title: Early intervention for back-injured nurses at a large Canadian tertiary care hospital: an evaluation of the effectiveness and cost benefits of a two-year pilot project. Efficiency of an Evidence-Based Intervention to Promote and Reinforce Tobacco Abstinence Among Elementary Schoolchildren in a School Transition Period A cognitive–behavioral return-to-work program: effects on pain patients with a history of long-term versus short-term sick leave Predictors and Modifiers of Treatment Effect Influencing Sick Leave in Subacute Low Back Pain Patients 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 Predictors for outcome of a multi-modal cognitive behavioural treatment program for low back pain patients-a 12-month follow-up study. A 5-Year Follow-Up Evaluation of the Health and Economic Consequences of an Early Cognitive Behavioral Intervention for Back Pain: A Randomized, Controlled Trial The effect of graded activity on patients with subacute low back pain: a randomized prospective clinical study with an operant-conditioning behavioral approach. A randomized controlled trial of two strategies to implement active sick leave for patients with low back pain. Prognostic Factors for Duration of Sick Leave Due to Low-Back Pain in Dutch Health Care Professionals Graded Activity for Low Back Pain in Occupational Health Care Does Early Intervention With a Light Mobilization Program Reduce Long-Term Sick Leave for Low Back Pain? Secondary Prevention of Work-Related Disability in Nonspecific Low Back Pain: Does Problem-Solving Therapy Help? A Randomized Clinical Trial A clinical return-to-work rule for patients with back pain Treatment- and Cost-Effectiveness of Early Intervention for Acute Low-Back Pain Patients: A One-Year Prospective Study The effectiveness of graded activity for low back pain in occupational healthcare The role of the psychologist in multidisciplinary treatments for chronic neck and shoulder pain: a controlled cost-effectiveness study. Early Workplace Intervention for Employees With Musculoskeletal-Related Absenteeism: A Prospective Controlled Intervention Study Multimodal cognitive behavioral treatment of patients sicklisted for musculoskeletal pain: a randomized controlled study. Good Prognosis for Low Back Pain When Left Untampered: A Randomized Clinical Trial Lost productive time and cost due to common pain conditions in the US workforce. Passive coping is a risk factor for disabling neck or low back pain Participatory ergonomics as a return-to-work intervention: a future challenge? Multidisciplinary Rehabilitation for Subacute Low Back Pain: Graded Activity or Workplace Intervention or Both?: A Randomized Controlled Trial Early Occupational Health Management of Patients with Back Pain: A Randomized Controlled Trial Coordination of Primary Health Care for Back Pain: A Randomized Controlled Trial
abstract: This study evaluated a two-year multidisciplinary early intervention pilot programme for back-injured nurses employed at a large teaching hospital , using a pre- versus post-programme analysis . The purpose was to ascertain whether this programme could reduce the incidence , morbidity , time lost and cost due to  back injuries in the 250 nurses employed on ten targeted high-risk wards . Injuries in the remaining 1395 nurses employed on the other 45 wards were monitored concurrently for comparison . The programme consisted of prompt assessment , treatment and rehabilitation through modified work . Evaluative data were gathered by one research nurse on st and ardized forms at the time of injury , weekly until return to work , and at a six-month follow-up . Time lost and cost data for up to one-year post-injury were derived from workers ' compensation statements . Compared to the two years prior to introduction of the programme , the rates of back injuries and lost-time back injuries decreased by 23 % and 43 % , respectively , on the targeted wards , while these increased on the control wards . Combined expenditure was 32 % lower per injury and 34 % lower per lost-time injury for those in the targeted group who consented to take part in the programme compared to their counterparts on the control wards , as the increased assessment and treatment costs per case attributable to the programme were more than offset by the savings in lower compensation ( wage loss ) costs . This programme thus reduced the incidence and time lost due to back injuries and was cost-beneficial This study reports the evaluation of an intervention design edto reinforcetobacco abstinence amongelementary schoolchildren in a school transition period . This intervention was developed according to the principles of Intervention Mapping . A total of 765 grade 5 students ( ages 10 - 12 ) was recruited in 32 elementary schools . A quasi-experimental longitudinal design was used to evaluate the outcomes . Results observed 2 and 8 months postintervention are reported here . It is shown that although the behavior remained largely unchanged by the intervention , some of its determinants were modified . Behavioral intention , behavioral and normative beliefs , perceived self-efficacy , and role beliefs were changed at one or both postintervention measures . An interesting feature of these results relates to the fact that the most positive outcomes were seen among at-risk children . Discussion considers the advisability to develop , implement , and evaluate evidence -based interventions targeting the psychosocial factors underlying maintenance of tobacco smoking abstinence in elementary