Health care and indemnity costs across the natural history of disability in occupational low back pain

Refining the design of a smartphone application for people with chronic low back pain using mixed quantitative and qualitative approaches

INTRODUCTION

A mobile application has the potential to involve people with chronic NSLBP in their rehabilitation. To refine the design of a smartphone application for people with chronic NSLBP using mixed quantitative and qualitative approaches.

METHODS

We used a user-centred design approach involving people with chronic NSLBP and healthcare professionals (HCPs). We used a three-step methodology: developing consensus on the features, content, and design of the app; developing a user interface; and usability testing of the app and assessing users' experience. Transcripts of interviews of users were analyzed by qualitative content analysis.

RESULTS

A total of 18 people (aged 45 [23-53] years old) with chronic NSLBP, and 7 HCPs (aged 29.5 [25-55] years old) involved in NSLBP management were interviewed. The overall experience of using the smartphone eLombactif app was initially assessed. Then, with close-ended questions we evaluated users' judgements on the content, its presentation and navigation. Finally, we asked for suggestions: "application content and functionality" and "content presentation" from participants regarding the use and development of the app analyzed by a qualitative methodology.

CONCLUSIONS

This study described how we refined the design of our application for people with chronic NSLBP using a qualitative and quantitative approaches. This methodology allows for deepening the knowledge of the needs and expectations of potential users by measuring their user experience.IMPLICATIONS FOR REHABILITATIONNon-specific low back pain (NSLBP) is a major global public health issue leading to considerable economic cost and is primarily responsible for pain and disability.Mobile application has the potential to involve people with chronic NSLBP in their rehabilitation.This study described how we refined the design of our application for people with chronic NSLBP using a qualitative and quantitative approaches.

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.

Methodological considerations in the assessment of direct and indirect costs of back pain: A systematic scoping review

Background

Back pain is a common and costly health problem worldwide. There is yet a lack of consistent methodologies to estimate the economic burden of back pain to society.

Objective

To systematically evaluate the methodologies used in the published cost of illness (COI) literature for estimating the direct and indirect costs attributed to back pain, and to present a summary of the estimated cost burden.

Methods

Six electronic databases were searched to identify COI studies of back pain published in English up to February 2021. A total of 1,588 abstracts were screened, and 55 full-text studies were subsequently reviewed. After applying the inclusion criteria, 45 studies pertaining to the direct and indirect costs of back pain were analysed.

Results

The studies reported data on 15 industrialised countries. The national cost estimates of back pain in 2015 USD ranged from $259 million ($29.1 per capita) in Sweden to $71.6 billion ($868.4 per capita) in Germany. There was high heterogeneity among the studies in terms of the methodologies used for analysis and the resulting costs reported. Most of the studies assessed costs from a societal perspective (n = 29). The magnitude and accuracy of the reported costs were influenced by the case definition of back pain, the source of data used, the cost components included and the analysis method. Among the studies that provided both direct and indirect cost estimates (n = 15), indirect costs resulting from lost or reduced work productivity far outweighed the direct costs.

Conclusion

Back pain imposes substantial economic burden on society. This review demonstrated that existing published COI studies of back pain used heterogeneous approaches reflecting a lack of consensus on methodology. A standardised methodological approach is required to increase credibility of the findings of COI studies and improve comparison of estimates across studies.

Intra-rater reliability of measurement of abdominal perimuscular connective tissue thickness on ultrasound images

[Purpose] The thickness of the perimuscular connective tissue (PMCT) reflects muscular atrophy and decreased flexibility that may cause low back pain. However, few studies have used ultrasound imaging to measure PMCT thickness. We aimed to examine and confirm the reliability of ultrasound in measuring the thickness of the PMCT of the abdominal wall muscle. [Participants and Methods] The participants were 38 healthy adult males without chronic back pain. The images were acquired in B mode with the participants in the supine position and the PMCT thickness of the abdominal wall muscle was measured on the images. The intraclass correlation coefficient (ICC) was used to confirm reliability. [Results] The ICC for both within-day and between-day PMCT measurements by ultrasound were 0.7–0.9. The 95% confidence interval ranged from 0.5–0.9. The standard error of measurement (SEM) was 0.02–0.1 mm in the abdominal wall muscle and 0.5 mm in the interrecti distance (IRD). The 95% confidence interval (95% CI) of the minimum detectable change (MDC95) was 0.1–0.3 mm in the abdominal wall muscle and 1.3–1.4 mm in the IRD. [Conclusion] We conducted a study to confirm the reliability of ultrasound-based measurement of PMCT thickness of the abdominal wall muscle, and the ICC results established reliability. However, since the values measured were small (0.02–1.4 mm) and there is a limit to visual observation, it was necessary to measure using computer software.

Cost-effectiveness analysis of chronic mechanical back pain treatment modalities

Objectives

This study aims to evaluate and compare the cost-effectiveness of inpatient physical therapy, outpatient physical therapy applications, and back school education in low back pain (LBP) treatment.

Patients and methods

Between March 2011 and September 2011, a total of 105 patients (43 males, 62 females; mean age 44.8±12.7 years; range, 27 to 58 years) who were treated for chronic LBP were included in this prospective study. Of the patients, 34 received inpatient physical therapy consisting of electrotherapy, superficial-deep heat application, and basic back exercise program, 35 received the same treatment in the outpatient setting, and 36 received back school education. Each patient was evaluated five times during the study using pain intensity Visual Analog Scale (VAS), spinal mobility measurements (inclinometer), general evaluation (VAS), functional disability measurement (Roland-Morris Disability Questionnaire [RMDQ]), and quality of life (Short Form-36 [SF-36]). All expenses and costs for treatment of LBP were estimated.

Results

At the end of six months of follow-up, all study groups had a statistically significant improvement in all variables. Improvements in spinal mobility, RMDQ, and SF-36 scores were significantly higher in the inpatient physical therapy group (p<0.001). Direct and total costs were the highest in the inpatient treatment group and were the lowest in the back school education group (p<0.001). No statistically significant differences were observed in terms of additional cost of one-unit improvement in these variables among the study groups.

