title: Assessing the Needs of Patients in Pain: A Matter of Opinion? A Cross-Sectional Study Correlating Degeneration of the Cervical Spine With Disability and Pain in United Kingdom Patients A longitudinal, prospective study of industrial back injury reporting. Mini-Intervention for Subacute Low Back Pain: A Randomized Controlled Trial High physical work load and low job satisfaction increase the risk of sickness absence due to low back pain: results of a prospective cohort study A Population‐Based, Randomized Clinical Trial on Back Pain Management The effect of graded activity on patients with subacute low back pain: a randomized prospective clinical study with an operant-conditioning behavioral approach. The Saskatchewan Health and Back Pain Survey: The Prevalence of Neck Pain and Related Disability in Saskatchewan Adults Incidence of musculoskeletal disorders among newly employed manufacturing workers. An Epidemiologic Study of Episodes of Back Pain Care Predicting Return to Work for Lower Back Pain Patients Receiving Worker's Compensation Does Early Intervention With a Light Mobilization Program Reduce Long-Term Sick Leave for Low Back Pain? Clinical findings in a population with back pain Relation to one-year outcome and long-term sick leave The Effects of Common Medical Interventions on Pain, Back Function, and Work Resumption in Patients With Chronic Low Back Pain: A Prospective 2-Year Cohort Study in Six Countries Prediction of return-to-work of low back pain patients sicklisted for 3–4 months A prospective, randomized 5-year follow-up study of functional restoration in chronic low back pain patients Clinical Management and the Duration of Disability for Work-Related Low Back Pain Can we screen for problematic back pain? A screening questionnaire for predicting outcome in acute and subacute back pain. The natural course of acute sciatica with nerve root symptoms in a double-blind placebo-controlled trial evaluating the effect of piroxicam. Good Prognosis for Low Back Pain When Left Untampered: A Randomized Clinical Trial The treatment of acute low back pain--bed rest, exercises, or ordinary activity? Risk Factors Associated With the Transition From Acute to Chronic Occupational Back Pain Working Disability Due to Occupational Back Pain: Three-year Follow-up of 2,300 Compensated Workers in Quebec Work-Related Outcomes in Occupational Low Back Pain: A Multidimensional Analysis Effect of Discharge Recommendations on Outcome High physical and psychosocial load at work and sickness absence due to neck pain. Determinants of return-to-work among low back pain patients The role of radiography in primary care patients with low back pain of at least 6 weeks duration: a randomised (unblinded) controlled trial. Socioeconomic Factors and Disability Retirement From Back Pain: A 1983–1993 Population-Based Prospective Study in Norway Coordination of Primary Health Care for Back Pain: A Randomized Controlled Trial Sociocultural factors and back pain. A population-based study in Belgian adults.
abstract: Study Design . A prospect i ve cohort study including patients with nonspecific spinal pain was performed . Objectives . To investigate whether the use of expert judgment in routine practice can provide a basis for reliable decision making concerning the need for intervention in patients with spinal pain and their ability to benefit from treatment . Summary of Background Data . A wide range of instruments and techniques are used to assess and treat patients with spinal pain . Many instruments are used without being clinimetrically tested . Methods . A question naire concerning the patients ’ need of treatment and their potential to assimilate it was sent to experts in the health care arena : physicians , physical therapists , social insurance officers . The experts included were those connected with patients participating in a larger outcome study . Two cohorts of patients ( sample 1 , n = 217 ; sample 2 , n = 257 ) were followed for 6 and 12 months , during which time the patients ’ health and work status were mapped . Results . No acceptable agreement was found between any of the experts ’ ratings of patients ’ needs and potential for rehabilitation . Logistic regression showed that the experts ’ judgments were based almost solely on the age of the patient . The prediction analyses showed that the most consistent predictor of the patients ’ status at the 6-month follow-up assessment was the patients ’ own belief in the existence of effective treatments and their perceived ability for learning to cope with the condition . Conclusions . Expert judgment as exercised in routine practice can not be used as basis for reliable decision making concerning the need of the patient with spinal pain for intervention and the patient ’s ability to benefit from treatment Study Design . A prospect i ve cross-sectional study was conducted . Objective . To determine the relation between degeneration of all the joints in the cervical spine , and to identify the effects of litigation on pain and disability levels in trauma and nontrauma patients . Summary of Background Data . The link between spinal degeneration and patient symptoms remains controversial . Two recent similar studies present conflicting results concerning the association between spinal degeneration and symptomatology . These two studies , performed in different countries , did not consider the impact of impending litigation on self-reported pain and disability levels . The role of the uncovertebral and facet articulations has hitherto not been investigated . Methods . Radiographic and question naire data from 180 consecutive patients with neck pain were collected .  Neck pain severity was measured using two time-dependent scales . All patients completed the Neck Disability Index ( NDI ) and questions about chronicity , etiology , and associated litigation . The radiographs were evaluated for the number of levels of degeneration and the severity of degeneration in the discs as well as the uncovertebral and facet articulations . Results . In this study , 71 patients ( 40.57 % ) reported neck pain  as a result of injury . However , only 5.1 % had associated litigation . There was no statistically significant difference in pain severity or disability levels between the patients with and those without cervical degeneration . According to the findings , the number of levels of cervical degeneration and the severity of degeneration in the discs , facets , and uncovertebral joints are not related to the levels of pain and disability . Patients reporting neck pain caused by injury had a tendency ( P = 0.055 ) to more pain during the preceding week and significantly more disability ( P < 0.001 ) . Significant differences included pain intensity ( P < 0.025 ) , reading ( P < 0.001 ) , headaches ( P < 0.025 ) , ability to drive ( P < 0.01 ) , and concentration ( P < 0.01 ) . Women reported significantly more pain ( P < 0.01 ) and disability ( P < 0.001 ) than men , but did not have more degeneration in any of the joints . Conclusions . In patients with neck pain , there is no difference in reported pain and disability levels between those with and those without evidence of cervical spine degeneration . Patients whose neck pain is the result of trauma report significantly more pain and disability than nontrauma patients . This is not because of more spinal degeneration or overriding litigation issues The authors prospect ively evaluated 3020 volunteers of the Boeing-Everett plant to assess risk factors that predispose workers to file industrial back injury cl aims . During four years of follow-up observation , more than 279 subjects reported acute back problems .  