title: Relation between indicators for quality of occupational rehabilitation of employees with low back pain. Implementation of a participatory ergonomics program in the rehabilitation of workers suffering from subacute back pain. A Population‐Based, Randomized Clinical Trial on Back Pain Management Back school in a first episode of compensated acute low back pain: a clinical trial to assess efficacy and prevent relapse. The Dominant Role of Psychosocial Risk Factors in the Development of Chronic Low Back Pain Disability Secondary Prevention of Work-Related Disability in Nonspecific Low Back Pain: Does Problem-Solving Therapy Help? A Randomized Clinical Trial Predicting who develops chronic low back pain in primary care: a prospective study Lack of effectiveness of bed rest for sciatica. Treatment- and Cost-Effectiveness of Early Intervention for Acute Low-Back Pain Patients: A One-Year Prospective Study Conservative treatment in patients sick-listed for acute low-back pain: a prospective randomised study with 12 months’ follow-up Five‐Year Follow‐Up Study of a Controlled Clinical Trial Using Light Mobilization and an Informative Approach to Low Back Pain Risk Factors Associated With the Transition From Acute to Chronic Occupational Back Pain The Intensity of Work Recovery in Low Back Pain Listening to injured workers: how recovery expectations predict outcomes--a prospective study.
abstract: OBJECTIVES : To assess if the implementation of guidelines for occupational rehabilitation of patients with low back pain by means of process variables -- a set of objective criteria for technical performance and continuity of care -- led to a better outcome in clinical and return to work variables . METHODS : The study group consisted of 59 patients with at least 10 days of sick leave because of low back pain . Univariate analyses as well as multiple logistic regression and Cox 's regression analyses were performed to assess the relation between quality of care and outcome . RESULTS : Process indicators for technical competence , continuity of care , and total performance were all significantly related to satisfaction of employees . Continuity of care and total performance were significantly related to working status at 3 months , and time to return to work . None of the process indicators was related to pain or disability after 3 months follow up . Satisfaction was not related to any of the other outcome variables . This indicates that if guidelines for occupational rehabilitation are met , outcome is better . CONCLUSION : Quality of the process of care was related to outcome . Interventions of occupational physicians need improvement in the areas of continuity of care and communication with treating physicians . The effectiveness of an improved intervention should be studied in a subsequent r and omised clinical trial This paper describes a participatory ergonomics program aim ed at early return to regular work of workers suffering from subacute occupational back pain and assesses the perceptions of the participants on the implementation of ergonomic solutions  in the workplace . The participatory ergonomics program was used in the rehabilitation of workers suffering from subacute back pain for more than 6 weeks , a program that was associated with an increased rate of return to work . The perceptions of the participatory ergonomics participants were assessed 6 months after completion of the ergonomic intervention through a question naire sent to employer representatives , union representatives and injured workers of participating workplaces . About half of the ergonomic solutions were implemented according to the perception of the participants , with a substantial agreement between respondents 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 OBJECTIVE To assess the efficacy of a back school program for patients with a first episode of acute work-related low back pain requiring compensation . DESIGN A r and omized single-blind controlled trial . SETTING A private physiatrics outpatient clinic . PATIENTS The mean duration of low back pain was 15 days . INTERVENTION Eligible patients were r and omized to a st and ard treatment program that included daily physiotherapy ( n = 86 ) or the same program with the addition of back school ( n = 82 ) . The back school program consisted of three 90-minute sessions given by a single trained instructor at 0 , 1 , and 8 weeks . MAIN OUTCOME MEASURES The primary outcomes were the time off work for the presenting episode of back pain and the number and duration of recurrences in the year following the study onset . Secondary outcomes included the level of pain , spinal mobility , active straight-leg raising , and functional disability assessed by the Oswestry and Rol and -Morris scales . RESULTS Those r and omized to the back school group gained significantly more knowledge , based on the multiple choice examination ( p = .0001 ) and performed the exercise program significantly better ( p = .0001 ) than the st and ard care group . There were no differences between the two treatment groups for either of the primary outcomes . The median time to return to work from r and omization was 33 days for both the back school and the st and ard care groups ( p = .48 ) . The number of compensated recurrences of low back pain over 1 year was similar ( back school = 14 , st and ard care = 10 , p = .16 ) , as was the median duration of these episodes ( back school = 25 days , st and ard care = 70 days , p = .21 ) . There were no significant differences favoring the back school group for any of the secondary outcomes at the posttreatment , 6-month , or 12-month assessment s. CONCLUSION A back school intervention in addition to st and ard care result ed in no reduction in the time to return to work or the number or duration of recurrences of low back pain requiring compensation over a period of one year Study Design An inception cohort design was used in which 421 patients were evaluated systematic ally with a st and ard battery of psychosocial assessment tests ( Structured Interview for DSM-III-R Diagnosis , Minnesota Multiphasic Personality Inventory , and Million Visual Pain Analog Scale ) within 