Guiding low back claimants to work: a randomized controlled trial

Fostering Stay at Work After a Period of Disability: A Scoping Review of Occupational Rehabilitation Strategies to Support Workers in the Adoption of Preventive Behaviours

PURPOSE

Based on the theoretical framework of the Model of Preventive Behaviours at Work, the aim of this study was to describe the the occupational rehabilitation strategies the literature reports that support workers who have suffered an occupational injury in adopting preventive behaviours.

METHODS

To conduct this scoping review, we used a systematic methodology in 7 steps : (1) definition of the research question and inclusion/exclusion criteria; (2) scientific and gray literature search; (3) determination of manuscripts' eligibility; (4) extraction and charting of information; (5) quality assessment; (6) interpretation; and (7) knowledge synthesis.

RESULTS

We selected 46 manuscripts of various types (e.g. randomized trials, qualitative studies, governmental documents). Manuscripts were mainly of good or high quality according to our quality assessment. The strategies for coaching, engaging, educating and collaborating were mostly reported in the literature to support the development of the six preventive behaviours during occupational rehabilitation. The results also suggest that heterogeneity exists regarding the specificity of the strategies reported in the literature, which may have hindered our ability to provide rich and detailed descriptions. Literature also mainly describes individually oriented behaviours and reports strategies requiring a low level of worker involvement, which represent issues to adress in future researh projects.

CONCLUSION

The strategies described in this article reprensent concrete levers that occupational rehabilitation professionals can use to support workers in the adoption of preventive behaviours at work on return from having suffered an occupational injury.

Determining what constitutes an effective psychosocial 'return to work' intervention: a systematic review and narrative synthesis

PURPOSE

Work can offer a myriad of social and health benefits. Long-term sick leave can be detrimental to employers, individuals, families, and societies. The burden of long-term sick leave has motivated the development of return to work (RTW) interventions. This study sought to determine what constitutes an effective psychosocial RTW intervention, which included exploring whether the level of intervention intensity and intervention characteristics matter to RTW outcomes.

METHODS

A systematic review and narrative synthesis were undertaken. Studies were identified through six databases (Ovid Medline, CINAHL (EBSCOhost), PsycInfo (Ovid), ProQuest, Scopus, and Google Scholar) between 2011 and 3 September 2019. Randomised controlled trials (RCTs) or reviews published in English were eligible for inclusion if they targeted adults who were on sick leave/unemployed trying to return to full-capacity employment, had at least one structured psychosocial RTW intervention, and assessed RTW. Study quality was assessed using checklists from the Joanna Briggs Institute.

RESULTS

Database searching yielded 12,311 records. Eighteen RCTs (comprising 42 intervention/comparison groups), seven reviews (comprising 153 studies), and five grey literature documents were included. Included studies were of moderate-to-high quality. Research was primarily conducted in Europe and focused on psychological or musculoskeletal problems. RTW outcomes included RTW status, time until RTW, insurance claims, and sick days. Participating in a RTW program was superior to care-as-usual. RTW outcomes were similar between diverse interventions of low, moderate, and high intensity. Common foundational characteristics seen across effective RTW interventions included a focus on RTW, psychoeducation, and behavioural activation.

CONCLUSIONS

Evidence suggests that a low intensity approach to RTW interventions may be an appropriate first option before investment in high intensity, and arguably more expensive interventions, as the latter appear to provide limited additional benefit. More high-quality RCTs, from diverse countries, are needed to provide stronger evidence.

Interventions for the Management of Acute and Chronic Low Back Pain: Revision 2021

Low back pain (LBP) remains a musculoskeletal condition with an adverse societal impact. Globally, LBP is highly prevalent and a leading cause of disability. This is an update to the 2012 Academy of Orthopaedic Physical Therapy (AOPT), formerly the Orthopaedic Section of the American Physical Therapy Association (APTA), clinical practice guideline (CPG) for LBP. The overall objective of this update was to provide recommendations on interventions delivered by physical therapists or studied in care settings that included physical therapy providers. It also focused on synthesizing new evidence, with the purpose of making recommendations for specific nonpharmacologic treatments. J Orthop Sports Phys Ther 2021;51(11):CPG1-CPG60. doi:10.2519/jospt.2021.0304.

Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of low back pain

BACKGROUND CONTEXT

The North American Spine Society's (NASS) Evidence Based Clinical Guideline for the Diagnosis and Treatment of Low Back Pain features evidence-based recommendations for diagnosing and treating adult patients with nonspecific low back pain. The guideline is intended to reflect contemporary treatment concepts for nonspecific low back pain as reflected in the highest quality clinical literature available on this subject as of February 2016.

