workers compensated for WRMSDs address workplace issues: physical and psychosocial demands at work, ability of the workers to fill these demands, work organization and support of the worker, and worker' beliefs and attitudes related to work. Successful intervention promotes collaboration, coordination between all actors and stakeholders involved in the process of rehabilitation. Strategies able to mobilize the employees, employers, insurers and health care providers are still needed to be implemented.

Return-to-work according to impairment type among occupationally injured workers in Korea

This study examined the association between return-to-work and impairment type. Database of the Korea Workers' Compensation and Welfare Service was used to identify disabled persons; and return-to-work information was obtained from the Korea Employment Information Services database. The study participants were 79,328 persons who received Workers' compensation and who were confirmed as disabled during 2009-2011. Logistic regression was used to analyze the association between return-to-work and impairment type, adjusted by age, sex, impairment severity, pre-injury businesses size, and pre-injury occupational category. Compared to injuries of the upper limbs, the odds ratio of return-to-work was 0.63 (95% CI, 0.60-0.65) for injuries involving the lower limbs, 0.62 (95% CI, 0.59-0.66) for the spine, 0.75 (95% CI, 0.66-0.86) for the eyes, 0.98 (95% CI, 0.77-1.25) for the oral cavity, 0.44 (95% CI, 0.37-0.53) for the ears, 1.02 (95% CI, 0.83-1.25) for the figure, 0.75 (95% CI, 0.72-0.79) for pain, and 0.36 (95% CI, 0.32-0.41) for neuropsychiatric impairment. These findings indicate that impairment type influences return-to-work rates.

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.

The impact of psychological symptoms on return to work in workers after occupational injury

INTRODUCTION

This study aimed to investigate the impact of psychological symptoms on return to work (RTW) in workers after occupational injuries.

METHODS

Our study candidates were injured workers who were hospitalized for 3 days or longer and received hospitalization benefits from the Labor Insurance. A self-reported questionnaire including Brief Symptom Rating Scale (BSRS-50) and RTW was sent to workers at 12 weeks after injury. At 1 year, all participants were contacted again to determine whether or not they had RTW.

RESULTS

A total of 2001 workers completed the questionnaire (response rate 45.5 %) at 12 weeks after injury, among them, 1,149 had returned to work. Among the 852 who were unable to return to work at 12 weeks after injury, 225 reportedly returned to work by 1 year. A proportional hazards regression indicated that after adjusting for all possible risk factors, higher scores in BSRS-50 and BSRS-5 at 12 weeks after injury were significant risk factors for not return to work (NRTW) at 1 year after injury. Other risk factors were gender, education level, length of hospitalization, affected physical appearance, and injury type. Among 10 psycho-physiological symptoms of BSRS-50, a proportional hazards regression indicated that high score in phobic-anxiety scale was a risk factor for NRTW.

CONCLUSIONS

After considering all other factors, psychological symptoms further predicted poorer probability of returning to work after occupational injury, and phobic-anxiety was the most significant symptom predicting poor RTW. Development of preventive measures among injured workers according to the risk factors identified in this study is warranted.

Self perceptions as predictors for return to work 2 years after rehabilitation in orthopedic trauma inpatients

PURPOSE

This study aimed to identify self-perception variables which may predict return to work (RTW) in orthopedic trauma patients 2 years after rehabilitation.

METHODS

A prospective cohort investigated 1,207 orthopedic trauma inpatients, hospitalised in rehabilitation, clinics at admission, discharge, and 2 years after discharge. Information on potential predictors was obtained from self administered questionnaires. Multiple logistic regression models were applied.

RESULTS

In the final model, a higher likelihood of RTW was predicted by: better general health and lower pain at admission; health and pain improvements during hospitalisation; lower impact of event (IES-R) avoidance behaviour score; higher IES-R hyperarousal score, higher SF-36 mental score and low perceived severity of the injury.

CONCLUSION

RTW is not only predicted by perceived health, pain and severity of the accident at the beginning of a rehabilitation program, but also by the changes in pain and health perceptions observed during hospitalisation.

Expectations about recovery from acute non-specific low back pain predict absence from usual work due to chronic low back pain: a systematic review

QUESTION

Do negative expectations in patients after the onset of acute low back pain increase the odds of absence from usual work due to progression to chronic low back pain?

DESIGN

Systematic review with meta-analysis of prospective inception cohort studies.

PARTICIPANTS

Adults with acute or subacute non-specific low back pain.

OUTCOME MEASURE

Absence from usual work at a given time point greater than 12 weeks after the onset of pain due to ongoing pain.