6 weeks of acute back pain onset . Objectives The present study evaluated the predictive power of a comprehensive assessment of psychosocial and personality factors in identifying acute low back pain patients who subsequently develop chronic pain disability problems  ( as measured by job-work status at 1-year follow-up evaluation ) . Summary of Background Data There has been a relative paucity of prospect i ve research in the United States comprehensively evaluating potential psychoscial risk factors that are associated with those injured workers who subsequently fail to return to work and productivity after 1 year because of low back pain disability . Such research has been quite limited because of the time and cost involved in conducting prospect i ve studies . Methods All study patients were symptomatic with lumbar pain syndrome for no more than 6 weeks , These acute patients were tracked every 3 months , culminating in a structured telephone interview being conducted 1 year after the initial evaluation to document return-to-work status . Results Logistic regression analyses , conducted to differentiate between patients who were back at work after 1 year versus patients who were not because of the original back injury , revealed the importance of three psychosocial measures : self-reported pain and disability , scores on Scale 3 of the Minnesota Multiphasic Personality Inventory , and workers ' compensation and personal injury insurance status . The model generated correctly classified 90.7 % of the cases . Results revealed that major psychopathology , such as depression and substance abuse , did not precede or cause the development of chronic pain disability . Conclusions These results show the presence of a robust “ psychosocial disability factor ” that is associated with those injured workers who are likely to develop chronic low back pain disability problems .  Based on these data , a statistical algorithm has been generated that can identify those acute patients who will require early intervention to prevent the development of chronic disability . The second major result is that preinjury or concomitant psychopathology does not appear to predispose patients to chronic pain disability , although high rates of psychopathology have been shown in chronic low back pain . Future research should be directed at emotional vulnerability and psychosocial events in the period after the injury that may lead to chronicity Objectives Given the individual and economic burden of chronic work disability in low back pain patients , there is a need for effective preventive interventions . The aim of the present study was to investigate whether problem-solving therapy had a supplemental value when added to behavioral grade d activity , regarding days of sick leave and work status . Design R and omized controlled trial . Patients and Setting Employees who were recently on sick leave as a result of nonspecific low back pain were referred to the rehabilitation center by general practitioner , occupational physician , or rehabilitation physician . Forty-five employees had been r and omly assigned to the experimental treatment condition that included behavioral grade d activity and problem-solving therapy ( GAPS ) , and 39 employees had been r and omly assigned to behavioral grade d activity and group education ( GAGE ) . Outcome Measures Days of sick leave and work status . Data were retrieved from occupational health services . Results Data analyses showed that employees in the GAPS group had significantly fewer days of sick leave in the second half-year after the intervention . Moreover , work status was more favorable for employees in this condition , in that more employees had a 100 % return-to-work and fewer patients ended up receiving disability pensions one year after the intervention . Sensitivity analyses confirmed these results . Conclusions The addition of problem-solving therapy to behavioral grade d activity had supplemental value in employees with nonspecific low back pain Abstract Objectives : To quantify the relative contribution of premorbid and episode specific factors in determining the long term persistence of disabling symptoms of low back pain . Design : Prospect i ve cohort study . Setting : Two general practice s in the south Manchester area . Participants : 180 patients , who previously participated in a cross sectional population survey , who consulted because of low back pain during the study period . They were followed at 1 week and 3 and 12 months after consultation . Main outcome measure : Persistent disabling low back pain in the 12 months after the consultation . Results : Disabling low back pain persisted in one third of participants after consultation and was more common with increasing age , among those with a history of low back pain , and in women .  Persistence of symptoms was associated with “ premorbid ” factors ( high levels of psychological distress ( odds ratio 3.3 ; 95 % confidence interval 1.5 to 7.2 ) , poor self rated health ( 3.6 ; 1.9 to 6.8 ) , low levels of physical activity ( 2.8 ; 1.4 to 5.6 ) , smoking ( 2.1 ; 1.0 to 4.3 ) , dissatisfaction with employment ( 2.4 ; 1.3 to 4.5 ) ) and factors related to the episode of low back pain ( duration of symptoms , pain radiating to the leg ( 2.6 ; 1.3 to 5.1 ) , widespread pain ( 6.4 ; 2.7 to 15 ) , and restriction in spinal mobility ) . A multivariate model based on six factors identified groups whose likelihood of persistent symptoms ranged from 6 % to 70 % . Conclusions : The presence of persistent low back pain is determined not only by clinical factors associated with pain but also by the premorbid BACKGROUND AND METHODS Bed rest is widely advocated for sciatica , but its effectiveness has not been established . To study the effectiveness of bed rest in patients with a lumbosacral radicular syndrome of sufficient severity to justify treatment with bed rest for two weeks , we r and omly assigned 183 subjects to either bed rest or watchful waiting for this period . The primary outcome measures were the investigator 's and patient 's global assessment s of improvement after 2 and 12 weeks , and the secondary outcome measures