The effect of the only predictive physical variable was explainable by a history of medical treatment . The most predictive individual factors were ( 1 ) job task dissatisfaction and ( 2 ) distress as reported on Scale 3 of the Minnesota Multiphasic Personality Inventory ( MMPI ) . This data perhaps explains why the focus on purely physical and injury-related factors has met with little success in dealing with what has become the most expensive orthopedic problem . Clinical ly , nonphysical factors that significantly impact the reporting of back injuries may also affect patients ' responses to medical treatment Study Design . R and omized controlled trial . Objectives . To investigate the effectiveness and costs of a mini-intervention , provided in addition to the usual care , and the incremental effect of a work site visit for patients with subacute disabling low back pain . Summary of Background Data . There is lack of data on cost-effectiveness of brief interventions for patients with prolonged low back pain . Methods . A total of 164 patients with subacute low back pain were r and omized to a  mini-intervention group ( A ) , a work site visit group ( B ) , or a usual care group ( C ) . Groups A ( n = 56 ) and B ( n = 51 ) underwent one assessment by a physician plus a physiotherapist . Group B received a work site visit in addition . Group C served as controls ( n = 57 ) and was treated in municipal primary health care . All patients received a leaflet on back pain . Pain , disability , specific and generic health-related quality of life , satisfaction with care , days on sick leave , and use and costs of health care consumption were measured at 3- , 6- , and 12-month follow-ups . Results . During follow-up , fewer subjects had daily pain in Groups A and B than in Group C ( Group A vs. Group C , P = 0.002 ; Group B vs. Group C , P = 0.030 ) . In Group A , pain was less bothersome ( Group A vs. Group C , P = 0.032 ) and interfered less with daily life ( Group A vs. Group C , P = 0.040 ) than among controls . Average days on sick leave were 19 in Group A , 28 in Group B , and 41 in Group C ( Group A vs. Group C , P = 0.019 ) . Treatment satisfaction was better in the intervention groups than among the controls , and costs were lowest in the mini-intervention group . Conclusions . Mini-intervention reduced daily back pain symptoms and sickness absence , improved adaptation to pain and patient satisfaction among patients with subacute low back pain , without increasing health care costs . A work site visit did not increase effectiveness Objective : To determine whether physical and psychosocial load at work influence sickness absence due to low back pain . Methods : The research was a part of the study on musculoskeletal disorders , absenteeism , stress , and health ( SMASH ) , a 3 year prospect i ve cohort study on risk factors for musculoskeletal disorders . Workers from 21 companies located throughout The Netherl and s participated in the part of this study on sickness absence due to low back pain . The study population consisted of 732 workers with no sickness absences of 3 days or longer due to low back pain in the 3 months before the baseline survey and complete data on the reasons for absences during the follow up period . The mean ( range ) period of follow up in this group was 37 ( 7–44 ) months . Physical load at work was assessed by analyses of video recordings . Baseline information on psychosocial work characteristics was obtained by a question naire . Data on sickness absence were collected from company records . The main outcome measure was the rate of sickness absences of 3 days or longer due to low back pain during the follow up period . Results : After adjustment of the work related physical and psychosocial factors for each other and for other potential determinants , significant rate ratios ranging from 2.0 to 3.2 were found for trunk flexion , trunk rotation , lifting , and low job satisfaction . A dose-response relation was found for trunk flexion , but not for trunk rotation or lifting . Non-significant rate ratios of about 1.4 were found for low supervisor support and low coworker support . Quantitative job dem and s , conflicting dem and s , decision authority , and skill discretion showed no relation with sickness absence due to low back pain . Conclusions : Flexion and rotation of the trunk , lifting , and low job satisfaction are risk factors for sickness absence due to low back pain . Some indications of a relation between low social support , either from supervisors or coworkers , and sickness absence due to low back pain are also present Study Design . Population ‐based r and omized clinical trial . Objectives . To develop and test a model of management of subacute back pain , to prevent prolonged disability . Summary of Background Data . The present management of back pain seems inadequate , and development of innovative models has been urged . Methods . A model for the treatment of subacute work‐related back pain has been developed and evaluated in a population ‐based r and omized clinical trial . Workers ( n = 130 ) from eligible workplaces in the Sherbrooke area ( N = 31 ) , who had been absent from work for more than 4 weeks for back pain , were r and omized , based on their workplace , in one of four treatment groups : usual care , clinical intervention , occupational intervention , and full intervention ( a combination of the last two ) . The duration of absence from regular work and from any work was evaluated using survival analysis . Functional status and pain were compared at study entry and after 1 year of follow‐up . Results . The full intervention group returned to regular work 2.41 times faster than the usual care intervention group ( 95 % confidence interval 1.19‐4.89 ; P = 0.01 ) . The specific effect of the occupational intervention accounted for the most important part of this result , with a rate ratio of return to regular work of 1.91 ( 95 % confidence interval = 1.18‐3.10 ; P < 0.01 ) . Pain and disability scales demonstrated either a statistically significant reduction or a trend toward reduction in the three intervention groups , compared with the trend in the usual care intervention group . Conclusions . Close association of occupational intervention with clinical care is of primary importance in impeding progression toward chronicity of low back pain The aim of this study was to determine whether grade d activity restored occupational function in industrial blue-collar workers who were sick-listed for 8 weeks because of subacute , nonspecific , mechanical low back pain ( LBP ) . Patients with LBP , who had been examined by an orthopedic surgeon and a social worker , were r and omly assigned to either an activity group ( n = 51 ) or a control group ( n = 52 ) . Patients with defined orthopedic , medical , or psychiatric diagnoses were excluded before r and omization . The grade d activity program consisted of four parts : ( 1 ) measurements of functional capacity ; ( 2 ) a work-place visit ; ( 3 ) back school education ; and ( 4 ) an individual , submaximal , gradually increased