RESULTS

Ten studies involving 4683 participants were included in the review. Participants with acute or subacute pain and negative expectations about their recovery had significantly greater odds of being absent from usual work at a given time point more than 12 weeks after the onset of pain: OR 2.17 (95% CI 1.61 to 2.91). The exclusion of five studies with the greatest risk of bias showed that the result was similar when more rigorous quality criteria were applied: OR 2.52 (95% CI 1.47 to 4.31).

CONCLUSION

The odds that adults with acute or subacute non-specific low back pain and negative recovery expectations will remain absent from work due to progression to chronic low back pain are two times greater than for those with more positive expectations. These results were consistent across the included studies despite variations in the risk of bias.

Predictors of sickness absence in patients with a new episode of low back pain in primary care

This study examines predictors of sickness absence in patients presenting to a health practitioner with acute/ subacute low back pain (LBP). Aims of this study were to identify baseline-variables that detect patients with a new LBP episode at risk of sickness absence and to identify prognostic models for sickness absence at different time points after initial presentation. Prospective cohort study investigating 310 patients presenting to a health practitioner with a new episode of LBP at baseline, three-, six-, twelve-week and six-month follow-up, addressing work-related, psychological and biomedical factors. Multivariate logistic regression analysis was performed to identify baseline-predictors of sickness absence at different time points. Prognostic models comprised 'job control', 'depression' and 'functional limitation' as predictive baseline-factors of sickness absence at three and six-week follow-up with 'job control' being the best single predictor (OR 0.47; 95%CI 0.26-0.87). The six-week model explained 47% of variance of sickness absence at six-week follow-up (p<0.001). The prediction of sickness absence beyond six-weeks is limited, and health practitioners should re-assess patients at six weeks, especially if they have previously been identified as at risk of sickness absence. This would allow timely intervention with measures designed to reduce the likelihood of prolonged sickness absence.

Absenteeism screening questionnaire (ASQ): a new tool for predicting long-term absenteeism among workers with low back pain

INTRODUCTION

Over the last decades, psychosocial factors were identified by many studies as significant predictive variables in the development of disability related to common low back disorders, which thus contributed to the development of biopsychosocial prevention interventions. Biopsychosocial interventions were supposed to be more effective than usual interventions in improving different outcomes. Unfortunately, most of these interventions show inconclusive results. The use of screening questionnaires was proposed as a solution to improve their efficacy. The aim of this study was to validate a new screening questionnaire to identify workers at risk of being absent from work for more than 182 cumulative days and who are more susceptible to benefit from prevention interventions.

METHODS

Injured workers receiving income replacement benefits from the Quebec Compensation Board (n = 535) completed a 67-item questionnaire in the sub-acute stage of pain and provided information about work-related events 6 and 12 months later. Reliability and validity of the 67-item questionnaire were determined respectively by test-retest reliability and internal consistency analysis, as well as by construct validity analyses. The Cox regression model and the maximum likelihood method were used to fix a model allowing calculation of a probability of absence of more than 182 days. Criterion validity and discriminative capacity of this model were calculated.

RESULTS

Sub-sections from the 67-item questionnaire were moderately to highly correlated 2 weeks later (r = 0.52-0.80) and showed moderate to good internal consistency (0.70-0.94). Among the 67-item questionnaire, six sub-sections and variables (22 items) were predictive of long-term absence from work: fear-avoidance beliefs related to work, return to work expectations, annual family income before-taxes, last level of education attained, work schedule and work concerns. The area under the ROC curve was 73%.

CONCLUSIONS

The significant predictive variables of long-term absence from work were dominated by workplace conditions and individual perceptions about work. In association with individual psychosocial variables, these variables could contribute to identify potentially useful prevention interventions and to reduce the significant costs associated with LBP long-term absenteeism.

The role of presurgical expectancies in predicting pain and function one year following total knee arthroplasty

The present study examined the prospective value of response expectancies (ie, pain, sleep) and behavioral outcome expectancies (ie, return to function) in the prediction of pain severity and functional limitations 12 months after total knee arthroplasty (TKA). The study sample consisted of 120 individuals (73 women, 47 men) with osteoarthritis of the knee who were scheduled for TKA. Measures of expectancies, pain severity, pain catastrophizing, pain-related fears of movement, and depression were completed prior to surgery. Participants also completed measures of pain severity and functional limitations 12 months following surgery. Analyses revealed that behavioral outcome expectancies were stronger predictors of follow-up pain and functional limitations than response expectancies. Consistent with previous research, analyses also revealed that pain catastrophizing, pain-related fear of movement, and depression predicted follow-up pain and function. In a multivariate analysis, only pain catastrophizing contributed significant unique variance to the prediction of follow-up pain and function. Behavioral outcome expectancies partially mediated the relation between catastrophizing and follow-up pain and function. The relation between catastrophizing and follow-up pain severity and functional limitations remained significant even when controlling for behavioral outcome expectancies. The results suggest that interventions designed to specifically target behavioral outcome expectancies and catastrophizing might improve post-surgical outcomes.