Conclusion

Our study results suggest that all three treatment modalities are effective in chronic LBP. In patients with LBP-related impairment in functional status and quality of life, inpatient physical therapy and rehabilitation should be preferred.

The feasibility and impact of instrument-assisted manual therapy (IAMT) for the lower back on the structural and functional properties of the lumbar area in female soccer players: a randomised, placebo-controlled pilot study design

BACKGROUND

Myofascial (self-)treatments, such as foam rollers to therapeutic instruments in manual therapy, are utilized increasingly in prevention and therapy in healthy people, athletes, and patients suffering from chronic back pain. However, there is limited knowledge about the effectiveness of treatment and the underlying mechanisms of myofascial therapies, especially for instrument-assisted manual therapy (IAMT). Therefore, this pilot study will investigate the feasibility and impact of IAMT for the lumbar area compared with heat application and placebo treatment as a basis for calculating the sample size for further full studies. The primary outcomes will be a critical analysis of the feasibility of the measurement protocol in terms of time economy and expressiveness and of the short- and long-term effects on shear motion of the single tissue layers of the lower back obtained through ultrasound imaging. Secondary outcomes will include thickness and compressibility of the lumbar structures and flexibility of the dorsal structures, indentometry, and superficial skin temperature.

METHODS

A minimum of 60 healthy, competitive 15-35-year-old female soccer players will be recruited and randomised into three groups. Short-term effects of IAMT on thoracolumbar structures will be compared with heat application and pressure-less placebo treatment. Long-term effects in the IAMT group will be tested after nine further interventions over a 5-week period (2×/week) and compared with the placebo group, which will not receive further treatments but will serve as a control. Intermediate and final testing of both groups will occur in weeks three and five.

DISCUSSION

This pilot study will assess the feasibility and the impact of IAMT for the lower back particularly by examining the structural and functional properties of myofascial tissue using diagnostic ultrasound. These outcomes could evaluate the feasibility of the measurements used, shall build a basis for sample size calculation of further full studies, and might generate a greater understanding of myofascial therapies, especially IAMT, for the lower back and its benefits. If this approach proves to be practicable, next steps will be further full studies with soccer players, other sports, and patients with low back pain.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS00012252) 20.06.2018; retrospectively registered.

Early Return to Work Has Benefits for Relief of Back Pain and Functional Recovery After Controlling for Multiple Confounds

OBJECTIVE

The aim of the study was to evaluate the effect on health outcomes of an early or immediate return-to-work (RTW) after acute low back pain (LBP).

METHODS

A longitudinal cohort of workers (N = 557) consulting for uncomplicated LBP were assessed on demographic, pain, occupational, and psychosocial variables. Pain and function were assessed at 3-month postpain onset. We tested the longitudinal effects of an early RTW on 3-month outcomes.

RESULTS

Pain and function improved more rapidly for workers with an immediate (30.7%) or early (1 to 7 days) RTW (36.8%). Eleven demographic, health, or workplace variables were identified as potential confounds, but controlling for these factors only partially attenuated the benefits of an early RTW.

CONCLUSIONS

An early RTW improves acute LBP and functional recovery, and alternate confounding explanations only partially eclipse this therapeutic effect.

Quebec Serve and Protect Low Back Pain Study: A Web-based Cross-sectional Investigation of Prevalence and Functional Impact Among Police Officers

STUDY DESIGN

Web-based cross-sectional study.

OBJECTIVE

The aim of this study was to describe the prevalence and the burden of low back pain (LBP) and chronic low back pain (CLBP) among Quebec police officers.

SUMMARY OF BACKGROUND DATA

Police officers have work-related factors associated with LBP, but chronicity and impacts of this condition have been little explored among this population.

METHODS

Between May and October 2014, a web-based cross-sectional study was conducted among police officers working in the province of Quebec (Canada). Nine police organizations accepted to disseminate the email invitation to their members. The survey included the French-Canadian version of the Nordic Musculoskeletal Questionnaire and other items regarding functional impact of LBP and associated treatments.

RESULTS

A total of 3589 police officers completed the questionnaire. Mean age was 38.5 ± 8.7 years, 32.0% were women, and 67.4% reported being car-patrol officers. A majority reported LBP symptoms in the past 12 months (67.7%) and 96.5% of them perceived that presence of LBP was totally/partially linked to their work in the police force. Prevalence of CLBP among all responders was 28.7%. Police officers reporting CLBP, as compared to those reporting acute or subacute LBP symptoms in the past 12 months, were more likely to report LBP-related reduction of work activities (64.4% vs. 45.7%; P < 0.001) and more working days lost in the past 12 months (average of 11.9 ± 43.5 vs. 1.5 ± 9.8; P < 0.001). A greater proportion also reported LBP-related health care visits in the past 12 months (86.2% vs. 64.2%; P < 0.001) and current use of pain medications/complementary alternative medicines (90.1% vs. 69.7%; P < 0.001).

CONCLUSION

CLBP is a frequent and burdensome condition among Quebec police officers. Our results underline the importance for police organizations to promote CLBP prevention and to implement workplace management programs.

LEVEL OF EVIDENCE

3.

Towards a preventive strategy for complaints of arm, neck and/or shoulder (CANS): the role of help seeking behaviour

Background

When developing an effective early preventive strategy for employees and students with CANS (Complaints of Arm, Neck or Shoulder, not caused by acute trauma or systemic disease), insight in help seeking behaviour and knowledge of factors associated with help seeking behaviour within the target population, is a prerequisite. The aim of this study was to examine whether perceived hindrance is associated with help seeking behaviour, specifically in employees and students identified with CANS. Additionally, the associations of factors related to functioning and participation, work-environment and demographics with help seeking behaviour were explored in these groups.

Methods

A cross-sectional survey was conducted among employees and students of two universities in the South of the Netherlands. The questionnaire included questions to assess (1) demographics, work/study and activity related factors (2) experience of CANS (3) perceived hindrance (4) help seeking behaviour. A subpopulation of the survey, consisting of those employees and students with self-reported CANS, received additional questionnaires to examine the impact of (1) participant characteristics (2) complaint and health related variables (3) functioning and participation (4) work-environment and social support, on help seeking behaviour.