PURPOSE

The purpose of the guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for adult patients with nonspecific low back pain. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition.

STUDY DESIGN

This is a guideline summary review.

METHODS

This guideline is the product of the Low Back Pain Work Group of NASS' Evidence-Based Clinical Guideline Development Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questions to address in the guideline. The literature search strategy was developed in consultation with medical librarians. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members utilized NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in webcasts and in-person recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guideline was submitted to an internal and external peer review process and ultimately approved by the NASS Board of Directors.

RESULTS

Eighty-two clinical questions were addressed, and the answers are summarized in this article. The respective recommendations were graded according to the levels of evidence of the supporting literature.

CONCLUSIONS

The evidence-based clinical guideline has been created using techniques of evidence-based medicine and best available evidence to aid practitioners in the diagnosis and treatment of adult patients with nonspecific low back pain. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flowchart, suggestions for future research, and all of the references, is available electronically on the NASS website at https://www.spine.org/ResearchClinicalCare/QualityImprovement/ClinicalGuidelines.aspx.

Effectiveness of Integration and Re-Integration into Work Strategies for Persons with Chronic Conditions: A Systematic Review of European Strategies

Due to low employment rates associated to chronic conditions in Europe, it is essential to foster effective integration and re-integration into work strategies. The objective of this systematic review is to summarize the evidence on the effectiveness of strategies for integration and re-integration to work for persons with chronic diseases or with musculoskeletal disorders, implemented in Europe in the past five years. A systematic search was conducted in MedLine, PsycINFO, CDR-HTA, CDR-DARE and Cochrane Systematic Reviews. Overall, 32 relevant publications were identified. Of these, 21 were considered eligible after a methodological assessment and included. Positive changes in employment status, return to work and sick leave outcomes were achieved with graded sickness-absence certificates, part-time sick leave, early ergonomic interventions for back pain, disability evaluation followed by information and advice, and with multidisciplinary, coordinated and tailored return to work interventions. Additionally, a positive association between the co-existence of active labour market policies to promote employment and passive support measures (e.g., pensions or benefits) and the probability of finding a job was observed. Research on the evaluation of the effectiveness of strategies targeting integration and re-integration into work for persons with chronic health conditions needs, however, to be improved and strengthened.

Return-to-work coordination programmes for improving return to work in workers on sick leave

BACKGROUND

To limit long-term sick leave and associated consequences, insurers, healthcare providers and employers provide programmes to facilitate disabled people's return to work. These programmes include a variety of coordinated and individualised interventions. Despite the increasing popularity of such programmes, their benefits remain uncertain. We conducted a systematic review to determine the long-term effectiveness of return-to-work coordination programmes compared to usual practice in workers at risk for long-term disability.

OBJECTIVES

To assess the effects of return-to-work coordination programmes versus usual practice for workers on sick leave or disability.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 11), MEDLINE, Embase, CINAHL and PsycINFO up to 1 November 2016.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that enrolled workers absent from work for at least four weeks and randomly assigned them to return-to-work coordination programmes or usual practice.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles, abstracts and full-text articles for study eligibility; extracted data; and assessed risk of bias from eligible trials. We contacted authors for additional data where required. We conducted random-effects meta-analyses and used the GRADE approach to rate the quality of the evidence.

MAIN RESULTS

We identified 14 studies from nine countries that enrolled 12,568 workers. Eleven studies focused on musculoskeletal problems, two on mental health and one on both. Most studies (11 of 14) followed workers 12 months or longer. Risk of bias was low in 10 and high in 4 studies, but findings were not sensitive to their exclusion.We found no benefits for return-to-work coordination programmes on return-to-work outcomes.For short-term follow-up of six months, we found no effect on time to return to work (hazard ratio (HR) 1.32, 95% confidence interval (CI) 0.93 to 1.88, low-quality evidence), cumulative sickness absence (mean difference (MD) -16.18 work days per year, 95% CI -32.42 to 0.06, moderate-quality evidence), the proportion of participants at work at end of the follow-up (risk ratio (RR) 1.06, 95% CI 0.86 to 1.30, low-quality evidence) or on the proportion of participants who had ever returned to work, that is, regardless of whether they had remained at work until last follow-up (RR 0.87, 95% CI 0.63 to 1.19, very low-quality evidence).For long-term follow-up of 12 months, we found no effect on time to return to work (HR 1.25, 95% CI 0.95 to 1.66, low-quality evidence), cumulative sickness absence (MD -14.84 work days per year, 95% CI -38.56 to 8.88, low-quality evidence), the proportion of participants at work at end of the follow-up (RR 1.06, 95% CI 0.99 to 1.15, low-quality evidence) or on the proportion of participants who had ever returned to work (RR 1.03, 95% CI 0.97 to 1.09, moderate-quality evidence).For very long-term follow-up of longer than 12 months, we found no effect on time to return to work (HR 0.93, 95% CI 0.74 to 1.17, low-quality evidence), cumulative sickness absence (MD 7.00 work days per year, 95% CI -15.17 to 29.17, moderate-quality evidence), the proportion of participants at work at end of the follow-up (RR 0.94, 95% CI 0.82 to 1.07, low-quality evidence) or on the proportion of participants who had ever returned to work (RR 0.95, 95% CI 0.88 to 1.02, low-quality evidence).We found only small benefits for return-to-work coordination programmes on patient-reported outcomes. All differences were below the minimal clinically important difference (MID).