school & NA ; A cognitive – behavioral return‐to‐work focused program was evaluated in a r and omized controlled design , and the effects were compared between two groups of women with musculoskeletal pain . One group of patients ( n=36 ) had a history of long‐term sick leave ( > 12 months ) at the start of the program and the other ( n=36 ) had a history of short‐term sick leave ( 2–6 months ) . The outpatient treatment program , conducted by a psychologist , included 12 sessions with the primary aim to help the patients return‐to‐work . The treatment first included teaching of coping strategies such as applied relaxation , stress management , grade d activity training and pacing . Thereafter the patients were taught how to manage difficulties at their return‐to‐work and how to generalize coping strategies to different risk factors at their work places . The control condition received treatment‐as‐usual . The results showed that the cognitive – behavioral return‐to‐work program  was more effective than the treatment‐as‐usual control condition in reducing the number of days on sick leave for patients on short‐term sick leave , but not for patients on long‐term sick leave . The treatment program also helped the patients on short‐term sick leave to increase their ability to control and decrease pain and to increase their general activity level compared to the control condition . These results underscore the need for an early return‐to‐work focused rehabilitation to prevent long‐term sick leave and disability Study Design . Modifying effects in multivariate analyses of a r and omized controlled trial . Objectives . To identify prognostic factors for the effect of a brief intervention ( “ modifiers ” ) at a spine clinic on return to work in patients with subacute low back pain . Summary of Background Data . A previous study of a brief intervention showed significant reduction of sick leave , compared with usual primary healthcare treatment . R and omized controlled trials give data only on the group as an average . Identifying prognostic factors that interact with the treatment ( “ modifiers ” ) may identify specific groups requiring this or other types of treatment . Methods . A total of 457 patients who had been sick-listed 8 to 12 weeks for low back pain were r and omized into an intervention group ( spine clinic with medical examination , information , reassurance , encouragement to engage in physical activity , n = 237 ) , and a control group ( primary health care , n = 220 ) . All subjects filled out question naires . Logistic regression and tests for interaction were used to identify prognostic factors and modifiers for return to work in the two groups , at 3 and 12 months of follow-up . Results . At 3 months of follow-up , the strongest modifying effect on return to work was the perception of constant back strain when working and beliefs about reduced ability to work . At 12 months , gastrointestinal complaints were the strongest modifier for the effect of the intervention . Conclusion . The spine clinic intervention seems to have a main effect on work absenteeism via interacting with the concerns of being unable to work 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 Low back pain patients ( n=142 ) on sick leave for at least 8 weeks were given a multi-modal cognitive behavioural treatment program ( MMCBT ) that lasted for 4 weeks . Before treatment , all patients were tested with a comprehensive test battery . The outcome at 12-month follow-up was predictable from the pretest , but only when combining medical and psychological data . Patients who returned to work ( Returners , 50 % ) in the  MMCBT group were characterised by less pain , more psychological strength , were evaluated by the physiotherapist as having a good prognosis for return to work , and were less educated . Patients who did not return to work ( Non-returners ) in the MMCBT group felt tense and unfit , felt hopelessness concerning the future , were less physically active , thought their complaints would worsen if they continued working , and reported fewer difficulties driving a car .  Returners to work ( 58 % ) in the r and omised control group ( n=81 ) , who received ordinary physical therapy , were characterised by high levels of energy , less subjective health complaints , less exhaustion for a condition test , and did not work in positions giving a constant load on the back . There was no significant differences between number of patients who had returned to work in the  MMCBT  and the control group . Non-returners in the control group lacked energy , trained less regularly , worked in occupations that gave an almost constant load on the back , and did not expect to be back to work in the course of a couple of weeks . It seems to be important to develop further diagnostic tools to identify those who might benefit from extensive or specific treatments . Copyright 1998 European Federation of Chapters of the International Association for the Study of Pain Study Design . A 5-year follow-up of a r and omized , controlled trial . Objective . To evaluate the long-term health and economic consequences of a cognitive behavioral intervention . Summary of Background Data . Linton and And ersson ( Spine 2000;25:2825–31 ) provide 1 of only a few studies on the preventive effects of a cognitive behavioral intervention . The present study is a 5-year follow-up . Methods . In the original study , 213 participants were r and omized to the cognitive-behavioral group intervention or to usual care plus information on self-care ( information comparison group ) .  