Results

37.3% of the employees and 41.4% of the students reported CANS. Of these, respectively 43.3% and 45.5%, did not seek help and had no intention to seek help either. Employees and students who had not sought help reported less hindrance, less perceived disabilities and shorter duration of complaints, compared those who did seek help. Employees and students within this group who had also no intention to seek help, perceived fewer disabilities and reported shorter duration of complaints.

Conclusion

The absence of help seeking behaviour in respondents with CANS is a bottleneck for implementation of preventive strategies. In employees and students with CANS, help seeking behaviour is primarily determined by factors related to experienced hindrance. Our findings emphasize the need to tailor preventive strategies, in order to optimize screening and participation in early interventions for CANS.

Testing a path-analytic mediation model of how motivational enhancement physiotherapy improves physical functioning in pain patients

PURPOSE

Pain is a complex phenomenon not easily discerned from psychological, social, and environmental characteristics and is an oft cited barrier to return to work for people experiencing low back pain (LBP). The purpose of this study was to evaluate a path-analytic mediation model to examine how motivational enhancement physiotherapy, which incorporates tenets of motivational interviewing, improves physical functioning of patients with chronic LBP.

METHODS

Seventy-six patients with chronic LBP were recruited from the outpatient physiotherapy department of a government hospital in Hong Kong.

RESULTS

The re-specified path-analytic model fit the data very well, χ (2)(3, N = 76) = 3.86, p = .57; comparative fit index = 1.00; and the root mean square error of approximation = 0.00. Specifically, results indicated that (a) using motivational interviewing techniques in physiotherapy was associated with increased working alliance with patients, (b) working alliance increased patients' outcome expectancy and (c) greater outcome expectancy resulted in a reduction of subjective pain intensity and improvement in physical functioning. Change in pain intensity also directly influenced improvement in physical functioning.

CONCLUSIONS

The effect of motivational enhancement therapy on physical functioning can be explained by social-cognitive factors such as motivation, outcome expectancy, and working alliance. The use of motivational interviewing techniques to increase outcome expectancy of patients and improve working alliance could further strengthen the impact of physiotherapy on rehabilitation outcomes of patients with chronic LBP.

Frequency and cost of claims by injury type from a state workers' compensation fund from 1998 through 2008

OBJECTIVE

To determine which work-related injuries are the most frequent and costly.

DESIGN

Secondary analysis of workers' compensation claims data.

SETTING

Data were provided by a large, Maryland workers' compensation insurer from 1998 through 2008.

PARTICIPANTS

Not applicable.

INTERVENTIONS

None.

MAIN OUTCOMES MEASURES

For 45 injury types, the number of claims and compensation amount was calculated for total compensation and for medical and indemnity compensation separately.

RESULTS

Back and knee injuries were the most frequently occurring single injury types, whereas heart attack and occupational disease were the most expensive in terms of mean compensation. When taking into account both the frequency and cost of injury (mean cost × number occurrences), back, knee, and shoulder injuries were the most expensive single injury types.

CONCLUSIONS

Successful prevention and management of back, knee, and shoulder injuries could lead to a substantial reduction in the burden associated with work-related injuries.

Do minimally invasive procedures have a place in the treatment of chronic low back pain?

Chronic low back pain is the leading cause of disability in the industrialized world. Medical and surgical treatments remain costly despite limited efficacy. The field of 'interventional pain' has grown enormously and evidence-based practice guidelines are systematically developed. In this article, the vast, complex and contradictory literature regarding the treatment of chronic low back pain is reviewed. Interventional pain literature suggests that there is moderate evidence (small randomized, nonrandomized, single group or matched-case controlled studies) for medial branch neurotomy and limited evidence (nonexperimental one or more center studies) for intradiscal treatments in mechanical low back pain. There is moderate evidence for the use of transforaminal epidural steroid injections, lumbar percutaneous adhesiolysis and spinal endoscopy for painful lumbar radiculopathy, and spinal cord stimulation and intrathecal pumps mostly after spinal surgery. In reality, there is no gold standard for the treatment of chronic low back pain, but these results appear promising.

Early predictors of lumbar spine surgery after occupational back injury: results from a prospective study of workers in Washington State

STUDY DESIGN

Prospective population-based cohort study.

OBJECTIVE

To identify early predictors of lumbar spine surgery within 3 years after occupational back injury.

SUMMARY OF BACKGROUND DATA

Back injuries are the most prevalent occupational injury in the United States. Few prospective studies have examined early predictors of spine surgery after work-related back injury.

METHODS

Using Disability Risk Identification Study Cohort (D-RISC) data, we examined the early predictors of lumbar spine surgery within 3 years among Washington State workers, with new workers compensation temporary total disability claims for back injuries. Baseline measures included worker-reported measures obtained approximately 3 weeks after claim submission. We used medical bill data to determine whether participants underwent surgery, covered by the claim, within 3 years. Baseline predictors (P < 0.10) of surgery in bivariate analyses were included in a multivariate logistic regression model predicting lumbar spine surgery. The area under the receiver operating characteristic curve of the model was used to determine the model's ability to identify correctly workers who underwent surgery.

RESULTS

In the D-RISC sample of 1885 workers, 174 (9.2%) had a lumbar spine surgery within 3 years. Baseline variables associated with surgery (P < 0.05) in the multivariate model included higher Roland-Morris Disability Questionnaire scores, greater injury severity, and surgeon as first provider seen for the injury. Reduced odds of surgery were observed for those younger than 35 years, females, Hispanics, and those whose first provider was a chiropractor. Approximately 42.7% of workers who first saw a surgeon had surgery, in contrast to only 1.5% of those who saw a chiropractor. The area under the receiver operating characteristic curve of the multivariate model was 0.93 (95% confidence interval, 0.92-0.95), indicating excellent ability to discriminate between workers who would versus would not have surgery.

CONCLUSION

Baseline variables in multiple domains predicted lumbar spine surgery. There was a very strong association between surgery and first provider seen for the injury even after adjustment for other important variables.

Multi-faceted case management: reducing compensation costs of musculoskeletal work injuries in Australia

OBJECTIVES

This study aimed to determine whether a multi-faceted model of management of work related musculoskeletal disorders reduced compensation claim costs and days of compensation for injured workers.

