Impact of chronic pain patients' job perception variables on actual return to work

Systematic review and tools appraisal of prognostic factors of return to work in workers on sick leave due to musculoskeletal and common mental disorders

With the overall objective of providing implication for clinical and research practices regarding the identification and measurement of modifiable predicting factors for return to work (RTW) in people with musculoskeletal disorders (MSDs) and common mental disorders (CMDs), this study 1) systematically examined and synthetized the research evidence available in the literature on the topic, and 2) critically evaluated the tools used to measure each identified factor. A systematic search of prognostic studies was conducted, considering four groups of keywords: 1) population (i.e., MSDs or CMDs), 2) study design (prospective), 3) modifiable factors, 4) outcomes of interest (i.e., RTW). Studies showing high risk of bias were eliminated. Tools used to measure prognostic factors were assessed using psychometric and usability criteria. From the 78 studies that met inclusion criteria, 19 (for MSDs) and 5 (for CMDs) factors reaching moderate or strong evidence were extracted. These factors included work accommodations, RTW expectations, job demands (physical), job demands (psychological), job strain, work ability, RTW self-efficacy, expectations of recovery, locus of control, referred pain (back pain), activities as assessed with disability questionnaires, pain catastrophizing, coping strategies, fears, illness behaviours, mental vitality, a positive health change, sleep quality, and participation. Measurement tools ranged from single-item tools to multi-item standardized questionnaires or subscales. The former generally showed low psychometric properties but excellent usability, whereas the later showed good to excellent psychometric properties and variable usability. The rigorous approach to the selection of eligible studies allowed the identification of a relatively small set of prognostic factors, but with a higher level of certainty. For each factor, the present tool assessment allows an informed choice to balance psychometric and usability criteria.

Associations between social integration, participation and productivity loss among persons with chronic pain: a registry based cross sectional study

Purpose

To examine associations between factors of social inclusion and participation and productivity loss in employed persons with chronic pain, assessed for an interprofessional pain rehabilitation programme. We hypothesized that factors of social inclusion and participation and work related social factors are significantly associated with productivity when experiencing chronic pain and we expected a moderate effect.

Methods

Cross-sectional study using data collected prospectively in an interprofessional patient registry for chronic pain. The primary end point was productivity loss, measured with the iMTA Productivity Costs Questionnaire. We included data from 161 individuals. To be included, persons had to be 18 years old or older, in paid work, and had to have a medical diagnosis of chronic pain syndrome with actual or potential tissue damage. In addition, participants had to have indicators of significant impairments in psychosocial functions.

Results

Linear regression analysis showed that a highly stressful professional situation, frequent problems regarding the compatibility of the family and job and not being Swiss were associated with a significantly higher total productivity loss. Similar results were found for productivity loss in paid work. However, problems concerning the compatibility of the family and job did not reach the significance level for productivity loss in paid work.

Conclusion

The results of this study underscore the importance of factors of social inclusion and participation for interprofessional rehabilitation programmes to manage chronic pain especially when focussing on productivity loss.

Can Patient Expectations of Returning to Work Documented Before, During, or at the End of Treatment Predict Actual Return to Work Post-treatment? An Evidence-Based Structured Systematic Review

BACKGROUND

There is significant evidence that patient expectations can impact their treatment outcomes. The hypothesis of this systematic review was then the following. There will be significant consistent evidence as specified by the Agency for Health Care Policy and Research (AHCPR) guidelines that chronic pain patient (CPP) expectations for returning to work documented before, during, or at the end of treatment will predict actual return to work post-treatment.

METHODS

Of 316 references, 12 studies fulfilled inclusion criteria. These studies analyzed expectations of returning to work documented before, during, or at the end of treatment and utilized these for predicting return to work post-treatment. Relevant aspects of these studies were abstracted into tabular form for numerical analysis. All studies were rated independently by two reviewers for quality. The percentage of the 12 studies supporting the hypothesis was determined. This was then utilized to determine an AHCPR guideline rating for consistency.