Of participants , 97 % completed a follow-up question naire 5 years after the intervention , and supplemental records were obtained from the National Insurance Authority . Results . The cognitive behavioral group had significantly less pain , was more active , enjoyed better quality of life , and had better general health relative to the information comparison group . There was no difference on health care use . The risk of long-term sick leave was 3 times higher in the information comparison group . The cognitive behavioral group had significantly less lost productivity costs and a lower total cost/y/person ( 16,514 Swedish kronor ) compared to the information comparison group ( 45,990 Swedish kronor ) . Conclusions . A cognitive-behavioral group intervention produces long-term health and economic benefits . Usual medical care might be improved considerably by implementing these psychologic methods 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 Cluster r and omized controlled trial . OBJECTIVE To evaluate the effectiveness of two strategies to improve the use of active sick leave ( ASL )  for patients with low back pain . SUMMARY OF BACKGROUND DATA ASL is a public sickness benefit scheme offered to promote early return to modified work for temporarily disabled workers . It was poorly used , and the authors design ed two community interventions to strengthen the implementation of ASL based on the results of a study of barriers to use among back pain patients , employers , general practitioners ( GPs ) , and local National Insurance Administration staff . METHODS Sixty-five municipalities in three counties in Norway , r and omly assigned to a passive intervention , a proactive intervention , or a control group . The interventions were targeted at patients on sick leave for low back pain for more than 16 days ( n = 6176 ) , their GPs , employers , and local insurance officers . The passive intervention included reminders about ASL on the sick leave form that GPs must complete , a st and ard agreement to facilitate ASL , targeted information , and a desktop summary for GPs of clinical practice guidelines for low back pain , emphasizing the importance of advice to stay active . The proactive intervention included these elements plus a re source person to facilitate the use of ASL and a continuing education workshop for GPs . The main outcome measure reported here is the proportion of eligible patients that used ASL . RESULTS ASL was used significantly more in the proactive intervention municipalities ( 17.7 % ) compared with the passive intervention and control municipalities ( 11.5 % , P = 0.018 ) . CONCLUSIONS A passive intervention that addressed identified barriers to the use of ASL did not increase its use . Although modest , a proactive intervention did increase its use . The main impact of the intervention was through direct contact and motivating telephone calls to patients . To the extent that GPs ' practice was changed , it was either patient mediated or by patients bypassing their GP Background : Information on prognostic factors for duration of sick leave  due to low-back pain ( LBP ) is growing . In this prospect i ve cohort study prognostic factors for duration of sick leave and course of disability were identified in a very early stage of sick leave due to LBP in an occupational health care setting . Methods : A total of 615 workers calling in sick from work due to LBP at an occupational health service ( OHS ) of one institution completed a question naire . Duration of follow-up was 26 weeks . Prognostic factors were identified by means of Cox regression analysis and multiple linear regression analysis , and explained variance was calculated . Results : Median time to first return to work ( RTW ) was 5 days ( Inter Quartile Range ( IQR ) = 2–12 ) . Median time to lasting return to work ( LRTW ) was 6 days ( IQR = 3–13 ) . The final model for delayed RTW included self-reported  expected duration of sick-leave  , treatment by GP or specialist , care-seeking , diminished mobility , and the interaction between care-seeking and diminished mobility . The final model for LRTW included : self-reported expected duration of sick-leave  ,  treatment by GP or specialist  , care-seeking , the interaction between the self-reported  expected duration of sick-leave and seeking care at OHS , complaints due to job stress , diminished mobility , and the interactions between expected duration of more then 10 days and seeking OP care and diminished mobility . Median total days on sick leave ( TDSL ) was 6 days ( IQR = 3–13 days ) . The final model for TDSL included : age , expected duration of sick leave , treatment by GP or medical specialist , seeking OP care , complaints due to physical load , and diminished mobility . Explained variance ( R2 ) of these models ranged from 30 to 35 % . Conclusions : Poor prognosis for duration of sick leave can be identified by means of a simple question naire administered on the first day of sick leave . Workers at high risk for longer duration of sick leave ( all outcomes ) expected to stay off work longer , were already being treated by a MD , sought OP care , and had diminished mobility . In case of delayed LRTW workers reported job stress as a possible cause of sick leave . Interactions were found in both RTW and LRTW between care-seeking and diminished mobility and in LRTW between expected duration of sick leave and seeking OP care . Older age increased TDSL with borderline significance Context Low back pain causes frequent disability and lost productive time . Contribution This r and omized trial compared a behavioral-oriented grade d activity program with usual care in 134 Dutch airline company workers who had missed work because of persistent low back pain .  