METHODS

An intervention including early reporting, employee centred case management and removal of barriers to return to work was instituted in 16 selected companies with a combined remuneration over $337 million. Outcomes were evaluated by an administrative dataset from the Victorian WorkCover Authority database. A 'quasi experimental' pre-post design was employed with 492 matched companies without the intervention used as a control group and an average of 21 months of post-intervention follow-up. Primary outcomes were average number of days of compensation and average cost of claims. Secondary outcomes were total medical costs and weekly benefits paid.

RESULTS

Information on 3,312 claims was analysed. In companies where the intervention was introduced the average cost of claims was reduced from $6,019 to $3,913 (estimated difference $2,329, 95 % CI $1,318-$3,340) and the number of days of compensation decreased from 33.5 to 14.1 (HR 0.77, 95 % CI 0.67-0.88). Medical costs and weekly benefits costs were also lower after the intervention (p < 0.05). Reduction in claims costs were noted across industry types, injury location and most employer sizes.

CONCLUSIONS

The model of claims management investigated was effective in reducing the number of days of compensation, total claim costs, total medical costs and the amount paid in weekly benefits. Further research should investigate whether the intervention improves non-financial outcomes in the return to work process.

Determinants of sickness absence duration after an occupational back injury in the Belgian population

BACKGROUND

This study aimed at assessing factors associated to the duration of sickness absence after a back injury in the Belgian working population, with a special emphasis on cultural factors.

METHODS

The data were retrieved from the Belgian Fund for Work Accidents database over a 3-year period (2001-2003). The population source involved all Belgian workers under a job contract in the private sector registered as compensated cases for an accident that occurred at the workplace (n = 558,276). From that database, all back injury cases involving a complete data set and registered during the first 6 months of each year (n = 11,262) were selected and eight factors (gender, age, seniority in the current job, job category, accident regional location, enterprise size, sector of activity, and accident circumstances) were analyzed in relation to the outcome variable, sick leave duration recorded as ordered time intervals between 0 and 183-366 days.

RESULTS

Sick leave duration was strongly associated in a multivariate model to age (≥40 years: OR = 2.18), blue-collar job (1.55), work in building industry (1.32), and enterprise size (>100: 0.85), and to a less extent to seniority (>10y: 0.88), and circumstance of accident (falls: 1.26). Injuries occurring in the French-speaking part of the country were associated to a longer sick leave (1.07; P = 0.034).

CONCLUSIONS

This study shows that besides well-known risk factors, subtle cultural language-linked factors and/or regional differences in economic climate may significantly influence the length of disability period after a back injury.

Design of a trial-based economic evaluation on the cost-effectiveness of employability interventions among work disabled employees or employees at risk of work disability: the CASE-study

BACKGROUND

In the Netherlands, absenteeism and reduced productivity due to work disability lead to high yearly costs reaching almost 5% of the gross national product. To reduce the economic burden of sick leave and reduced productivity, different employability interventions for work-disabled employees or employees at risk of work disability have been developed. Within this study, called 'CASE-study' (Cost-effectiveness Analysis of Sustainable Employability), five different employability interventions directed at work disabled employees with divergent health complaints will be analysed on their effectiveness and cost-effectiveness. This paper describes a consistent and transparent methodological design to do so.

METHODS/DESIGN

Per employability intervention 142 participants are needed whereof approximately 66 participants receiving the intervention will be compared with 66 participants receiving usual care. Based on the intervention-specific characteristics, a randomized control trial or a quasi-experiment with match-criteria will be conducted. Notwithstanding the study design, eligible participants will be employees aged 18 to 63, working at least 12 h per week, and at risk of work disability, or already work-disabled due to medical restrictions. The primary outcome will be the duration of sick leave. Secondary outcomes are health status and quality of life. Outcomes will be assessed at baseline and then 6, 12 and 18 months later. Economic costs will consist of healthcare costs and cost of lost production due to work disability, and will be evaluated from a societal perspective.

DISCUSSION

The CASE-study is the first to conduct economic evaluations of multiple different employability interventions based on a similar methodological framework. The cost-effectiveness results for every employability intervention will be published in 2014, but the methods, strengths and weaknesses of the study protocol are discussed in this paper. To contribute to treatment options in occupational health practice and enable the development of guidelines on how to conduct economic evaluation better suited to this field; this paper provides an important first step.

TRIAL REGISTRATION

Four trials involved in the CASE-study are registered with the Netherlands Trial Registry: Care for Work (NTR2886), Health and Motion (NTR3111), Guidance to Excel in Return to Work (NTR3151), Care for Companies/Second Care (NTR3136).

Fear-avoidance beliefs and pain coping strategies in relation to lower back problems in a South African steel industry

The objective was to determine the association between the prevalence of lower back problems (LBP), fear-avoidance beliefs and pain coping strategies using an analytical cross-sectional epidemiological study among a group of 366 workers in a South African stainless steel industry. Outcome (LBP) was defined using a questionnaire and a functional rating index. Exposure to psychosocial risk was determined using the Fear-Avoidance Beliefs (FABQ) and Coping Strategies (CSQ) questionnaires. Multivariate logistic regression analyses for LBP indicated the following significant risk factors: work-related fear-avoidance beliefs (OR 3.40; 95% CI 2.20-5.25), catastrophizing (1.31; 1.01-1.7) and pain coping self statements (1.47; 1.16-1.87). Significant protective associations were found for increased activity levels (OR 0.57; 95% CI 0.42-0.78). These findings have utility in preventative screening procedures to identify workers with such beliefs and coping strategies who are at risk for prolonged work restrictions.

Colorado workers' compensation: medical vs chiropractic costs for the treatment of low back pain

OBJECTIVE

Low back disorders (LBDs) are the most common complaint among workers; therefore, many questions arise about cost-effective treatment approaches. This investigation evaluated the differences in cost-related factors among a population of patients selecting chiropractic vs allopathic care for the treatment of nonspecific LBDs. The study hypothesis was that chiropractic care would be more cost-effective or equivalent to allopathic care for the noncomplicated LBDs.