RESULTS

No studies had a rejection quality score. All studies were type 4. The hypothesis was supported by 91.6% of the studies. According to the AHCPR guidelines, this translated into an A rating: consistent findings from multiple type 4 studies.

CONCLUSIONS

CPP expectations of returning to work as documented before, during, or at the end of treatment may predict actual return to work post-treatment.

A pilot study of the individual placement and support model for patients with chronic pain

Background

Individual Placement and Support (IPS) is an evidence-based work rehabilitation model with well-documented effects for people with mental illness. The model has, however, never been tested out for people with chronic pain. This pilot study aimed to investigate chronic pain patients’ experiences with the IPS job support model.

Methods

We recruited eight consecutive patients referred for various chronic pain conditions at a hospital outpatient pain clinic. They were offered IPS job support as an integrated part of their interdisciplinary pain rehabilitation. The patients’ experiences were investigated through semi-structured interviews 3 months after inclusion in the study.

Results

The participants reported mostly positive experiences with IPS. One participant dropped out of the study after deterioration of symptoms, while the remaining participants were satisfied with the intervention. Particular helpful aspects of the IPS intervention were the follow-up from the employment specialist, focus on competitive employment, focus on work despite pain complaints, reframing work into something positive, administrative support, and practice in writing applications. No participants reported adverse experiences from the IPS intervention. Within a 12-months time frame, 3 of the 8 participants gained competitive employment.

Conclusions

This is the first report of the IPS model of supported employment applied in an outpatient setting for chronic pain patients. The results suggest that IPS can be successfully integrated with interdisciplinary pain rehabilitation, and warrants large-scale testing in a randomized controlled trial.

Returning the chronically unemployed with low back pain to employment

Much of the research into return to work following rehabilitation for low back pain in the literature reflects work done in those employed. Unemployment is a consequence of chronic low back pain which has considerable health and economic consequences for the individual and society. This paper describes an occupationally orientated rehabilitation programme for long-term unemployed people (mean duration of unemployment 38.9 months). The aim of the project was to identify factors which predict return to work and progress towards employment. Eight six subjects underwent a pain management rehabilitation programme incorporating vocational focussing and advice, subjects were followed up at 6 months to determine work status. At follow-up 38.4% of subjects were employed and another 23% were in voluntary work, or education/training. There were no significant differences on presenting characteristics between those who returned to work and those who did not. Subjects were divided into those who made positive progress (work, education/training or voluntary work) and those who did not (remained unemployed, dropped out of the programme or lost to follow up). Those who failed to make positive progress were characterised by longer duration of unemployment and higher scores on somatic anxiety and depression. A predictive model was able to identify 80% of those who failed to make progress but prediction of those achieving a positive outcome was poor (44% correct prediction). The factors predicting return to work in unemployed people with low back pain differs from the employed, the need for employment skills training and a vocational focus to rehabilitation are highlighted.

Predicting work status following interdisciplinary treatment for chronic pain

The effectiveness of interdisciplinary treatments for chronic pain is well established. In general, these treatments decrease psychosocial distress and increase physical abilities. Further, return to work rates following interdisciplinary treatment tend to be quite high. Previous studies have highlighted a number of factors that individually influence return to work rates; however, there is a need for more comprehensive and unified models that allow an evaluation of the inter-relations among these factors. The present investigation examined how demographic and treatment outcome variables interacted to influence post-treatment return to work rates in a sample of individuals with chronic pain following interdisciplinary treatment. Results indicated that patient age, lifting ability, pain duration, depression level, and reported disability were individually related to return to work; however, when these variables were evaluated relative to one another, level of depression and patient age had the best ability to predict post-treatment work status. These results add to the literature by specifically highlighting post-treatment factors that best discriminate patients who had returned to work from those that had not. Furthermore, they provide evidence that general emotional distress is perhaps the most important predictor of work status following treatment.