AUTHORS' CONCLUSIONS

Offering return-to-work coordination programmes for workers on sick leave for at least four weeks results in no benefits when compared to usual practice. We found no significant differences for the outcomes time to return to work, cumulative sickness absence, the proportion of participants at work at end of the follow-up or the proportion of participants who had ever returned to work at short-term, long-term or very long-term follow-up. For patient-reported outcomes, we found only marginal effects below the MID. The quality of the evidence ranged from very low to moderate across all outcomes.

Efficacy of Tailored Physical Activity or Chronic Pain Self-Management Programme on return to work for sick-listed citizens: A 3-month randomised controlled trial

OBJECTIVES

The aim was to evaluate the efficacy of 'Tailored Physical Activity' (TPA) and a 'Chronic Pain Self-management Programme' (CPSMP) compared with a reference group (REF) on return to work after 3 months as sick-listed citizens with pain related to the back or the upper body.

METHODS

Using a randomised controlled trial design all participants (n= 141) received health guidance for 1.5 hours and were randomised to TPA, CPSMP or REF. Characteristics of participants were collected from a questionnaire. The primary endpoint was proportion of participants returned to work as registered by the municipality and the co-primary endpoint was duration of the sickness absence period. Secondary outcomes consisted of pain, body mass index, aerobic capacity, grip strength, work ability and kinesiophobia. The trial was conducted in Sonderborg Municipality from March 2011 to October 2013.

RESULTS

TPA was more effective on return to work than REF, while CPSMP only tended to be more effective than REF, and the primary outcome was the only between-groups significant difference. TPA participants also reached a highly significant reduction in pain from baseline to follow-up with no similar effect seen in CPSMP or REF. In contrast, no benefit of TPA and CPSMP was evident regarding work ability, kinesiophobia or physical capacity after 3 months of follow-up.

CONCLUSIONS

The results suggest that TPA is a promising intervention to facilitate return to work and reduce pain among sick-listed citizens with pain related to the back or upper body compared to REF.

Efficacy of temporary work modifications on disability related to musculoskeletal pain or depressive symptoms--study protocol for a controlled trial

INTRODUCTION

Previous research suggests that work with a suitable workload may promote health and work retention in people with disability. This study will examine whether temporary work modifications at the early stage of work disability are effective in enhancing return to work (RTW) or staying at work among workers with musculoskeletal or depressive symptoms.

METHODS AND ANALYSIS

A single-centre controlled trial with modified stepped wedge design will be carried out in eight enterprises and their occupational health services (OHSs) in nine cities in Finland. Patients seeking medical advice due to musculoskeletal pain (≥4 on a scale from 0-10) or depressive symptoms (≥1 positive response to 2 screening questions) and fulfilling other inclusion criteria are eligible. The study involves an educational intervention among occupational physicians to enhance the initiation of work modifications. Primary outcomes are sustained RTW (≥4 weeks at work without a new sickness absence (SA)) and the total number of SA days during a 12-month follow-up. Secondary outcomes are intensity of musculoskeletal pain (scale 0-10), pain interference with work or sleep (scale 0-10) and severity of depressive symptoms (Patient Health Questionnaire, PHQ-9), inquired via online questionnaires at baseline and 3, 6, 9 and 12 months after recruitment. Information on SA days will be collected from the medical records of the OHSs over 12 months, before and after recruitment. The findings will give new information about the possibilities of training physicians to initiate work modifications and their effects on RTW in employees with work disability due to musculoskeletal pain or depressive symptoms.