METHODS

Cases were extracted from an insurance company database of patients reporting work-related low back injuries who were treated with either chiropractic or allopathic approaches. Cases were matched using the International Classification of Diseases, Ninth Revision, codes 722 (intervertebral disk disorders), 724 (other and unspecified disorders of the back), and 847 (sprains and strains of other and unspecified parts). The data set included 76 chiropractic cases and 2386 medical cases.

RESULTS

The total amount paid by the insurance company was 1.7 times higher for patients treated by doctors of chiropractic (DCs) compared with those treated by medical doctors (MDs), and the cost of clinical treatment was 3.3 times higher for the DCs than MDs.

CONCLUSION

The cost for treatment by DCs was greater than that of MDs for similarly classified conditions affecting the low back. The amount paid by the insurance company was primarily related to the number of services given by each provider.

Prevention and management of work disability in Asia Pacific: challenges and opportunities

INTRODUCTION

The economic growth in Asia Pacific brings with it challenges and opportunities in many areas of work and health. As economies grow and work demands increase so do accidents, injures and work disability.

METHODS

Burns, chemical exposures, and construction related injuries are often catastrophic in severity and lead to work disability, major acute medical and subsequent rehabilitation efforts. In addition to these acute injuries, musculoskeletal and chronic illnesses are also sources of work disability.

RESULTS

Industrial injuries and health problems are often explained and managed based on the classic unidimensional hazard prevention model. In contrast, work disability is a multi-factorial problem and requires more complex conceptualizations than an exposure outcome model. The economic impact of disability, limitations of the widely used impairment based disability determination method, lack of adherence to wide scale implementation of evidence based clinical approaches, the need for meaningful stakeholder involvement and the potential of a multivariable view of work disability, in all aspects of work disability prevention, management and policy are discussed in the context of Asia Pacific economic growth.

CONCLUSIONS

With ideal alignment of diverse goals and incentives along with consideration of past efforts in disability prevention and management, new models, processes and policies can be created as commerce in these countries continues to grow.

Factorial structure of the Pain Rehabilitation Expectations Scale: a preliminary study

The aim of this study was to report the preliminary validation results for the Pain Rehabilitation Expectations Scale (PRES). The PRES is a clinical tool developed to measure the expectations about rehabilitation treatment and outcome for people with back pain. Fifty people with chronic back pain were recruited from 11 physiotherapy outpatient clinics in Hong Kong for this study. Multitrait scaling analysis indicated that the three subscales of the PRES (working alliance, proxy efficacy, and motivation/expectation) were internally consistent, with Cronbach's alpha reliability coefficients ranging from 0.93 to 0.96. Proxy efficacy was found to be related to working alliance, and working alliance was positively related to client motivation and expectations. The preliminary psychometric analysis results suggested that the PRES could potentially be used to measure chronic pain patients' expectations about pain rehabilitation treatments. However, this study is based on a very small sample size; psychometric validation of the PRES with a larger sample of chronic pain patients to confirm the measurement structure of the PRES using confirmatory factor analysis is warranted.

Ultrasound evidence of altered lumbar connective tissue structure in human subjects with chronic low back pain

BACKGROUND

Although the connective tissues forming the fascial planes of the back have been hypothesized to play a role in the pathogenesis of chronic low back pain (LBP), there have been no previous studies quantitatively evaluating connective tissue structure in this condition. The goal of this study was to perform an ultrasound-based comparison of perimuscular connective tissue structure in the lumbar region in a group of human subjects with chronic or recurrent LBP for more than 12 months, compared with a group of subjects without LBP.

METHODS

In each of 107 human subjects (60 with LBP and 47 without LBP), parasagittal ultrasound images were acquired bilaterally centered on a point 2 cm lateral to the midpoint of the L2-3 interspinous ligament. The outcome measures based on these images were subcutaneous and perimuscular connective tissue thickness and echogenicity measured by ultrasound.

RESULTS

There were no significant differences in age, sex, body mass index (BMI) or activity levels between LBP and No-LBP groups. Perimuscular thickness and echogenicity were not correlated with age but were positively correlated with BMI. The LBP group had approximately 25% greater perimuscular thickness and echogenicity compared with the No-LBP group (ANCOVA adjusted for BMI, p<0.01 and p<0.001 respectively).

CONCLUSION

This is the first report of abnormal connective tissue structure in the lumbar region in a group of subjects with chronic or recurrent LBP. This finding was not attributable to differences in age, sex, BMI or activity level between groups. Possible causes include genetic factors, abnormal movement patterns and chronic inflammation.

Cord blood--an alternative source for bone regeneration

Bone regeneration is one of the best investigated pathways in mesenchymal stromal cell (MSC) biology. Therefore strong efforts have been made to introduce tissue engineering and cell therapeutics as an alternative treatment option for patients with bone defects. This review of the literature gives an overview of MSC biology aiming for clinical application including advantages but also specific challenges and problems which are associated with cord blood derived stromal cell (CB-MSC) as a source for bone regeneration. The use of postnatal CB-MSC is ethically uncomplicated and requires no invasive harvesting procedure. Moreover, most data document a high osteogenic potential of CB-MCS and also low immunoreactivity compared with other MSC types. The expression profile of CB-MSC during osteogenic differentiation shows similarities to that of other MSC types. Within the umbilical cord different MSC types have been characterized which are potent to differentiate into osteoblasts. In contrast to a large number of in vitro investigations there are only few in vivo studies available so far.

Estimating investment worthiness of an ergonomic intervention for preventing low back pain from a firm's perspective

A mathematical model was developed for estimating the net present value (NPV) of the cash flow resulting from an investment in an intervention to prevent occupational low back pain (LBP). It combines biomechanics, epidemiology, and finance to give an integrated tool for a firm to use to estimate the investment worthiness of an intervention based on a biomechanical analysis of working postures and hand loads. The model can be used by an ergonomist to estimate the investment worthiness of a proposed intervention. The analysis would begin with a biomechanical evaluation of the current job design and post-intervention job. Economic factors such as hourly labor cost, overhead, workers' compensation costs of LBP claims, and discount rate are combined with the biomechanical analysis to estimate the investment worthiness of the proposed intervention. While this model is limited to low back pain, the simulation framework could be applied to other musculoskeletal disorders. The model uses Monte Carlo simulation to compute the statistical distribution of NPV, and it uses a discrete event simulation paradigm based on four states: (1) working and no history of lost time due to LBP, (2) working and history of lost time due to LBP, (3) lost time due to LBP, and (4) leave job. Probabilities of transitions are based on an extensive review of the epidemiologic review of the low back pain literature. An example is presented.