Grade d activity consisted of biweekly 1-hour exercise sessions with physiotherapists who emphasized operant-conditioning principles . Over 6 months of follow-up , participants in the grade d activity program missed 58 days of work , while participants receiving usual care missed 87 days . Implication s A behavioral-oriented grade d activity program returned participants with low back pain to work more often than did usual care . The Editors Nonspecific low back pain is an uncomfortable medical condition that causes frequent disability and absence from work . Most episodes of low back pain resolve fairly quickly and cause only short periods of absence from work . However , some workers with low back pain miss work for several days to weeks and are at risk for more permanent disability ( 1 ) . To reduce the individual and socioeconomic burden related to this absenteeism , we need effective intervention strategies in occupational health care setting s that promote safe and rapid return to work . One promising and often-advocated intervention strategy for workers with prolonged nonspecific low back pain is active rehabilitation that is directed toward return to normal activity and work ( 2 ) . Examples are grade d activity interventions that include physical exercise , application of operant-conditioning behavioral principals , and promotion of improved functioning and safe return to work even if pain persists ( 3 - 6 ) . In a r and omized , controlled trial , Lindstrm and colleagues ( 3 , 4 ) found that a grade d activity intervention reduced absence from work more than did traditional care in Swedish workers employed in the automobile industry . We investigate , in a second r and omized , controlled trial , whether absence from work because of low back pain is reduced more with grade d activity intervention than with traditional care in an occupational health care setting in the Netherl and s. Methods Study Design and Sample The study was a single-blind , r and omized , controlled trial in an occupational health services center ( KLM Health , Safety and Environment ) at Schiphol Airport , Amsterdam , the Netherl and s. The center provides occupational health services for all employees of a major Dutch airline ( KLM Royal Dutch Airlines ) . The source sample ( n = 20 000 ) consisted of workers who were employed in the following organizational units of the airline : baggage and aircraft turnaround services , passenger services , engineering and maintenance , cargo , and cabin and cockpit . Workers who were listed as absent from work because of low back pain were invited for a consultation with the occupational physician . Those who were thought to be eligible for inclusion were referred to the research assistant , who judged whether they met the inclusion criteria : full or partial absence from work because of nonspecific low back pain and low back pain symptoms with a minimum duration of 4 weeks in succession . The exclusion criteria were low back pain with radiation below the knee with signs of nerve-root compression ( 7 ) ; cardiovascular contraindications for physical activity , as checked according to the Physical Activities Readiness Question naire ( 8 , 9 ) ; any conflict between worker and employer with legal involvement ; or pregnancy . Workers who met the inclusion criteria were informed of the purpose and procedures of the study and were enrolled after giving informed consent . The Medical Ethical Committee of the VU University Medical Center , Amsterdam , the Netherl and s , approved the study . Treatment Allocation The participants were assigned to grade d activity or usual care on the basis of block r and omization , after prestratification for the organizational unit in the workplace from which they were recruited ( the 5 organizational units listed earlier ) and for the severity of pain symptoms ( scored on a scale of 0 to 10 ; severity scores were < 6 or 6 points ) . This result ed in a total of 10 strata . R and omized , permuted blocks of 4 allocations were generated for each stratum through a computer-generated r and om-sequence table . Opaque , sequentially numbered , sealed envelopes were prepared for each stratum by a research er who was not involved in enrolling the participants or assigning them to their groups . The envelopes contained a sheet of paper that indicated 1 of the 2 interventions . Participants learned their group assignments after a research assistant completed the baseline measurements and delivered the sealed envelopes . Blinding The research assistants who collected the data were blinded to the treatment allocation . All participants were repeatedly asked not to reveal any information about their treatment allocation . The participants and treatment providers were not blinded to treatment allocation . Interventions In the Dutch occupational health care system , occupational physicians guide disabled workers who are absent from work through their disability period . These occupational physicians are employed by occupational health services that are paid for by the companies . The occupational physicians adhere to back pain management strategies that consist of advising workers on ergonomics , prevention , and return-to-work schedules and advising and communicating with other stakeholders ( such as health care providers and representatives of the workplace ) . Disabled workers who participated in the present study were assigned to either grade d activity or usual care within the context of the Dutch occupational health care setting . Grade d Activity The intervention group received the usual guidance from the occupational physician about work-related problems and barriers to return to work as well as the grade d activity intervention supervised by a physiotherapist .  