The impact of psychiatric comorbidity on the return to work in patients undergoing herniated disc surgery

INTRODUCTION

This study examines (1) return to work (RTW) and ability to work (ATW) rates, and the association with (2) psychiatric comorbidity and (3) socio-demographic, illness-related, vocational and rehabilitation-related characteristics in herniated disc surgery patients.

METHODS

In this longitudinal observational study 305 consecutive patients took part in face-to-face interviews during hospital stay. 277 patients also participated in a 3-month follow-up survey via telephone (drop-out rate 9%). Psychiatric comorbidity was assessed with the Composite International Diagnostic Interview (CIDI-DIA-X). Calculations were conducted via Chi-Square tests, independent T-tests and binary logistic regression analyses.

RESULTS

40.1% of the herniated disc patients in this study were able to RTW, 44.4% had regained their ATW 3 months after surgery. Psychiatric comorbidity appeared to be an important risk factor for RTW and ATW. Other risk factors were lower educational qualification, unemployment status, a lower subjective prognosis of gainful employment, a higher number of herniated discs in medical history, cervical disc surgery, and the existence of other chronic diseases, a longer hospital stay and higher pain intensity. Patients who did not RTW, or did not regain their ATW participated more often in inpatient rehabilitation.

CONCLUSIONS

Identifying a high risk group for RTW and ATW at an early age is of utmost importance for the purpose of improving rehabilitation effects and to make a return to the work place easier. Specific interventions, such as social-medical counselling, pain therapy and management, as well as the assistance of mental health professionals during hospital and rehabilitation treatment are recommended for this risk group.

Expectations, perceptions, and physiotherapy predict prolonged sick leave in subacute low back pain

BACKGROUND

Brief intervention programs for subacute low back pain (LBP) result in significant reduction of sick leave compared to treatment as usual. Although effective, a substantial proportion of the patients do not return to work. This study investigates predictors of return to work in LBP patients participating in a randomized controlled trial comparing a brief intervention program (BI) with BI and physical exercise.

METHODS

Predictors for not returning to work was examined in 246 patients sick listed 8-12 weeks for low back pain. The patients had participated in a randomized controlled trial, with BI (n = 122) and BI + physical exercise (n = 124). There were no significant differences between the two intervention groups on return to work. The groups were therefore merged in the analyses of predictors. Multiple logistic regression analysis was used to identify predictors for non return to work at 3, 12, and 24 months of follow-up.

RESULTS

At 3 months of follow-up, the strongest predictors for not returning to work were pain intensity while resting (OR = 5.6; CI = 1.7-19), the perception of constant back strain when working (OR = 4.1; CI = 1.5-12), negative expectations for return to work (OR = 4.2; CI = 1.7-10), and having been to a physiotherapist prior to participation in the trial (OR = 3.3; CI = 1.3-8.3). At 12 months, perceived reduced ability to walk far due to the complaints (OR = 2.6; CI = 1.3-5.4), pain during activities (OR = 2.4; CI = 1.1-5.1), and having been to a physiotherapist prior to participation in the trial (OR = 2.1; CI = 1.1-4.3) were the strongest predictors for non return to work. At 24 months age below 41 years (OR = 2.9; CI = 1.4-6.0) was the only significant predictor for non return to work.

CONCLUSION

It appears that return to work is highly dependant on individual and cognitive factors. Patients not returning to work after the interventions were characterized by negative expectations, perceptions about pain and disability, and previous physiotherapy treatment. This is the first study reporting that previous treatment by physiotherapists is a risk factor for long-term sick leave. This has not been reported before and is an interesting finding that deserves more scrutiny.

Alcohol use self report in chronic back pain—relationships to psychosocial factors, function performance, and medication use

BACKGROUND CONTEXT

Alcohol consumption is a known risk factor for spinal disability, but there is no data on the relationship between reported alcohol consumption and behaviours in persons who are disabled.

PURPOSE

To determine the interaction between reported alcohol consumption, physical performance, and medication use in this group. To determine psychosocial correlates of reported alcohol consumption in this group.