ETHICS AND DISSEMINATION

The Coordinating Ethics Committee of Hospital District of Helsinki and Uusimaa has granted approval for this study. The results will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ISRCTN74743666.

Fusion via transpsoas lateral approach: considerations and initial results

OBJECTIVE: To present some technical considerations about interbody fusion by direct lateral retroperitoneal transpsoas approach and its initial results. METHODS: Non-randomized prospective study of 14 patients undergoing interbody fusion via lateral approach, with evaluation of initial results and complications. RESULTS: We collected and analyzed data from 14 patients with a total of 27 levels operated. The average operative time was 146 minutes and blood loss was on average less than 50 ml. Ten patients required supplemental percutaneous fixation with pedicle screws. VAS scores for the lumbar region and lower limbs and ODI had significant improvement in the postoperative period. There was an associated case of postoperative infection and thromboembolism that required reoperations. CONCLUSION: This technique has revolutionized the care of patients requiring fusion of T6-7 to L4-5. Following the five basic steps and using intraoperative monitoring, this technique is safe and reproducible with encouraging clinical results and low rate of serious complications.

Return to work after spinal stenosis surgery and the patient's quality of life

INTRODUCTION

The return to work of patients who undergo spinal surgery poses important medical and social challenge.

OBJECTIVES

1) To establish whether patients who undergo spinal stenosis surgery later return to work. 2) To establish the patient's attitude towards employment. 3) To assess the quality of life of the patients and its influence on their attitude to work.

MATERIALS AND METHODS

The study population consisted of 58 patients aged from 21 to 80 years (the mean age was 52.33±14.12). There were 29 women (50%) and 29 men (50%) in the group. The patients' quality of life was measured by the use of the WHOQOL-BREF instrument. Individual interviews were conducted 3 to 8 months (a mean of 5.72 months ±1.6) after the surgery.

RESULTS

1) Although 13 patients (22.3%) returned to work, 44 (75.9%) did not, these being manual workers of vocational secondary education. 2) Almost half of the patients (27 patients, i.e. 44%) intend to apply for disability pension, 16 patients (27.6%) consider themselves unfit to work, 22 patients (37.9%) do not feel like working again. 3) The quality of life of the patients decreased. Domain scores for the WHOQOL-BREF are transformed to a 0-100 scale. The mean physical health amounted to 60.67 (±16.31), the mean psychological health was 58.78 (±16.01), while the mean social relations with family and friends were 59.91 (±20.69), and the mean environment 59.62 (±12.48).

CONCLUSIONS

1) A total of 75% of the patients operated for lumbar spinal stenosis do not return to their preoperative work. Difficulties in returning to work and decreased quality of life are associated with female sex, lower-level education, hard physical work and low income. 2) Physical health, psychological health, social relations and environment decreased to the mean of approximately 60. 3) The quality of life of the patients who did return to work was similar to that of healthy people.

A decade's experience in lumbar spine surgery in Belgium: sickness fund beneficiaries, 2000-2009

PURPOSE

The purpose is to study rates, trends, geographic variations and outcome of lumbar spine surgery in the Belgian population during the last decade.

METHODS

This is a retrospective cohort study using administrative data of the largest Belgian sickness fund from January 1, 2000 through December 31, 2009. Cases included lumbar laminectomy, combined discectomy and fusion, posterior interarticular fusion, anterior lumbar interbody fusion (ALIF), posterior lumbar interbody fusion (PLIF) and standard discectomy. The main outcome measures were age- and sex-adjusted rates of lumbar spine surgery, 1-year mortality, 1-year iterative surgery, no return to work (RTW) rate 1 year after surgery and length of hospital stay. Multivariate logistic regression analysis was used to determine the association between age, sex, geographic region, type of surgery, year of intervention and duration of pre-operative sick leave on outcome.

RESULTS

Spine surgery rates rose 44 % from 2001 through 2009 and data for 2009 showed twofold variations in spine surgery rates among 10 Belgian provinces. Reported 1-year mortality varied from 0.6 to 2.5 % among surgical procedures performed in 2008. The overall 5-year reoperation rate was 12 %. RTW rates 1 year after standard discectomy, ALIF, PLIF and combined discectomy and fusion for the follow-up sample of 2008 were 14.4, 22.7, 26.1 and 30.6 %, respectively. The median length of hospital stay significantly decreased throughout the decade. Type of surgery and geographic region were significantly related to patient outcomes.

CONCLUSIONS

Regional variations highlight professional uncertainty and controversy. The study results point to the need for peer comparisons and surgeon feedback.