exercise program , with an operant-conditioning behavioral approach , based on the results of the tests and the dem and s of the patient 's work . Records of the amount of sick leave taken over a 3-year period ( ie , the 1-year periods before , during , and after intervention ) were obtained from each patient 's Social Insurance Office . The patients in the activity group returned to work significantly earlier than did the patients in the control group . The median number of physical therapist appointments before return to work was 5 , and the average number of appointments was 10.7 ( SD = 12.3 ) . The average duration of sick leave attributable to LBP during the second follow-up year was 12.1 weeks ( SD = 18.4 ) in the activity group and 19.6 weeks ( SD = 20.7 ) in the control group . Four patients in the control group and 1 patient in the activity group received permanent disability pensions . The grade d activity program made the patients occupationally functional again , as measured by return to work and significantly reduced long-term sick leave Study Design . Population ‐based , cross‐sectional mailed survey . Objective . To determine the lifetime , period , and point prevalence of neck pain and its related disability among Saskatchewan adults and investigate the presence and strength of nonresponse bias . Summary of Background Data . In Europe , the life‐time and point prevalence of neck pain is almost as high as the prevalence of low back pain . Similarly , chronic neck pain is highly prevalent and a common source of disability in the working‐age population . However , no studies specifically have documented the prevalence of neck pain and its related disability in North America . Methods . The Saskatchewan Health and Back Pain Survey was mailed to 2184 r and omly selected Saskatchewan adults aged 20‐69 years . Fifty‐five percent of the study population participated . The presence of nonresponse bias was investigated through logistic regression and wave analysis . The Chronic Pain Question naire was used to classify the severity of chronic neck pain . Results . The age‐st and ardized lifetime prevalence of neck pain is 66.7 % ( 95 % confidence interval , 63.8‐69.5 ) , and the point prevalence is 22.2 % ( 95 % confidence interval , 19.7‐24.7 ) . The age‐st and ardized 6‐month prevalence of low‐intensity and low‐disability neck pain is 39.7 % ( 95 % confidence interval , 36.7‐42.7 ) , whereas it is 10.1 % ( 95 % confidence interval , 8.2‐11.9 ) for high‐intensity and low‐disability neck pain and 4.6 % ( 95 % confidence interval , 3.3‐5.8 ) for significantly disabling neck pain . The prevalence of low‐intensity and low‐disability neck pain decreases with age . More women experience high‐disability neck pain than men . Wave analysis suggests that the point prevalence and 6‐month prevalence of high‐intensity and low‐disability neck pain are overestimated in this survey . Conclusion . This cross‐sectional study shows that neck pain is highly prevalent in Saskatchewan and that it significantly disables 4.6 % ( 95 % confidence interval , 3.3‐5.8 ) of the adult population OBJECTIVES The incidence of upper-limb , neck-shoulder , and low-back disorders and their induction times were investigated among new workers in tasks with various physical workloads . METHODS New trailer assemblers ( N=364 ) were followed prospect ively for 45 months -- the workers ' health status via medical records and exposure to physical workload factors via job titles , walk-throughs , task descriptions , and some direct measurements . The incidence rate of first sick leave due to such disorders was calculated for different workload groups . The proportion of workers surviving without musculoskeletal disorders was estimated by the Kaplan-Maier product-limit estimator , and the effect of the exposure on the risk of incident disorders was estimated with the Cox proportional hazards model . RESULTS The highest annual incidences were observed for strenuous tasks , the incidence rate for men being 16.8 per 100 person-years [ 95 % confidence interval ( 95 % CI ) 8.0 - 30.9 ] for upper-limb disorders in strenuous tasks and 6.1 ( 95 % CI 2.0 - 14.1 ) in nonstrenuous tasks and that for women being 32.0 ( 95 % CI 11.7 - 69.7 ) and 9.9 ( 95 % CI 0.2 - 54.9 ) , respectively . The men 's risk of contracting an upper-limb or neck-shoulder disorder in strenuous tasks was about threefold [ hazard ratio ( HR ) 3.2 ( 95 % CI 1.1 - 9.4 ) for upper-limb disorders and 2.7 ( 95 % CI 0.9 - 8.1 ) for neck-shoulder disorders ] that of nonstrenuous tasks , whereas workload seemed not to affect low-back disorders . The workers first sought medical advice for their disorders typically some months after employment began . CONCLUSIONS Newly employed workers in h and -intensive tasks have a high risk of upper-limb and neck-shoulder disorders . An etiologic role for activities involving high force dem and s in upper-limb and neck-shoulder disorders is possible Study Design This was a prospect i ve community-based , observational design . Objective To describe the epidemiology and risk/prognostic factors for back pain episodes of care in a population representing the nonelderly in the United States . Summary of Background Data Previous United States studies of the epidemiology of back pain care have used defined industrial population s or have relied on the patient 's recall of symptoms and care . Methods Cl aims forms from the R AND Health insurance Experiment , a r and omized controlled trial of the use of health services , were analyzed . Cl aims forms were selected if one of the patient- design ated reasons for the visit was back pain . Visits were grouped into episodes of care . Descriptive statistics were calculated for episodes . Multivariate logistic regression was used to calculate adjusted odds ratios for independent explanatory sociodemographic and health status variables associated with back pain episodes of care . Results The 3105 adults in the Health Insurance Experiment had a combined 11 , 171 person-years of exposure . Six-hundred-eighty-six persons ( 22 % ) had a total 1020 episodes of back pain care , representing 8825 visits . Seventy-one percent of persons had a single episode during the Health Insurance Experiment , and 40 % of these episodes consisted of a single visit . There were 9.1 episodes per 100 person-years . Insurance status , geographic site , white race , lesser education , poorer physical functioning , and greater pain at baseline all were independently associated with having a back pain episode of care . Conclusions Back pain episodes of care occur commonly in the adult U.S. population , but usually are brief and recur infrequently The results of a prospect i ve study of 134 patients with lower back pain suggest that nonorganic factors are better predictors of return of work than organic findings . Patients who returned to work had fewer job , personal , or family rotated problems . There were no significant differences between patients who returned to work and those who did not when comparing myelograms , computed tomographic scans , or roentgenographs . The only significant difference in physical organic findings was for muscle atrophy . Patients who did not return to work had a statistically higher incidence rate of muscle atrophy . Length of time off from work was significantly related to outcome , but when patients were