Three physiotherapists who worked in a private practice at Schiphol Airport provided the treatment according to the grade d activity protocol . Two of those physiotherapists were also trained as manual therapists , and 1 was also a human movement scientist . Before the study , the physiotherapists had been specifically trained to treat patients with low back pain according to behavioral principles . A research physiotherapist who was experienced in treating patients with chronic pain in rehabilitation centers instructed the physiotherapists in three 2-hour sessions and practice d patienttherapist interactions with them through role-play . Before the study , the physiotherapists treated several patients according to the grade d activity protocol to gain more experience . The physiotherapists made audiotapes of the intervention sessions before and during the study period . The contents of these audiotapes were assessed and discussed with the research physiotherapist in 3 additional meetings . Furthermore , the physiotherapists summarized the treatment after each session , and research ers used these summaries to review the sessions . The same physiotherapist treated participants each time , except for temporary st and -in sessions that were supervised by colleagues because of holidays or other reasons . Specific therapists were not systematic ally selected to treat specific participants ; selection was based on pragmatic reasons , such as the time available in the work schedules of the physiotherapists or the days of treatment preferred by the participants . Table 1 presents the concept and content of the grade d activity intervention . The intervention consisted of 1-hour exercise sessions that participants attended twice per week until they returned completely to regular work or until the maximum therapy duration of 3 months was reached . At the start of the intervention , the physiotherapist inquired about the participant 's medical history and completed a brief physical examination consisting of flexion , extension , and lateroflexion of the lumbar spine and a brief screening for nerve-root pain ( 10 ) . The purpose of the physical examination was to confirm the diagnosis of benign , nonspecific low back pain and to reduce participants ' fears about any presumed underlying disease . The participants were reassured that despite the annoying pain , nothing was seriously wrong with their backs . Subsequently , the physiotherapist and participant decided on a set of general exercises and individually tailored exercises . Both types of exercises had to be performed during each session . The general exercises were aerobic exercises , such as cycling or rowing , and strengthening exercises for large muscle groups , and most were carried out in a gym while using exercise equipment . The strengthening exercises were a floor abdominal sit-up exercise , a dynamic back extension exercise , a leg-press exercise , a latissimus pull-down exercise , and st and ing up from a low chair .  Participants in the grade d activity group had to perform not only these general exercises but also individually tailored exercises , which imitated physical tasks at work or difficult and painful activities of daily living . For example , a participant who reported back problems while lifting and moving suitcases from a luggage wagon into an airplane might be given an exercise to practice lifting and moving a suitcase with a certain number of repetitions . During the first 3 sessions , the maximal performance ( for example , the maximum number of repetitions ) was assessed for each exercise separately , and the average score for each exercise over the 3 sessions was used as a baseline value for specifying a gradually progressive exercise scheme . Subsequently , the participant was asked to propose a date for full return to regular work , which would consequently be the end point of the physical exercise program . Before returning to full regular work , participants could return to work with modified hours and duties . Advised by the physiotherapist , the participant 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 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 Background : Tools for early identification of workers with back pain who are at high risk of adverse occupational outcome would help concentrate clinical attention on the patients who need it most , while helping reduce unnecessary interventions ( and costs ) among the others . This study was conducted to develop and vali date clinical rules to predict the 2-year work disability status of people consulting for nonspecific back pain in primary care setting s. Methods : This was a 2-year prospect i ve cohort study conducted in 7 primary care setting s in the Quebec City area . The study enrolled 1007 workers ( participation , 68.4 % of potential participants expected to be eligible ) aged 18–64 years who consulted for nonspecific back pain associated with at least 1 day 's absence from work . The