were changes in functional status and in pain scores ( after 2 , 3 , and 12 weeks ) , absenteeism from work , and the need for surgical intervention . Neither the investigators who assessed the outcomes nor those involved in data entry and analysis were aware of the patients ' treatment assignments . RESULTS After two weeks , 64 of the 92 patients in the bed-rest group ( 70 percent ) reported improvement , as compared with 59 of the 91 patients in the control ( watchful-waiting ) group ( 65 percent ) ( adjusted odds ratio for improvement in the bed-rest group , 1.2 ; 95 percent confidence interval , 0.6 to 2.3 ) . After 12 weeks , 87 percent of the patients in both groups reported improvement . The results of assessment s of the intensity of pain , the bothersomeness of symptoms , and functional status revealed no significant differences between the two groups . The extent of absenteeism from work and rates of surgical intervention were similar in the two groups . CONCLUSIONS Among patients with symptoms and signs of a lumbosacral radicular syndrome , bed rest is not a more effective therapy than watchful waiting In an attempt to prevent acute low-back pain from becoming a chronic disability problem , an earlier study developed a statistical algorithm which accurately identified those acute low-back pain patients who were at high risk for developing such chronicity . The major goal of the present study was to evaluate the clinical effectiveness of employing an early intervention program with these high-risk patients in order to prevent the development of chronic disability at a 1-year follow-up . Approximately 700 acute low-back pain patients were screened for their high-risk versus low-risk status . On the basis of this screening , high-risk patients were then r and omly assigned to one of two groups : a functional restoration early intervention group ( n = 22 ) , or a nonintervention group ( n = 48 ) . A group of low-risk subjects ( n = 54 ) who did not receive any early intervention  was also evaluated . All these subjects were prospect ively tracked at 3-month intervals starting from the date of their initial evaluation , culminating in a 12-month follow-up . During these follow-up evaluations , pain disability and socioeconomic outcomes ( such as return-to-work and healthcare utilization ) were assessed . Results clearly indicated that the high-risk subjects who received early intervention displayed statistically significant fewer indices of chronic pain disability on a wide range of work , healthcare utilization , medication use , and self-report pain variables , relative to the high-risk subjects who do not receive such early intervention . In addition , the high-risk nonintervention group displayed significantly more symptoms of chronic pain disability on these variables relative to the initially low-risk subjects . Cost-comparison savings data were also evaluated . These data revealed that there were greater cost savings associated with the early intervention group versus the no early intervention group . The overall results of this study clearly demonstrate the treatment- and cost-effectiveness of an early intervention program for acute low-back pain patients Abstract We evaluated three different conservative treatment methods for acute low-back pain patients in groups following a manual therapy programme , an intensive training programme , or a general practitioner programme  , the latter serving as the control group . Patients aged 19–64 years on sick leave for low-back pain with or without sciatica were included in a prospect i ve r and omised study evaluating outcomes such as impairment , pain , functional disability , socio-economic disability and satisfaction with the treatment or explanations . Evaluation by unbiased observers was performed at 1 , 3 and 12 months . The three treatment groups were comparable at baseline . With regard to satisfaction , the patients in the manual therapy programme and those in the intensive training programme were more satisfied with the treatment than those in the general practitioner programme at all follow-ups . With regard to the explanations of current low-back pain episodes , the patients in the manual therapy programme were more satisfied than those in the general practitioner programme at all follow-ups . The manual therapy programme group were also more satisfied with the explanations than those in the intensive training programme at the 1-month follow-up . However , no differences were revealed between the groups with respect to outcomes on measures of impairment , pain , functional disability or socio-economic disability . All three study groups showed rapid improvement . After 1 month a significant improvement was noted in all outcome values compared with the values on entry to the study . Within the limitations discussed in our study , it is concluded that ( 1 ) patients sick listed with acute low-back pain , with or without sciatica , will be significantly improved after 1 month regardless of conservative treatment programme ; ( 2 ) they will be more satisfied with the treatment if they are referred to a manual treatment programme or a training treatment programme ; ( 3 ) they will be more satisfied with the explanations of the acute low-back problem if they are referred to one of the above groups , especially the manual treatment group ; ( 4 ) they will not show any other differences with respect to subjective and objective variables , either at short-term or at long-term follow-ups Study Design . A controlled clinical trial . Objectives . To examine the long‐term effect of an informative approach to low back pain . Summary of Background Data . In management and prevention of low back pain , back school based on an ergonomic approach have played an important role . The effect of such informative interventions is not clear . Methods . A 5‐year follow‐up study was done on patients included in a previous study . The outcome was measured by return to work or still on sick leave . The patients were allocated to an intervention group ( n = 245 ) and a control group ( n = 244 ) . Only the intervention group was called in for examination and intervention and