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.

Psychosocial risk factors for chronic low back pain in primary care--a systematic review

BACKGROUND

Low back pain (LBP) is a major public health problem, often encountered in primary care. Guidelines recommend early identification of psychosocial factors that could prevent recovery from acute LBP.

METHODS

To review the evidence on the prognostic value of psychosocial factors on transition from acute to chronic non-specific LBP in the adult general population. Systematic review is the design of the study. A systematic search was undertaken for prospective studies dealing with psychosocial risk factors for poor outcome of LBP in primary care, screening PubMed, PsychInfo and Cochrane Library databases. The methodological quality of studies was assessed independently by two reviewers using standardized criteria before analysing their main results.

RESULTS

Twenty-three papers fulfilled the inclusion criteria, covering 18 different cohorts. Sixteen psychosocial factors were analysed in three domains: social and socio-occupational, psychological and cognitive and behavioural. Depression, psychological distress, passive coping strategies and fear-avoidance beliefs were sometimes found to be independently linked with poor outcome, whereas most social and socio-occupational factors were not. The predictive ability of a patient's self-perceived general health at baseline was difficult to interpret because of biomedical confounding factors. The initial patient's or care provider's perceived risk of persistence of LBP was the factor that was most consistently linked with actual outcome.

CONCLUSION

Few independent psychosocial risk factors have been demonstrated to exist. Randomized clinical trials aimed at modifying these factors have shown little impact on patient prognosis. Qualitative research might be valuable to explore further the field of LBP and to define new management strategies.

Individual expectation: an overlooked, but pertinent, factor in the treatment of individuals experiencing musculoskeletal pain

Physical therapists consider many factors in the treatment of patients with musculoskeletal pain. The current literature suggests expectation is an influential component of clinical outcomes related to musculoskeletal pain for which physical therapists frequently do not account. The purpose of this clinical perspective is to highlight the potential role of expectation in the clinical outcomes associated with the rehabilitation of individuals experiencing musculoskeletal pain. The discussion focuses on the definition and measurement of expectation, the relationship between expectation and outcomes related to musculoskeletal pain conditions, the mechanisms through which expectation may alter musculoskeletal pain conditions, and suggested ways in which clinicians may integrate the current literature regarding expectation into clinical practice.

Fatigue in older adults: an early indicator of the aging process?

The aim of this paper is to give an overview of research on fatigue in older adults, with a focus on fatigue as an early indicator of the aging process. Fatigue is a strong predictor of functional limitations, disability, mortality, and other adverse outcomes in young-old and old-old populations, between men and women, and in different geographic localities. Several biological, physiological and social explanations are proposed: fatigue may be seen not only as a self-reported indicator of frailty, defined as a physiologic state of increased vulnerability to stressors, which results from decreased physiologic reserves and even dysregulation of multiple physiologic systems, but also this state may be accelerated because of the cumulative impact of social, mental and biological factors throughout life.

Waddell's symptoms as correlates of vulnerabilities associated with fear-anxiety-avoidance models of pain: pain-related anxiety, catastrophic thinking, perceived disability, and treatment outcome

INTRODUCTION

Fear-anxiety-avoidance models of chronic pain emphasize psychological constructs as key vulnerabilities for the development and maintenance of disabling chronic pain. Complementarily, Waddell described physical signs and symptoms thought inconsistent with anatomic and pathologic disease patterns that might function as indications of pain-related psychological distress. Research has not supported using Waddell's signs due to low inter-rater reliability and limited associations with psychological distress; however, these findings are equivocal. Similarly, theorists have suggested that endorsement of Waddell's symptoms may indicate psychological distress; however, the precedent research has not included the psychological constructs described in fear-anxiety-avoidance models as vulnerability factors for the development and maintenance of chronic pain.

METHODS

Participants for the current study were patients (n = 68; 35% women) with chronic low back pain involved in a multi-disciplinary work-hardening program provided by a third-party insurer. Patients endorsing more than two of Waddell's symptoms were compared with those who did not on demographic variables as well as established self-report psychological measures, measures of perceived disability, functional capacity, and treatment outcome.

RESULTS

Patients endorsing more than two of Waddell's symptoms reported higher levels of depressive symptoms, pain-related anxiety, fear, catastrophizing, and pain intensity. Unexpectedly, there were no significant differences in functional capacity. Similar differences were found between those who did and did not return to work.