Back pain recurrence: an evaluation of existing indicators and direction for future research

STUDY DESIGN

Literature review.

OBJECTIVE

To present a framework for future analyses of back pain recurrence and explore the applicability and relevance of existing recurrence indicators.

SUMMARY OF BACKGROUND DATA

Empirical studies of back pain have included a variety of indicators of recurrence, resulting in a range of findings about recurrence rates and associated factors. Little is known about the relationships between existing indicators.

METHODS

Literature overview, expert panel, and workshop discussion at the IX International Forum on Primary Care Research on Low Back Pain.

RESULTS

Using the International Classification of Functioning, Disability, and Health (ICF), disabling back pain was conceptualized as a health condition, i.e., back pain disorder (BPD), and BPD recurrence was conceptualized as involving a return of atypical back pain and/or back-pain-related difficulty performing tasks and actions related to the initial episode. Using the ICF, 2 types of recurrence indicators were identified: those directly describing components of BPD and those indirectly doing so (e.g., recurrence of health care utilization).

CONCLUSION

In light of the difficulty in measuring BPD recurrence, transparent definitions and a clear understanding of the implications of using particular indicators is required. Future research should focus: on examining the capture BPD recurrence by various research instruments, improving understanding of the relationship between indicators, and gaining insight into how individuals experiencing BPD view recurrence.

Physical therapy utilization in subjects with work-related musculoskeletal disorders: Taiwan experience

INTRODUCTION

This study aimed to investigate the use of physical therapy (PT) services by subjects with work-related musculoskeletal disorders (WMSDs) and to identify factors associated with long-term use of PT in Taiwan.

METHODS

Data including demographic characteristics, work history, pain and disability ratings, and psychosocial status were collected by questionnaire. Subjects who were referred to PT were interviewed weekly by telephone to obtain information about use of PT.

RESULTS

A total of 160 subjects participated in this study. Of these, 85 subjects (53.1%) did not receive PT. Of the 75 subjects who received PT, 53 (70.7%) received short-term treatment (<30 days) and 22 (29.3%) received long-term treatment (> or =30 days). The number of treatment sessions for the treatment groups was 7.8 sessions +/- 9.0. Logistic regression analysis identified age (odds ratio [OR] = 1.074, P = 0.007) and the subject's confidence that the disorder would be diagnosed as an occupational injury ("yes" and "not sure" vs. "no"; OR = 4.288, P = 0.012) as significant factors affecting the duration of treatment.

CONCLUSIONS

Almost 30% of the subjects referred to PT received long-term treatment (> or =30 days), the significant factors affecting this classification were subject's age and confidence in a diagnosis of WMSD.

ISSLS prize winner: early predictors of chronic work disability: a prospective, population-based study of workers with back injuries

STUDY DESIGN

Prospective population-based cohort study.

OBJECTIVE

To identify early predictors of chronic work disability after work-related back injury.

SUMMARY OF BACKGROUND DATA

Identification of early predictors of prolonged disability after back injury could increase understanding concerning the development of chronic, disabling pain, and aid in secondary prevention. Few studies have examined predictors across multiple domains in a large, population-based sample.

METHODS

Workers (N = 1885) were interviewed 3 weeks (average) after submitting a lost work-time claim for a back injury. Sociodemographic, employment-related, pain and function, clinical, health care, administrative/legal, health behavior, and psychological domain variables were assessed via worker interviews, medical records, and administrative databases. Logistic regression analyses identified early predictors of work disability compensation 1 year after claim submission.

RESULTS

Significant baseline predictors of 1-year work disability in the final multidomain model were injury severity (rated from medical records), specialty of the first health care provider seen for the injury (obtained from administrative data), and worker-reported physical disability (Roland-Morris disability questionnaire), number of pain sites, "very hectic" job, no offer of a job accommodation (e.g., light duty), and previous injury involving a month or more off work. The model showed excellent ability to discriminate between workers who were/were not disabled at 1 year (area under the receiver operating characteristic curve = 0.88, 95% CI = 0.86-0.90).

CONCLUSION

Among workers with new lost work-time back injury claims, risk factors for chronic disability include radiculopathy, substantial functional disability, and to a lesser extent, more widespread pain and previous injury with extended time off work. The roles of employers and health care providers also seem important, supporting the need to incorporate factors external to the worker in models of the development of chronic disability and in disability prevention efforts.

Screening questionnaire Balansmeter proved successful in predicting future long-term sickness absence in office workers

OBJECTIVE

To develop and validate a screening instrument to identify employees at high risk for future long-term sickness absence.

STUDY DESIGN AND SETTING

The instrument was developed (n=5,601) and internally validated (n=3,383) through data analyses of the Maastricht Cohort Study, among a group of office workers not absent from work. External validation was performed in a cohort of 3,895 bank employees.

RESULTS

The screening instrument, Balansmeter, captures 34 questions on demographics, work environment, private situation, (mental) health, and sickness absence history. The Balansmeter showed good predictive values for future sickness absence (>28 days) in men (internal validation relative risk [RR] 4.69 [95% confidence interval (CI): 2.74, 8.02]; external validation RR 3.90 [95% CI: 2.35, 6.45]) and women (internal validation RR 4.16 [95% CI: 2.05, 8.43]; external validation RR 2.62 [95% CI: 1.44, 4.77]).

CONCLUSION

It is possible to predict future sickness absence. The Balansmeter can be considered a valuable screening instrument.

Structured early consultation with the occupational physician reduces sickness absence among office workers at high risk for long-term sickness absence: a randomized controlled trial

OBJECTIVE

To examine the efficacy of structured early consultation among employees at high risk for future long-term sickness absence, in the prevention and/or reduction of sickness absence. The focus of the experiment was the timing of the intervention, that is, treatment before sickness absence actually occurs.