categorized according to time off the job , different factors predicted failure to return for patients , off work for less than 6 months and patients off for more than 6 months . For patients off for less than 6 months , important predictors were a high Oswestry score , history of leg pain , family relocation , short tenure on the job , verbal magnification of pain , reports of moderate to severe pain an superficial palpation , and positive reaction to a “ sham ” sciatic tension test . None of these was a significant predictor for the group off for more than 6 months . For the group off work for more than 6 month , previous injuries , and stability of family living arrangements were among the significant predictors not significant for the group off less than 6 months . Using 21 factors selected from a larger group of 92 factors , three statistically significant ( P ≤ 0.001 ) predictive measures were developed . These measures predicted return to work for the total sample , and for the two subgroups ( off more than , or less than 6 months ) more accurately than did the total set of 90 factors Study Design . A controlled r and omized clinical trial was performed . Objective . To investigate the effect of a light mobilization program on the duration of sick leave for patients with subacute low back pain . Summary of Background Data . Early intervention with information , diagnostics , and light mobilization may be a cost-effective method for returning patients quickly to normal activity . In this experiment , patients were referred to a low back pain clinic and given this simple and systematic program as an outpatient treatment . Methods . In this study , 457 patients sick-listed 8 to 12 weeks for low back pain , as recorded by the National Insurance Offices , were r and omized into two groups : an intervention group ( n = 237 ) and a control group  ( n = 220 ) . The intervention group was examined at a spine clinic and given information and advice to stay active . The control group was not examined at the clinic , but was treated with conventional primary health care . Results . At 12-month follow-up assessment , 68.4 % in the intervention group had returned to full-duty work , as compared with 56.4 % in the control group . Conclusions . Early intervention with examination , information , and recommendations to stay active showed significant effects in reducing sick leave for patients with low back pain Objective - To investigate whether physical examination findings can be used in predicting recovery from back pain and new episodes of sick leave . Design - One-year prospect i ve study of a single cohort . Setting s - Semi-rural Swedish county . Population - A cross-section of a general population with back pain ( 207 women , 176 men ) between 20 and 59 years of age . Main outcome measures - Cumulative incidence of sick leave due to back pain , cumulative incidence of sick leave due to back pain > 30 days , incidence of recovery from back pain . Results - For recovery from pain , the absence of tenderness in the trapezius muscle ( OR 0.33 ; CI 0.1 - 0.5 ) was predictive . New sick leave was predicted by tenderness in the trapezius muscle ( OR 2.67 ; CI 1.5?4.9 ) , and had a tendency to be associated with a flattened lumbar lordosis and a restricted cervical range of motion . For long-term sick leave , the same findings and also observation of scoliosis ( OR 3.44 ; CI 1.1?10.5 ) were predictive . Conclusion ? There are subgroups with back pain predisposed to development of more persistent symptoms and a higher risk for sick-listing Study Design . A prospect i ve cohort study with identical question naires and inclusion criteria was performed . Objectives . To compare in six different countries the frequencies and effects of the common medical interventions used for patients with low back pain who are work incapacitated . Summary of Background Data . Low back pain is a huge problem with increasing costs for health care , industry , and society . Methods . Cohorts of employed men and women ages 18 to 59 years who had been sick-listed ( 100 % ) for a minimum of 90 days because of low back pain were recruited in Denmark , Germany , Israel , Sweden , the Netherl and s , and the United States . The subjects received three separate question naires with identical questions after 90 days , 1 year , and 2 years . The question naires included separate questions about background factors , treatment , and the like , as well as vali date d scales such as the Hannover Activities of Daily Living , von Korff pain score , Short Form-36 , and Karasek-Theorell . Working status was obtained from registers . Main outcome measures were working/not working , back function , and pain . Results . All three question naires were completed by 2080 subjects in the six countries . With few exceptions , there were great similarities in the appointments , examinations , and treatments in the different countries . Considerable differences were found between the back surgery rates , which ranged from 6 % in Sweden to 32 % in the United States during the first 90 days of the study . Very few of the interventions had any noticeable positive effects on work resumption , pain , or back function . Back surgery in Sweden was a striking exception , positively affecting all three outcome measures . The frequencies of work resumption within the first year ranged from 73 % in the Netherl and s to 32 % in Denmark . Conclusions . Almost none of the commonly occurring and frequently practice d medical interventions for patients who are sick-listed because of low back pain had any positive effects on either the recorded health measures or work resumption & NA ; The purpose of this Dutch prospect i ve population ‐based study was to identify prognostic factors for return‐to‐work of employees with 3–4 months sick leave due to low back pain ( LBP ) . A cohort of 328 employees was formed and baseline data were collected . One year after the first day of the sick leave , 91 % of the original cohort participated in a second interview ( n=298 ) . During the baseline measurement , information was collected about health status , history of LBP , occupational variables , job characteristics and social economic variables . At the second interview , 66 % of the employees had returned to work ( n=198 ) . Return‐to‐work was independently predicted by having a better general health status ( OR 1.53 ; 95 % CI 1.30–1.80 ) , having better job satisfaction ( OR 1.26 ; 95 % CI 1.11–1.44 ) , being a bread winner ( OR 2.46 ; 95 % CI 1.37–4.40 ) , having a lower age ( OR 0.70 ; 95 % CI 0.52–0.93 ) and reporting less pain ( OR 0.85 ; 95 % CI 0.73–0.99 ) all measured at cohort entry . This study shows that psycho‐social aspects of health and work in combination with economic aspects have a significantly larger impact on return‐to‐work when compared to relatively more physical aspects of disability and physical requirements of the job . This suggests that interventions aim ed at return‐to‐work of employees sicklisted with LBP should predominantly be focused on these psycho‐social aspects such as health behavior and job satisfaction , and on the ( lack of ) economic incentives for return‐to‐work Abstract A functional restoration ( FR ) program , dealing with a combination of intensive physical and ergonomic training , psychological pain management , and patient education , was tested in two r