majority ( 86 % ) completed 5 telephone interviews documenting a large array of variables . Clinical information was abstract ed from the medical files . The outcome measure was “ return to work in good health ” at 2 years , a variable that combined patients ' occupational status , functional limitations and recurrences of work absence . Predictive models of 2-year outcome were developed with a recursive partitioning approach on a 40 % r and om sample of our study subjects , then vali date d on the rest . Results : The best predictive model included 7 baseline variables ( patient 's recovery expectations , radiating pain , previous back surgery , pain intensity , frequent change of position because of back pain , irritability and bad temper , and difficulty sleeping ) and was particularly efficient at identifying patients with no adverse occupational outcome ( negative predictive value 78%– 94 % ) . Interpretation : A clinical prediction rule accurately identified a large proportion of workers with back pain consulting in a primary care setting who were at a low risk of an adverse occupational outcome 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 Background : Low back pain is a common medical and social problem associated with disability and absence from work . Knowledge on effective return to work ( RTW ) interventions is scarce . Objective : To determine the effectiveness of grade d activity as part of a multistage RTW programme . Design : R and omised controlled trial . Setting : Occupational healthcare . Subjects : 112 workers absent from work for more than eight weeks due to low back pain were r and omised to either grade d activity ( n = 55 ) or usual care ( n = 57 ) . Intervention : Grade d activity , a physical exercise programme aim ed at RTW based on operant-conditioning behavioural principles . Main outcome measures : The number of days off work until first RTW for more then 28 days , total number of days on sick leave during follow up , functional status , and severity of pain . Follow up was 26 weeks . Results : Grade d activity  prolonged RTW . Median time until RTW was equal to the total number of days on sick leave and was 139 ( IQR = 69 ) days in the grade d activity group and 111 ( IQR = 76 ) days in the usual care group ( hazard ratio = 0.52 , 95 % CI 0.32 to 0.86 ) . An interaction between a prior workplace intervention and grade d activity , together with a delay in the start of the grade d activity intervention , explained most of the delay in RTW ( hazard ratio = 0.86 , 95 % CI 0.40 to 1.84 without prior intervention and 0.39 , 95 % CI 0.19 to 0.81 with prior intervention ) . Grade d activity did not improve pain or functional status clinical ly significantly . Conclusions : Grade d activity was not effective for any of the outcome measures . Different interventions combined can lead to a delay in RTW . Delay in referral to grade d activity delays RTW . In implementing grade d activity special attention should be paid to the structure and process of care This study was design ed to determine a cost-effective use of psychologist re sources in multimodal cognitive-behavioural treatments ( MMCBT ) for chronic neck/shoulder pain . A r and omised controlled trial was conducted with 66 patients divided in two groups . The first group ( A ) was treated following the approach of MMCBT with the clinical psychologist only functioning as a " coach " to the other health professionals . In this group , the psychologist had on average 5 hours of input per patients . The second group ( B ) was treated with the same inpatient MMCBT but with the behavioural component administered by the clinical psychologist directly to the patients . In this second group the psychologist had on average 17 hours of input per patient in the entire intervention . The outcome variables included physical , emotional and social factors , and sick-leave . Both groups showed significant improvements over time . The improvements were evident only in sub-groups , specifically in women . The only significant difference between the groups was in " perceived helplessness " favouring the " psychologist contact " setting . It is concluded that in terms of input of clinical psychology , the treatment setting with the " coaching " technique proved to be the most cost-effective use of the psychologist in the two treatment setting s investigated Sickness absenteeism caused by musculoskeletal disorders ( MSDs ) is a persistent and costly occupational health challenge . In a prospect i ve controlled trial , we compared the effects on sickness absenteeism of a more proactive role for insurance case managers as well as workplace ergonomic interventions with that of traditional case management .  