METHODS

In the current prospective randomized controlled trial (RCT), employees at high risk for long-term sickness absence were selected based on responses to a 34-item screening questionnaire including demographic, workplace, health and psychosocial factors associated with long-term sickness absence (>28 days). A total of 299 subjects at risk for future long-term sickness absence were randomized in an experimental group (n = 147) or in a control group (n = 152). Subjects in the experimental group received a structured early consult with their occupational physician (OP), in some cases followed by targeted intervention. The control group received care as usual. Sickness absence was assessed objectively through record linkage with the company registers on sickness absence over a 1 year follow-up period.

RESULTS

Modified intention-to-treat analysis revealed substantial and statistically significant differences (p = 0.007) in total sickness absence duration over 1 year follow-up between the experimental (mean 18.98; SD 29.50) and control group (mean 31.13; SD 55.47). Per-protocol analysis additionally showed that the proportion of long-term sickness absence spells (>28 days) over 1 year follow-up was significantly (p = 0.048) lower in the experimental (9.1%) versus control group (18.3%).

CONCLUSIONS

Structured early consultation with the OP among employees at high risk for future long-term sickness absence is successful in reducing total sickness absence.

Timing makes a difference: early nurse case management intervention and low back pain

PURPOSE OF STUDY

* To examine whether early nurse contacts influenced workers' satisfaction with their nurse case management, their healthcare, and the way the firm was treating their injury.* To examine whether early nurse contacts influenced self-reported measures of back pain and returns to work.

PRIMARY PRACTICE SETTING(S)

Workers with low back pain resulting in workers' compensation claims.

METHODOLOGY AND SAMPLE

To quantify the influence of nurse case management on workers' satisfaction with their treatment by the firm and their healthcare provider, as well return to work, we follow 747 Marriott workers with incident episodes of low back pain in a prospective analysis. Predictors of outcomes include demographics, injury severity, and the timing of nurse case manager and work supervisor contacts.

RESULTS

While early contacts do not have much impact on satisfaction with the treatment by the healthcare provider, early nurse case management contacts improve worker satisfaction with the firm's treatment of their claim, increasing satisfaction by 0.5 standard deviations (on a 4-point scale). The change in odds ratio with respect to a contact during the first week after injury is 8, indicating a 50-percentage point increase in the likelihood of continual employment.

IMPLICATIONS FOR CM PRACTICE

*Among workers with low back pain, early nurse case management contacts improved workers' satisfaction with their healthcare provider and their treatment by the firm.* Contacts made during the first week after the injury were most valuable, but in our sample it did not matter when during that first week the contact was made (as long as it was within the first week).* Early nurse case management contacts substantially improved the odds of continual employment, dominating the influence of age, job satisfaction, and the expectation of a good recovery.

Patterns of sick-leave and health outcomes in injured workers with back pain

Little is known about the sick-leave experiences of workers who make a workers' compensation claim for back pain. Our objective is to describe the 1-year patterns of sick-leave and the health outcomes of a cohort of workers who make a workers' compensation claim for back pain. We studied a cohort of 1,831 workers from five large US firms who made incident workers' compensation claims for back pain between January 1, 1999 and June 30, 2002. Injured workers were interviewed 1 month (n = 1,321), 6 months (n = 810) and 1 year (n = 462) following the onset of their pain. We described the course of back pain using four patterns of sick-leave: (1) no sick-leave, (2) returned to worked and stayed, (3) multiple episodes of sick-leave and (4) not yet returned to work. We described the health outcomes as back and/or leg pain intensity, functional limitations and health-related quality of life. We analyzed data from participants who completed all follow-up interviews (n = 457) to compute the probabilities of transition between patterns of sick-leave. A significant proportion of workers experienced multiple episodes of sick-leave (30.2%; 95% CI 25.0-35.1) during the 1-year follow-up. The proportion of workers who did not report sick-leave declined from 42.4% (95% CI 39.0-46.1) at 1 month to 33.6% (28.0-38.7) at 1 year. One year after the injury, 2.9% (1.6-4.9) of workers had not yet returned to work. Workers who did not report sick-leave and those who returned and stayed at work reported better health outcomes than workers who experienced multiple episodes of sick-leave or workers who had not returned to work. Almost a third of workers with an incident episode of back pain experience recurrent spells of work absenteeism during the following year. Our data suggest that stable patterns of sick-leave are associated with better health.

The effect of loading rate and degeneration on neutral region motion in human cadaveric lumbar motion segments

BACKGROUND

The quasistatic neutral zone is a surrogate for neutral region stiffness of spinal motion segments. No similar measure of dynamic stiffness has been validated. Because parameters related to stiffness are likely to be affected by loading rate and disc degeneration, we examined the effect of those factors on motion parameters derived from continuous motion data.

METHODS

Fifteen human lumbar motion segments were tested with continuous flexion-extension pure moments at 0.5, 3.0 and 6.0 degrees /s. Range of motion, width of the hysteresis loop, transitional zone width, and slopes of the upper and lower arms of the hysteresis loop within the transitional zone were measured. Discs were then graded for degeneration.

FINDINGS

As the loading rate increased from 0.5 degrees /s to 6.0 degrees /s there were significant increases in range of motion, hysteresis area, hysteresis loop width, and the upper and lower transitional zone slopes. At the same time transitional zone width decreased significantly. Degeneration had a significant effect on all parameters except hysteresis loop width. The transition zone slopes appeared to best discriminate between normal and degenerative discs.

INTERPRETATION

Loading rate had a significant effect on all parameters. As degeneration increased consistent effects were observed indicating decreasing stiffness from grade 1 to grade 3 then slightly increased stiffness in grade 4 specimens. The slopes of the transitional zone have potential to be a useful measure of neutral region stiffness during dynamic motion testing.

A systematic review of low back pain cost of illness studies in the United States and internationally

BACKGROUND CONTEXT

The economic burden of low back pain (LBP) is very large and appears to be growing. It is not possible to impact this burden without understanding the strengths and weaknesses of the research on which these costs are calculated.

PURPOSE

To conduct a systematic review of LBP cost of illness studies in the United States and internationally.

STUDY DESIGN/SETTING

Systematic review of the literature.