and omized , parallel group studies . In one of these patients following the FR program were compared with a non-treated control group ( project A ) , and in the other with patients on two less intensive treatment programs ( project B ) . A total of 238 chronic low back pain patients participated in the two studies , 106 entering project A and 132 project B. Patients from the two projects were comparable except that the patients in project A were recruited from all over the country , whereas patients in project B all were living in and around Copenhagen . Thirteen patients never started any treatment , and 20 patients ( 9 % ) dropped out during the treatment period . Of the 207 who completed treatment , 89 % returned a mailed question naire 5 years later . This was the case for 55 % of the drop-outs . The questions referred to work situation , pain level , activities of daily living , days of sick leave , contact with health care professionals , physical activity , use of medication , and a subjective overall assessment . The results show that in project A the treated group reported significantly fewer contacts with the health care system and significantly fewer days of sick leave over the 5-year follow-up period compared to the control group . In all other parameters , including work ability , there was no statistically significant difference between the two groups . In project B , patients treated in the FR program did significantly better in most measured parameters , except in leg pain , use of pain medication and sport activity , where no significant differences were found between groups . The overall result shows a positive long-term effect of the FR program , but it also shows the necessity of testing a given treatment in different projects and design s , among other things due to statistical variations Clinical practice guidelines recommend a conservative approach to management of acute low back pain ( LBP ) . The present study sought to determine whether health care utilization and the physician ’s initial management of work-related LBP were associated with disability duration . Clinical management information was obtained for 98 r and omly selected , workers ’ compensation cl aim ants with acute , uncomplicated , disabling work-related LBP .  Length of disability was based on indemnity ( wage replacement ) payments . Disability was significantly associated with increased utilization of specialty referrals ( P = 0.013 ) and provider visits ( P < 0.001 ) , use of magnetic resonance imaging ( P = 0.003 ) , and use of  opioids for more than 7 days ( P = 0.013 ) . Effects of early diagnostic imaging ( first 30 days of care ) on length of disability were observed ( P = 0.001 ) . Patients whose treatment course did not involve extended opioid use and early diagnostic testing were 3.78 times more likely ( 95 % confidence interval , 1.6 to 8.9 ) to have gone off disability status by the end of the study . The nature of the association between these initial clinical management aspects and LBP disability duration merits further exploration OBJECTIVES Because musculoskeletal pain is the second most frequent reason for seeking health care , the aims of this study were to determine the value of psychosocial variables in evaluating risk for developing chronic back pain problems and to develop a screening methodology to identify patients likely to have a poor prognosis . STUDY DESIGN A prospect i ve study was conducted on consecutive patients with acute or subacute back pain , in which patients completed a screening question naire and were then followed up for 6 months to determine outcome . The primary outcome variable was accumulated sick leave . METHODS One hundred forty-two consecutive patients were asked to complete a question naire design ed for this study . This question naire contained 24 items concerning psychosocial aspects of the problem . Six months later , patients were contacted to complete outcome questions about accumulated sick leave .  RESULTS A total of 97 % of the patients completed both question naires . Although patients , on average , improved greatly , 18 % had 1 - 30 days and 20 % had fewer than 30 days of sick leave during the follow-up period . Five variables were found to be the strongest predictors of sick leave outcome ( fear-avoidance work beliefs , perceived improvement , problems with work function , stress , and previous sick leave ) , correctly classifying 73 % of the patients as opposed to a chance rate of 33 % . A total score was evaluated as a means of judging risk and found to be strongly related to outcome . CONCLUSION Potent psychosocial risk factors associated with future sick absenteeism were identified . Because the total score was related to outcome , the instrument may have use in screening patients with acute or subacute spinal pain in clinical situations To study the natural history of acute sciatica , 208 patients with obvious symptoms and signs of a lumbar radiculopathy ( L5 and S1 ) were examined within 14 days of onset . A concomitant double-blind investigation of the effect of the nonsteroidal anti-inflammatory drug piroxicam was performed . The results measured by visual analog scale and Rol and 's functional tests showed a satisfactory improvement throughout the 4 weeks of observation . The piroxicam-treated group had same results as the control group . Based on question naires at months 3 and 12 approximately 30 % of the patients still complained about back trouble and 19.5 % were out of work after 1 year . Four patients underwent surgery during this period Objective . This r and omized clinical trial was design ed to determine the effect of treating low back pain as a benign , self limiting condition by light normal activity . Methods . Patients on sickness leave from work for more than 8 weeks were r and omized into two groups :  intervention ( n = 463 ) and  control ( n = 512 ) . Those in the intervention group were examined , provided information , and given instruction . Outcome was measured by return or failure to return to work ( still on sickness leave ) . Results . Survival analysis showed a highly significant ( P = 0.000 ) reduction in sickness leave in the intervention group as compared with the control group . At 200 days 60 % were still on sickness leave in the control group vs. 30 % in the intervention group . A multivariate analysis with age , sex , and treatment as cofactors showed that sex had no effect on length of sickness leave and that treatment retained its effect when adjusting for differences in age composition . Conclusion . This study indicates that low back pain treated as a benign , self limiting condition recommended to light mobilization gives superior results as compared to treatment within a conventional medical system BACKGROUND Bed rest and back-extension exercises are often prescribed for patients with acute low back pain , but the effectiveness of these two competing treatments remains controversial . METHODS We conducted a controlled trial among employees of the city of Helsinki , Finl and , who presented to an occupational health care center with acute , nonspecific low back pain . The patients were r and omly assigned to one of three treatments : bed rest for two days ( 67 patients ) , back-mobilizing exercises ( 52 patients ) , or the continuation of ordinary activities as tolerated ( the control group ; 67 patients ) . Outcomes and costs were assessed after 3 and 12 weeks . RESULTS After 3 and 12 weeks , the patients in the control group had better recovery than those prescribed either bed rest or exercises . There were statistically significant differences favoring the control group in the duration of pain , pain intensity , lumbar flexion , ability to work as measured subjectively , the Oswestry back-disability index , and number of days absent from work . Recovery was slowest among the patients assigned to bed rest . The overall costs of care did not differ significantly among the three groups . CONCLUSIONS Among patients with acute low back pain , continuing ordinary activities within the limits permitted by the pain leads to more rapid recovery than either bed rest or back-mobilizing exercises Study Design . A prospect i ve cohort study was conducted on workers cl aim ing earnings-related compensation for low back pain . Information obtained at the time of the initial cl aim was linked to compensation status ( still cl aim ing or not cl aim ing ) 3 months later . Objective . To identify individual , psychosocial , and workplace risk factors associated with the transition from acute to chronic occupational back pain . Summary of Background Data . Despite the magnitude of the economic and social costs associated with chronic occupational back pain , few prospect i ve studies have investigated risk factors identifiable in the acute stage . Methods . At the time of the initial compensation cl aim , a self-administered question naire was used to gather information on a wide range of risk factors . Then 3 months later , chronicity was determined from cl aim ants ’ computerized records . Results . The findings showed that 3 months after the initial assessment , 204 of the recruited 854 cl aim ants ( 23.9 % ) still were receiving compensation payments . A combined multiple regression model of individual , psychosocial , and workplace risk factors demonstrated that severe leg pain ( odds ratio [ OR ] , 1.9 ) , obesity ( OR , 1.7 ) , all three Oswestry Disability Index categories above minimal disability ( OR , 3.1–4 ) , a General Health Question naire score of at least 6 ( OR , 1.9 ) , unavailability of light duties on return to work ( OR , 1.7 ) , and a job requirement of lifting for three fourths of the day or more all were significant , independent determinants of chronicity ( P < 0.05 ) . Conclusions . Simple self-report measures of individual , psychosocial , and workplace factors administered when earnings-related compensation for back pain is cl aim ed initially can identify individuals with increased odds for development of chronic occupational disability A cohort of3,342 cases constituting a r and om sample of all occupational back injuries compensated in Quebec ( Canada ) during 1981 was observed prospect ively for 3 years to study associations between cumulative duration of absence from work  and sex , age , site of symptoms ( cervical , thoracic , and lumbar ) , and occupation . Of the cohort members , 287 ( 9.7 % ) cumulated 6 months of absence or more . A logistic regression model showed age and site of symptoms to be the two most important risk factors associated with absences of 6 months or more . No association was found with sex or occupation . The results showed discrepancies between measures of frequency distribution of back injuries and duration of absence from work , an important finding in terms of identifying health priorities Objectives . This pilot study explored a broad range of work-related outcomes for occupational low back injuries . Methods . A model of occupational outcomes and a survey instrument were developed on the basis of interviews , expert opinion , and literature review s. New Hampshire workers who had an occupational back injury a year before the study were sample d from first reports of injury and sent a mailed survey about their postinjury experiences and related factors . Results . Of 251 r and omly selected cases , a valid address could be identified for 121 , and 99 patients responded . Almost 60 % of the respondents had lost 1 week of work or more . At 1 year after injury , half of the respondents had returned to their preinjury job and employer , and 20 % were unemployed , half of them because of the injury . Most working respondents reported no decrease in their work capacity . However , 68 % still had pain exacerbated by work , and 47 % worried that their condition would worsen with continued work . Reinjury occurred in 42 % of the respondents . The work-related outcome measures were largely independent of each other . Exploratory multivariate analyses demonstrated unique patterns of factors associated with each outcome . Reinjury risk was significantly greater in respondents whose employers offered accommodations or whose postinjury jobs had greater ergonomic risk . The small sample size limited the ability to achieve statistically significant results in multivariate analyses . Conclusions . Simply measuring return to work did not appear to capture the full range of job-related consequences from occupational back injuries in this pilot evaluation . Timing of return to work , occupational ergonomic risks , and appropriate job modifications appeared to be particularly important in a safe return to the job after an occupational low back injury . Results suggest opportunities to address risk factors that may improve work outcomes Study Design The incidence of two common discharge recommendations , return to work unrestricted ( RTWU ) and restricted ( RTWR ) suggested that most restrictions were applied on the basis of patients ' subjective reports of pain or therapist 's unfounded fears that return to full duty would result in physical harm . Objectives This prospect i ve study compares the therapist 's return to work recommendation to the patient 's actual work status and analyzes the effect of that recommendation on outcome . Methods There were 1438 consecutive patients review ed by structured telephone interviews  during the two halves of the study : the control group when pain was accepted as a reason for restriction and the study group when it was not . Summary of Background Data In the control group , 44 % of the patients were recommended to RTWU ; for the study group , 81 % received this recommendation . Compliance was 84 % for the control subjects and 78 % for the study group . Results The absolute number of patients who returned to unrestricted work doubled in the study group . Conclusions The probability of a successful return to normal duty increased with a recommendation of RTWU ( P = 0.0001 ) , whereas the probability of failure increased when restrictions were imposed ( P = 0.0001 ) OBJECTIVES This study investigates the relationship between physical and psychosocial load at work and sickness absence due to  neck pain . METHODS A prospect i ve cohort study with a follow-up period of 3 years ( 1994 - 1998 ) was performed among a working population . At the beginning of the study , physical load at work was quantified by means of video recordings .  