Patients with physician-diagnosed MSDs were r and omized either to the  intervention group or  the reference group offered the traditional case management routines . Participants filled out a comprehensive question naire at the initiation of the study and after 6 months . In addition , administrative data were collected at 0 , 6 , and 12 months after the initiation of the project . For the entire 12-month period , the total mean number of sick days for the intervention group was 144.9 ( SEM 11.8 ) days/person as compared to 197.9 ( 14.0 ) days in the reference group ( P < 0.01 ) . Compared with the reference group , employees in the intervention group significantly more often received a complete rehabilitation investigation ( 84 % versus 27 % ) . The time for doing this was reduced by half ( 59.4 ( 5.2 ) days versus 126.8 ( 19.2 ) , P < .01 ) . The odds ratio for returning to work in the intervention group was 2.5 ( 95 % confidence interval 1.2–5.1 ) as compared with the reference group . The direct cost savings were USD 1195 per case , yielding a direct benefit-to-cost ratio of 6.8 . It is suggested that the management of MSDs should to a greater degree focus on early return to work and building on functional capacity and employee ability . Allowing the case managers a more active role as well as involving an ergonomist in workplace adaptation meetings might also be beneficial In a r and omized controlled study multimodal cognitive behavioral treatment ( MMCBT ) , including physical treatment , cognitive behavioral modification , education , and examination of the work situation for each patient , was given to patients sick-listed for musculoskeletal pain ( n = 469 ) . Patients were recruited through the National Insurance System . After a pre-test by an independent physiotherapist the patients were allocated at r and om to the  intervention group ( n = 312 ) or the control group ( n = 157 ) . The MMBCT program lasted for 4 weeks . The control group returned to their general practitioners , without any feedback or advice on therapy from the project . At the one year follow-up the MMCBT group had not returned to work at a higher rate than the control group receiving ordinary treatment available through their general practitioners . However , the MMCBT group had improved their ergonomic behavior , work potential , life quality , physical , and psychological health 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 CONTEXT Common pain conditions appear to have an adverse effect on work , but no comprehensive estimates exist on the amount of productive time lost in the US workforce due to pain . OBJECTIVE To measure lost productive time ( absence and reduced performance due to common pain conditions ) during a 2-week period . DESIGN AND SETTING Cross-sectional study using survey data from the American Productivity Audit ( a telephone survey that uses the Work and Health Interview ) of working adults between August 1 , 2001 , and July 30 , 2002 . PARTICIPANTS R and om sample of 28 902 working adults in the United States . MAIN OUTCOME MEASURES Lost productive time due to common pain conditions ( arthritis , back , headache , and other musculoskeletal ) expressed in hours per worker per week and calculated in US dollars . RESULTS Thirteen percent of the total workforce experienced a loss in productive time during a 2-week period due to a common pain condition . Headache was the most common ( 5.4 % ) pain condition result ing in lost productive time . It was followed by back pain ( 3.2 % ) , arthritis pain ( 2.0 % ) , and other musculoskeletal pain ( 2.0 % ) . Workers who experienced lost productive time from a pain condition lost a mean ( SE ) of 4.6 ( 0.09 ) h/wk . Workers who had a headache had a mean ( SE ) loss in productive time of 3.5 ( 0.1 ) h/wk . Workers who reported arthritis or back pain had mean ( SE ) lost productive times of 5.2 ( 0.25 ) h/wk . Other common pain conditions result ed in a mean ( SE ) loss in productive time of 5.5 ( 0.22 ) h/wk . Lost productive time from common pain conditions among active workers costs an estimated 61.2 billion dollars per year . The majority ( 76.6 % ) of the lost productive time was explained by reduced performance while at work and not work absence . CONCLUSIONS Pain is an inordinately common and disabling condition in the US workforce . Most of the pain-related lost productive time occurs while employees are at work and is in the form of reduced performance & NA ; Background : Despite evidence suggesting that coping is an important concept in the study of pain , its role in predicting the development of disabling pain has not been previously studied . To assess the relationship between coping and the development of disabling pain . Methods : From a r and om sample of adults , we formed a cohort of individuals with non‐disabling neck and /or low back pain ( n=571 ) . Participants were followed 6 and 12 months after the index survey .  Coping  was measured with the V and erbilt Pain Management Inventory . The Chronic Pain Question naire was used to measure the presence of disabling neck and /or low back pain . We used Cox proportional hazards regression analyses to investigate the role of passive coping in the development of disabling pain while controlling for confounders . Results : Passive coping was a strong , independent risk factor for disabling neck and /or back pain . Those using moderate to high levels of passive coping strategies were at an over five‐fold increased risk of developing disabling pain ( Moderate : HRR=5.19 , 95 % CI=1.78–15.1 ; High : HRR=6.80 , 95 % CI=2.36–19.6 ) . Active coping was not found to be a significant risk factor for disabling neck and /or back pain . Conclusion : Passive coping is a strong and independent predictor of disabling neck and /or back pain . This strong relationship identifies passive coping as a marker for risk of disability and can allow for the identification of individuals at risk and in need of intervention to aid in improving their overall adjustment BACKGROUND Participatory ergonomics ( PE ) are often applied for prevention of low back pain ( LBP ) . In this pilot- study , a PE-program is applied to the disability management of workers sick listed due to LBP . METHODS The process , implementation , satisfaction , and barriers for implementation concerning the