METHODS

Medline was searched to uncover studies about the direct or indirect costs of LBP published in English from 1997 to 2007. Data extracted for each eligible study included study design, population, definition of LBP, methods of estimating costs, year of data, and estimates of direct, indirect, or total costs. Results were synthesized descriptively.

RESULTS

The search yielded 147 studies, of which 21 were deemed relevant; 4 other studies and 2 additional abstracts were found by searching reference lists, bringing the total to 27 relevant studies. The studies reported on data from Australia, Belgium, Japan, Korea, the Netherlands, Sweden, the UK, and the United States. Nine studies estimated direct costs only, nine indirect costs only, and nine both direct and indirect costs, from a societal (n=18) or private insurer (n=9) perspective. Methodology used to derive both direct and indirect cost estimates differed markedly among the studies. Among studies providing a breakdown on direct costs, the largest proportion of direct medical costs for LBP was spent on physical therapy (17%) and inpatient services (17%), followed by pharmacy (13%) and primary care (13%). Among studies providing estimates of total costs, indirect costs resulting from lost work productivity represented a majority of overall costs associated with LBP. Three studies reported that estimates with the friction period approach were 56% lower than with the human capital approach.

CONCLUSIONS

Several studies have attempted to estimate the direct, indirect, or total costs associated with LBP in various countries using heterogeneous methodology. Estimates of the economic costs in different countries vary greatly depending on study methodology but by any standards must be considered a substantial burden on society. This review did not identify any studies estimating the total costs of LBP in the United States from a societal perspective. Such studies may be helpful in determining appropriate allocation of health-care resources devoted to this condition.

Models of return to work for musculoskeletal disorders

BACKGROUND

Musculoskeletal pain disorders are the most prevalent, costly, disabling, and commonly researched conditions in the workplace, yet the development of overarching conceptual models of return to work (RTW) in these conditions has been lagging.

METHOD

A critical review of the literature was performed using multiple medical and health search engines in order to provide an evaluation of the evolution and the state of the art of health and disability models with a focus on specific models of RTW.

RESULTS

The main tenets, implications for diagnosis, treatment, and disability compensation, are the key perspectives analyzed for the following specific models of RTW: biomedical, psychosocial, forensic, ecological/case management, biopsychosocial, and two more recent models developed by the Institute of Medicine and the World Health Organization, respectively.

CONCLUSIONS

Future development of models that are truly transdisciplinary, and address temporal and multidimensional aspects of occupational disability, remains a goal.

Pathophysiological model for chronic low back pain integrating connective tissue and nervous system mechanisms

Although chronic low back pain (cLBP) is increasingly recognized as a complex syndrome with multifactorial etiology, the pathogenic mechanisms leading to the development of chronic pain in this condition remain poorly understood. This article presents a new, testable pathophysiological model integrating connective tissue plasticity mechanisms with several well-developed areas of research on cLBP (pain psychology, postural control, neuroplasticity). We hypothesize that pain-related fear leads to a cycle of decreased movement, connective tissue remodeling, inflammation, nervous system sensitization and further decreased mobility. In addition to providing a new, testable framework for future mechanistic studies of cLBP, the integration of connective tissue and nervous system plasticity into the model will potentially illuminate the mechanisms of a variety of treatments that may reverse these abnormalities by applying mechanical forces to soft tissues (e.g. physical therapy, massage, chiropractic manipulation, acupuncture), by changing specific movement patterns (e.g. movement therapies, yoga) or more generally by increasing activity levels (e.g. recreational exercise). Non-invasive measures of connective tissue remodeling may eventually become important tools to evaluate and follow patients with cLBP in research and clinical practice. An integrative mechanistic model incorporating behavioral and structural aspects of cLBP will strengthen the rationale for a multidisciplinary treatment approach including direct mechanical tissue stimulation, movement reeducation, psychosocial intervention and pharmacological treatment to address this common and debilitating condition.

Intervertebral Disc Regeneration Using Platelet-Rich Plasma and Biodegradable Gelatin Hydrogel Microspheres

This study evaluated the regenerative effects of platelet-rich plasma (PRP) for the degenerated intervertebral disc (IVD) in vivo. After induction of IVD degeneration in rabbits, we prepared PRP by centrifuging blood obtained from these rabbits. These PRP were injected into the nucleus pulposus (NP) of the degenerated IVDs after impregnation into gelatin hydrogel microspheres that can immobilize PRP growth factors physiochemically and release them in a sustained manner with the degradation of the microspheres. As controls, microspheres impregnated with phosphate-buffered saline (PBS) and PRP without microspheres were similarly injected. Histologically, notable progress in IVD degeneration with time courses was observed in the PBS control, PRP-only, and sham groups. In contrast, progress was remarkably suppressed over the 8-week period in the PRP group. Moreover, in immunohistochemistry, intense immunostaining for proteoglycan in the NP and inner layer of the annulus fibrosus was observed 8 weeks after administration of PRP-impregnated microspheres. Almost all microspheres were indistinct 8 weeks after the injection, and there were no apparent side effects in this study. Our results suggest that the combined administration of PRP and gelatin hydrogel microspheres into the IVD may be a promising therapeutic modality for IVD degeneration.

Substantial sick-leave costs savings due to a graded activity intervention for workers with non-specific sub-acute low back pain

The objective of this study is to compare the costs and benefits of a graded activity (GA) intervention to usual care (UC) for sick-listed workers with non-specific low back pain (LBP). The study is a single-blind, randomized controlled trial with 3-year follow-up. A total of 134 (126 men and 8 women) predominantly blue-collar workers, sick-listed due to LBP were recruited and randomly assigned to either GA (N = 67; mean age 39 +/- 9 years) or to UC (N = 67; mean age 37 +/- 8 years). The main outcome measures were the costs of health care utilization during the first follow-up year and the costs of productivity loss during the second and the third follow-up year. At the end of the first follow-up year an average investment for the GA intervention of 475 euros per worker, only 83 euros more than health care utilization costs in UC group, yielded an average savings of at least 999 euros (95% CI: -1,073; 3,115) due to a reduction in productivity loss. The potential cumulative savings were an average of 1,661 euros (95% CI: -4,154; 6,913) per worker over a 3-year follow-up period. It may be concluded that the GA intervention for non-specific LBP is a cost-beneficial return-to-work intervention.