Work-related psychosocial variables were measured by means of the Job Content Question naire . The frequency of sickness absence due to neck pain with a minimal duration of 3 days was assessed on the basis of company registration s during the follow-up period . Altogether 758 workers were included in the analyses . Possible confounding by individual characteristics , physical load , and psychosocial load was studied . RESULTS Work-related neck flexion and neck rotation , low decision authority , and medium skill discretion showed statistically significant increased risks for sickness absence due to neck pain ( adjusted rate ratios ranging from 1.6 to 4.2 ) . High quantitative job dem and s , low skill discretion , and low job security showed nonsignificant increased risks for sickness absence due to neck pain ( adjusted rate ratios of 2.0 , 1.6 and 1.7 , respectively ) . Work-related sitting , conflicting job dem and s , supervisor support , and co-worker support did not increase sickness absence due to neck pain . CONCLUSION Work-related neck flexion , neck rotation , low decision authority , and medium skill discretion are risk factors for sickness absence due to neck pain . There are indications that high job dem and s , low skill discretion , and low job security are also risk factors for sickness absence due to neck pain & NA ; This prospect i ve study identifies physical , behavioral , and psychosocial correlates of subsequent employment status in a sample of low back pain patients . The sample of 150 subjects was drawn from 2 population s of persons with chronic low back pain : 87 individuals who were receiving care at a university low back pain clinic , and 63 individuals who had applied for ( but not yet received ) Social Security compensation on the basis of low back pain . All subjects had worked at least 3 months prior to their latest unemployment period and were currently out of work . Initial assessment included a medical history , physical examination , biomechanical testing , psychiatric interview , and MMPI testing .  All subjects were followed up 6 months later to determine whether they had returned to work . Cross‐sectional group comparisons at the time of initial assessment showed that , after controlling for the effects of age , the two sample s differed on several physical and biomechanical measures , the Social Security group reflecting a more chronic picture . Group differences on physical variables were found , but most significant differences disappeared when adjusted for length of time out‐of‐work . Longitudinal analyses showed that few objective physical or biomechanical measures were associated with return‐to‐work at 6 months , while a number of psychosocial variables were significant predictors of 6‐month work status . The data suggest that exclusive reliance on the physical examination to determine level of disability , without consideration of psychosocial conditions , and without adjusting for the confounding effects of age and length of time out‐of‐work , is not empirically justified . Logistic regression analysis was used to ascertain the relative contribution of each predictor to outcome and to illustrate the hypothetical effects of changes in the levels of selected risk factors on the likelihood of return‐to‐work . Implication s for interventions with low back pain patients are discussed and future research directions suggested OBJECTIVES To test the hypotheses that : ( 1 ) Lumbar spine radiography in primary care patients with low back pain is not associated with improved patient outcomes , including pain , disability , health status , sickness absence , reassurance , and patient satisfaction or belief in the value of radiography . ( 2 ) Lumbar spine radiography in primary care patients with low back pain is not associated with changes in patient management , including medication use , and the use of primary and secondary care services , physical therapies and complementary therapies . ( 3 ) Participants choosing their treatment group ( i.e. radiography or no radiography ) do not have better outcomes than those r and omised to a treatment group . ( 4 ) Lumbar spine radiography is not cost-effective compared with usual care without lumbar spine radiography . DESIGN A r and omised unblinded controlled trial . SETTING Seventy-three general practice s in Nottingham , North Nottinghamshire , Southern Derbyshire , North Lincolnshire and North Leicestershire . Fifty-two practice s recruited participants to the trial . SUBJECTS R and omised arm : 421 participants with low back pain , with median duration of 10 weeks . Patient preference arm : 55 participants with low back pain , with median duration of 11 weeks . INTERVENTION Lumbar spine radiography and usual care versus usual care without radiography . MAIN OUTCOME MEASURES Rol and adaptation of the Sickness Impact Profile , visual analogue pain scale , health status scale , EuroQol , use of primary and secondary care services , and physical and complementary therapies , sickness absence , medication use , patient satisfaction , reassurance and belief in value of radiography at 3 and 9 months post-r and omisation . RESULTS Participants r and omised to receive an X-ray were more likely to report low back pain at 3 months ( odds ratio ( OR ) = 1.56 ; 95 % confidence interval ( CI ) , 1.02 to 2.40 ) and had a lower overall health status score ( p = 0.02 ) . There were no differences in health or functional status at 9 months . A higher proportion of participants consulted the general practitioner ( GP ) in the 3 months following an X-ray ( OR = 2.72 ; 95 % CI , 1.80 to 4.10 ) . There were no differences in use of any other services , medication use or sickness absence at 3 or 9 months . No serious spinal pathology was identified in either group . The commonest X-ray reports were of discovertebral degeneration and normal findings . Many patients did not perceive their information needs were met within the consultation . Satisfaction with care was greater in the group receiving radiography at 9 months . Participants r and omised to receive an X-ray were not less worried , or more reassured about serious disease causing their low back pain . Satisfaction was associated with meeting participants ' information needs and reduced belief in the necessity for investigations for low back pain , including X-rays and blood tests . In both groups , at 3 and 9 months 80 % of participants would choose to have an X-ray if the choice was available . Participants in the patient preference group achieved marginally better outcomes than those r and omised to a treatment group , but the clinical significance of these differences is unclear . Lumbar spine radiography was associated with a net economic loss at 3 and 9 months . CONCLUSIONS Lumbar spine radiography in primary care patients with low back pain of at least 6 weeks duration is not associated with improved functioning , severity of pain or overall health status , and is associated with an increase in GP workload . Participants receiving X-rays are more satisfied with their care , but are not less worried or more reassured about serious disease causing their low back pain . CONCLUSIONS - RECOMMENDATIONS FOR FURTHER RESEARCH : Further work is required to develop and test an educational package that educates patients and GPs about the utility of radiography and provides strategies for identifying and meeting the information needs of patients , and the needs of patients and GPs to be reassured about missing serious disease . Guidelines on the management of low back pain in primary care should be consistent about not recommending lumbar spine radiography in patients with low back pain in the absence of red flags for serious spinal pathology , even if the pain has persisted for at least 6 weeks Study Design . A prospect i ve observational study with an 11-year follow-up period was performed . Objective . To investigate the influence of education and socioeconomic position on the incidence of permanent disability retirement from  back pain .  