CONCLUSIONS

While Waddell's symptoms must still be interpreted judiciously, they may provide much needed cross-disciplinary utility as indicators that more detailed psychological assessment is warranted. Comprehensive implications and directions for future research are discussed.

Predictors for successful vocational rehabilitation for clients with back pain problems

PURPOSE

The aim of this study was to identify predicting factors for successful vocational rehabilitation for people with back pain problems.

METHOD

The study was based on data from 347 long-term sick-listed clients collected at the onset of vocational rehabilitation. The outcome was measured 6 months after the conclusion of rehabilitation.

RESULTS

In a first bi-variate analysis, a considerable number of variables were associated with the rehabilitation outcome. In a second multivariate analysis, only four associations remained. These were age, general health, vitality and internal locus of control. Young vital clients in good general health, with a high internal locus of control were more likely than others to return to work.

CONCLUSION

The findings regarding age, general health and vitality are well in line with previous studies. The findings regarding internal locus of control are more unique.

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

The objective of the study was to provide an inventory of predictive instruments and their constituting parameters associated with return to work in patients with subacute (2-10 weeks pain duration) and chronic (10-24 weeks pain duration) non-specific low back pain (NSLBP). Data sources included systematic review in Medline, Embase, Cinahl, Central, PEDro, Psyndex, PsychInfo/PsycLit, and Sociofile up to September 2008, in reference lists of systematic reviews on risk factors, and of included studies. For the systematic review, two reviewers independently assessed study eligibility and quality, and extracted data. Disagreements were resolved by consensus. Risk factors were inventorised and grouped into a somatic and psychosocial domain. 23 studies reporting on subacute and 16 studies reporting on chronic patients were included. The studies on subacute patients reported on a total of 56 biomedical factors out of which 35 (63%) were modifiable and 61 psychosocial factors out of which 51 (84%) were modifiable. The corresponding values in studies on chronic patients were 44 biomedical [27 (62%) modifiable] and 61 [40 (66%) modifiable] respectively. Our data suggest that the interdisciplinary approach in patients at risk to develop persistent NSLBP is justified in both, the subacute and chronic disease stages. Psychosocial interventions might be more effective in subacute stages since a higher proportion of modifiable risk factors were identified in that group.

The Back Disability Risk Questionnaire for work-related, acute back pain: prediction of unresolved problems at 3-month follow-up

OBJECTIVE

To assess the validity of the Back Disability Risk Questionnaire (BDRQ) to predict developing chronic back disability.

METHODS

Five hundred nineteen working adults (67% male) seeking outpatient care for acute, work-related back pain (<or=14 days) completed the BDRQ. After the initial medical evaluation, clinicians provided prognostic impressions in a 10-item questionnaire. Pain, functional limitation, and work status were assessed at 3-month follow-up.

RESULTS

In multivariate analyses, the presence of persistent pain, functional limitation, or impaired work status (31.4%) was predicted by six BDRQ questions: injury type, work absence preceding medical evaluation, job tenure, prior back surgery, worries about re-injury, expectation for early return-to-work, and stress. Classification accuracy at 3 months was 76.3%. Initial clinician impressions showed no multivariate associations with outcomes.

CONCLUSIONS

The BDRQ may provide prognostic information not observed in a routine medical evaluation for acute BP.

Waddell's symptoms as indicators of psychological distress, perceived disability, and treatment outcome

INTRODUCTION

Waddell's signs and symptoms have been described as patient presentations not within usual anatomic patterns of injury pathology. Waddell's signs were thought to indicate psychological distress and were termed "non-organic findings"; similarly, Waddell's symptoms were described as inappropriate and attributable to psychological features. Endorsement of more than two of Waddell's symptoms is thought to be associated with psychological distress, disability, and poor treatment outcomes; however, this has not been empirically assessed.

METHODS

The current study used a sample of patients (n = 108; 30% women) involved in a multi-disciplinary work hardening program provided by a third-party insurer. Patients who endorsed more than two of Waddell's symptoms were compared with those who did not on demographic variables as well as self-report measures of psychological distress, disability, and treatment outcome.

RESULTS

Patients who endorsed more than two of Waddell's symptoms reported higher levels of psychological distress, perceived disability, pain intensity, and pain durations. Moreover, consistent with previous research on Waddell's symptoms, patients endorsing more than two symptoms were also less likely to return to work.

CONCLUSIONS

Waddell's symptoms were associated with increased perceived disability and pervasive pain interference. Patients who endorsed more than two symptoms were significantly less likely to return to work than those who endorsed zero, one, or two symptoms. Patients who endorsed more than two symptoms may indeed be affected by factors beyond tissue pathology that nonetheless warrant clinical attention. Waddell's symptoms appear to have promise as a quick indicator of treatment complexity and outcome.