answered a battery of tests for psychological and health factors . The intervention apart from the clinical examination consisted of education in a " mini back school . " The program was based on a new medical model for low back pain . Results . Forty‐seven ( 19 % ) of the patients in the intervention group , compared with 84 patients ( 34 % ) in the control group , were still on sick leave after 5 years ( P < 0.001 ) . There were fewer recurrences of sick leave ( P < 0.03 ) in the intervention group than in the control group . Based on Internal Health Locus of Control , number of children , and income , 75 % were correctly classified as nonreturners in the intervention group . Conclusions . This study indicates that subchronic low back pain may be managed successfully with an approach that includes clinical examination combined with information for patients about the nature of the problem , provided in a manner design ed to reduce fear and give them reason to resume light activity 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 The intensity of work recovery in LBP has been studied using the National Health Register . Nine hundred forty men , 40 - 47 years old , were selected r and omly from the census register of the city of Göteborg , Sweden .  Sickness absence data were obtained from the Health Register , in which all sickness absence from age 16 is recorded . The rate of return to work decreases as expected with an increase in absence period . Different rates were found for different diagnoses , however , with low return intensities in patients with sciatica compared with those with back pain , ie , return to work was slower in patients with sciatica . Men with manual work had a significantly longer average sickness absence than white-collar workers . The intensity of work recovery was lower in blue-collar workers during the first 20 days of absence , while the reverse was true after 20 days of sickness absence , ie , the white-collar workers who were absent more than 20 days had a slower rate of recovery than blue-collar workers who had been absent for 20 days . Data as presented here can be used to study the effect of intervention ( for example , manual therapy ) on the natural course of work recovery . It also can be used , as above , to study differences in sickness absence patterns between different diagnoses and work groups BACKGROUND Rigorous evidence on factors affecting the prognosis of work-related soft-tissue injuries remains limited . Although shown to be important for a wide variety of clinical conditions , recovery expectations have rarely been assessed as prognostic factors for workers with soft-tissue injuries . We examined the predictive role of various measures of recovery expectations among workers with injuries result ing in time off work . METHODS We identified a prospect i ve cohort of 1566 injured workers shortly after they filed a cl aim for their injury with the Ontario Workers ' Compensation Board ( OWCB ) . They had soft-tissue injuries to the back or upper or lower extremities , had new , lost-time cl aims from May to November 1993 and were still off work at the time of the first interview . We interviewed participants by telephone within 3 weeks after the injury and measured their recovery expectations ( perceptions regarding progress , expected change in condition , expected time until return to usual activities  and  expectations regarding return to usual job ) along with other , potentially important prognostic factors . The primary outcome was total time receiving 100 % wage-replacement benefits during the year following injury , obtained from OWCB administrative files . Self-reported measures of pain , health-related quality of life and functional status , obtained up to 4 times during the year following injury , were both independent predictors and secondary outcomes . RESULTS The 4 measures of recovery expectations together explained one-sixth of the variation in time receiving benefits . All but expectations regarding return to usual job were individually predictive of time receiving benefits . Judging one 's recovery as much better than expected result ed in a 30 % ( 95 % confidence interval [ CI ] 9%-46 % ) faster rate of stopping receiving benefits ( and likely returning to work ) compared with judging one 's recovery as much worse than expected . Similarly , participants who expected to return to usual activities within 3 weeks had a 37 % ( 95 % CI 26%-47 % ) faster rate of stopping receiving benefits than those who responded " Do n't know " to this question , and participants who stated that they were fully recovered or would get better soon had a 25 % ( CI 5%-40 % ) faster rate than those who thought they would never get or stay better . Positive recovery expectations were also associated with reductions in pain grade and improvement in functional status outcomes . INTERPRETATION Expectations regarding recovery may provide useful information on the complex process of recovering from work-related soft-tissue injuries . For clinicians , patients ' negative or uncertain expectations may indicate the need for further probing and intervention on psychosocial factors to facilitate recovery
target: Specific LBP , higher disability levels , older age , female gender , more social dysfunction and more social isolation , heavier work , and receiving higher compensation were identified as predictors for a longer duration of sick leave .
  A history of LBP , job satisfaction , educational level , marital status , number of dependants , smoking , working more than 8 hour shifts , occupation , and size of industry or company do not influence duration of sick leave due to LBP .
  Many different constructs were measured to identify psychosocial predictors of long term sick leave , which made it impossible to determine the role of these factors
background: BACKGROUND The percentages of patients with acute low back pain ( LBP ) that go on to a chronic state varies between studies from 2 % to 34 % .
  In some of these cases low back pain leads to great costs .
  AIMS To evaluate the evidence for prognostic factors for return to work among workers sick listed with acute LBP .