Summary of Background Data . Early retirement because of back pain is the extreme end point of a disabling process that is a great burden to the individual and costly for the society . Groups of employees at particular risk for permanent back pain disability need to be identified . Methods . All employed men and women in Norway between the ages of 20 and 53 years in 1980 were included ( n = 1,333,556 ) . Outcome measures were disability retirement from inflammatory back pain ( ICD-9 code 720 ) and noninflammatory back pain ( ICD-9 codes 721 to 724 ) . Results . The 11-year cumulative incidence was 0.15 % ( n = 1990 ) for disability retirement from inflammatory back pain and 1.64 % ( n = 21,829 ) for noninflammatory back pain and was somewhat higher in women than in men . Each year of formal education was independently associated with decreased risk for disability retirement from noninflammatory back pain ( odds ratio [ OR ] = 0.78 ; 95 % confidence interval [ CI ] = 0.77–0.79 ) and from inflammatory back pain ( OR = 0.83 ; 95 % CI = 0.81–0.86 ) . Whereas disability from inflammatory back pain was moderately associated with socioeconomic status , there was a consistent upward trend in the association between disability retirement from noninflammatory back pain and lower socioeconomic position . The OR for unskilled workers was 3.1 ( 95 % CI = 2.6–3.7 ) for men and 2.1 ( 95 % CI = 1.7–2.5 ) for women , as compared with that of higher professionals . Stepwise analyses suggest that the effect of education is not mediated by socioeconomic status . Conclusions . The consistent upward trend in the relation of disability retirement to lower levels of education and socioeconomic position , even for inflammatory back pain , shows that factors related to the occupational and social environment play an important role in the disabling process . The stepwise , monotonic relation between socioeconomic position and disability retirement from back pain , even at the higher end of the socioeconomic scale , suggests that the relation between social class and back pain disability can not be explained solely in terms of manual versus nonmanual jobs Study Design . A r and omized controlled trial comparing usual care with a program for the coordination of primary health care ( CORE ) for the treatment of subacute low-back pain patients . Objectives . To measure the effectiveness of the CORE program  as a mean for implementing clinical practice guidelines for low-back pain in an urban community . Summary of Background Data . Clinical practice guidelines have been developed for primary care physicians and patients on the clinical management of low-back pain . The implementation of the guidelines in a large community is difficult with the multiplicity of medical and nonmedical back care providers and products . The CORE program was design ed to make the guidelines fit in this complex environment . Methods . One hundred ten workers compensated for low-back pain for 4 to 8 weeks in metropolitan Montreal were r and omized in two groups : usual care ( N=56 ) and the CORE program ( N=54 ) . Coordination of primary health care was performed by two primary care physicians and a nurse in liaison with the treating physicians , and included a complete examination , recommendations for the clinical management , and support to carry out the recommendations . All workers were followed for 6 months . Back pain and functional status were assessed at baseline , 3 months , and 6 months . Results . In the 6-month follow-up , the CORE group returned to work 6.6 days ( st and ard error = 8.9 ) quicker than the control group , a difference that was not statistically significant . However , the CORE group showed a sustained improvement in pain and functional status with two-fold differences at the end of the 6 months of follow-up . This represented nine points on the Oswestry scale ( P = 0.02 ) and 12 points on the Quebec Back Pain Disability Scale ( P = 0.01 ) . The CORE group also used three times less specialized imaging tests of the spine at 3 months ( P < 0.01 ) and exercised twice as much at 6 months ( P < 0.05 ) than the controls . Conclusions . The therapeutic results for workers with low-back pain could be improved by implementing the clinical practice guidelines with primary care physicians in a large community , without delaying the return to work . The CORE intervention for back pain patients ishighly relevant to primary care practice . It is simple in its application , flexible to accommo date physicians ’ and patients ’ preferences in health care , and it is effective on patients ’ clinical outcome A  population -based survey of approximately 4000 adults in Belgium , a bi-cultural country with a uniform health care system , explored the relationships of socio-cultural and employment factors to the reported experience of  low back pain ( LBP ) .  Predictors of 1 ) history of LBP , 2 ) first LBP , and 3 ) daily LBP were examined by multiple logistic regression analysis . Thirty-three percent of the population had current LBP , including 5 % experiencing their first episode ; 26 % had past but not current LBP , and 41 % had never had LBP . Increasing age ( OR > 2.0 , P = .000 ) and female gender ( OR 2.16 , P = .000 ) were associated with history of LBP ; only gender ( OR 1.40 , P = .02 ) was associated with first episode ; neither was associated with daily LBP . Language was associated with history ( OR 1.80 , P = .000 ) and first occurrence ( OR 1.77 , P = .000 ) but not daily LBP . Among those employed , work dissatisfaction was associated with history of LBP ( OR > 2.4 , P = .02 ) and daily LBP ( OR 3.85 , P = .02 ) , but not with first episode . The results suggest that sociocultural factors influence the expression of LBP , but not the risk of chronicity once LBP is reported , and that work satisfaction may not be causally related to LBP , but may intervene along with type of occupation in the possibility of continuing employment once LBP is present . Prospect i ve studies are needed to confirm these results and eluci date causal relationships
target: The following factors were found to have consistent , but limited , support as regards their influence on the risk for sick leave due to back and neck disorders : ( a ) heavy physical workload , bent or twisted working position , and low work satisfaction increases the risk for short-term and long-term sick leave ; ( b ) specific back diagnoses and previous sick leave due to back disorders increases the risk for short-term and long-term sick leave ; ( c ) female gender , smoking , exposure to vibration , and deficient social support were not found to significantly increase the risk for short-term and long-term sick leave ; ( d ) self-reported pain and functional impairments were associated with a high risk for long-term sick leave ; ( e ) longer employment periods reduced the risk for short-term sick leave ; ( f ) perceived dem and s at work did not influence short-term sick leave ; ( g ) female gender and higher age increases the risk for disability pension
background: nan