PE-program were analyzed quantitatively and qualitatively for 35 workers sick listed 2 - 6 weeks due to LBP and their ergonomists . RESULTS Two-hundred- and -seventy ergonomic solutions were proposed to the employer . They were targeted more at work design and organization of work ( 58.9 % ) than at workplace and equipment design ( 38.9 % ) . They were planned mostly on a short-term basis ( 74.8 % ) . Almost half ( 48.9 % ) of the solutions for work adjustment were completely or partially implemented within 3 months after the first day of absenteeism . Most workers were satisfied about the  PE-program  ( median score 7.8 on a 10-point scale ) and reported a stimulating effect on return-to-work ( 66.7 % ) . Main obstacles to implementation were technical or organizational difficulties ( 50.0 % ) and physical disabilities of the worker ( 44.8 % ) . CONCLUSIONS This study suggests that compliance , acceptance , and satisfaction related to the PE-program were good for all participants . Almost half of the proposed solutions were implemented Study design . Population -based r and omized controlled trial . Objective . To assess the effectiveness of workplace intervention and grade d activity , separately and combined , for multidisciplinary rehabilitation of low back pain ( LBP ) . Summary of Background Data . Effective components for multidisciplinary rehabilitation of LBP are not yet established . Methods . Participants sick-listed 2 to 6 weeks due to nonspecific LBP were r and omized to workplace intervention ( n = 96 ) or usual care ( n = 100 ) .  Workplace intervention consisted of workplace assessment , work modifications , and case management involving all stakeholders . Participants still sick-listed at 8 weeks were r and omized for grade d activity  ( n = 55 ) or usual care ( n = 57 ) . Grade d activity comprised biweekly 1-hour exercise sessions based on operant-conditioning principles . Outcomes were lasting return to work , pain intensity and functional status , assessed at baseline , and at 12 , 26 , and 52 weeks after the start of sick leave . Results . Time until return to work for workers with workplace intervention was 77 versus 104 days ( median ) for workers without this intervention ( P = 0.02 ) . Workplace intervention was effective on return to work ( hazard ratio = 1.7 ; 95 % CI , 1.2–2.3 ; P = 0.002 ) .  Grade d activity had a negative effect on return to work ( hazard ratio = 0.4 ; 95 % CI , 0.3–0.6 ; P < 0.001 ) and functional status . Combined intervention had no effect . Conclusion . Workplace intervention is advised for multidisciplinary rehabilitation of subacute LBP . Grade d activity or combined intervention is not advised Study Design . A r and omized controlled trial in occupational health practice was conducted . Objective . To study the efficacy of early management of workers with low back pain by occupational physicians  , as compared with management by the supervisor only . Summary of Background data . Health care and university workers with back pain and on sick leave for less than 1 month were included in the study . Methods . Patients with low back pain for at least 10 days on sick leave were r and omly assigned to early management by the occupational physician ( n = 61 ) or to a reference group with management by the worker ’s supervisor during the first 3 months of sick leave  ( n = 59 ) . The patients were observed for 1 year and compared in terms of time until return to work , pain intensity , functional disability , and general health perception . The occupational physicians were provided with management guidelines . Results . No significant differences were found after 3 and 12 months of follow-up evaluation in terms of time until return to work ( hazard ratio , 1.3 ; 95 % CI , 0.90–1.90 ) or in terms of other health outcomes . Recurrences , however , occurred more frequently in the intervention group , but the total duration of sick leave in 1 year did not differ between the groups . Conclusions . The findings do not show a significant positive effect of an early intervention by occupational physicians on workers with low back pain . This might reflect the early phase of disability or the low intensity of the intervention result ing from overestimation of the physicians ’ compliance with the guidelines 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
target: The key features of the program include ; having trained personnel coordinate the RTW process , identifying and ranking barriers and solutions to RTW from the perspective of all important stakeholders , mediating practical solutions at the workplace and , empowering the injured worker in RTW decision-making .
background: Background Despite over 2 decades of research , the ability to prevent  work-related low back pain ( LBP ) and disability  remains elusive .
  Recent research suggests that interventions that are focused at the workplace and incorporate the principals of participatory ergonomics and return-to-work ( RTW ) coordination can improve RTW and reduce disability following a work-related back injury .
  Workplace interventions or programs to improve RTW  are difficult to design and implement given the various individuals and environments involved , each with their own unique circumstances .
  Intervention mapping provides a framework for design ing and implementing complex interventions or programs .
  The objective of this study is to design a best evidence RTW program for occupational LBP tailored to the Ontario setting using an intervention mapping approach .