METHODS

A retrospective review 147 men and 136 women with more than 3 months disability who underwent a multidisciplinary physical, functional and psychosocial Spine Team Assessment. Questions about alcohol consumption were related to outcome measures.

RESULTS

None of the women reported more than 5 drinks/week. Ten men reported more than 12 drinks per week. These performed significantly better on the Progressive Isoinertial Lifting Evaluation (PILE) low lift and the Functional Assessment Screening Test (FAST) 5 minute twisting test, and trended towards better performance on all other tests (the PILE high lift, all 4 other FAST components, Sorenson trunk extension test, and bicycle ergometer submaximal stress test). They had less back pain disability (Quebec p = 0.061), but no difference in depression (CESD), pain (visual analog scale) or fear (Tampa). They used fewer Non-steroidal medications, but similar narcotic medications as the others. No significant differences in the SF-36 were noted.

CONCLUSIONS

This first assessment of the relationship of alcohol consumption with back pain disability suggests that women with chronic back pain disability seldom report heavy alcohol consumption. Men with back pain disability who consume large amounts of alcohol have less physical disability despite similar pain. Despite potential interactions, heavy drinkers with pain do not use fewer narcotic analgesics than light drinkers.

Frequency and interrelations of risk factors for chronic low back pain in a primary care setting

Introduction

Many risk factors have been identified for chronic low back pain (cLBP), but only one study evaluated their interrelations. We aimed to investigate the frequency of cLBP risk factors and their interrelations in patients consulting their general practitioners (GPs) for cLBP.

Methods

A cross-sectional, descriptive, national survey was performed. 3000 GPs randomly selected were asked to include at least one patient consulting for cLBP. Demographic, clinical characteristics and the presence of cLBP risk factors were recorded. The frequency of each cLBP risk factor was calculated and multiple correspondence analysis (MCA) was performed to study their interrelations.

Results

A total of 2068 GPs (68.9%) included at least 1 patient, for 4522 questionnaires analyzed. In the whole sample of patients, the 2 risk factors most commonly observed were history of recurrent LBP (72.1%) and initial limitation of activities of daily living (66.4%). For working patients, common professional risk factors were beliefs, that LBP was due to maintaining a specific posture at work (79.0%) and frequent heavy lifting at work (65.5%). On MCA, we identified 3 risk-factor dimensions (axes) for working and nonworking patients. The main dimension for working patients involved professional risk factors and among these factors, patients' job satisfaction and job recognition largely contribute to this dimension.

Discussion

Our results shed in light for the first time the interrelation and the respective contribution of several previously identified cLBP risk factors. They suggest that risk factors representing a “work-related” dimension are the most important cLBP risk factors in the working population.

Does smoking status affect multidisciplinary pain facility treatment outcome?

OBJECTIVES

Smoking may be a major problem in chronic low back pain (LBP) patients. The goal of this study was to determine whether smoking status affected multidisciplinary pain facility treatment outcome.

DESIGN

As part of a grant study, chronic LBP patients identified themselves as either current smokers (N = 81) or current nonsmokers (N = 140), and were compared by chi-square for employment status at 1, 6, 12, and 24 months after multidisciplinary pain facility treatment. Smokers who were unemployed at each time interval were then compared with employed smokers for a large number of assessment scales and clinical variables of interest by chi-square or Student's t-test. The significant independent variables from these analyses were then utilized in a logistic regression to determine predictors for smoker nonemployment.

SETTING

Pain facility.

RESULTS

Current smokers were less likely to be employed at each follow-up time point. Pain levels over the previous 24 hours predicted employment status for current smokers at 1-, 12-, and 24-month follow-up, while worker compensation status predicted employment status at 6 months.

CONCLUSIONS

Current smoking status appears to be associated with poorer treatment outcome after multidisciplinary pain facility treatment. Return to work within smokers is predicted by pain and worker compensation status. Pain facilities should target current smokers with significant perceived pain for close treatment monitoring in an attempt to improve treatment outcome.

Measuring return to work

BACKGROUND

It is argued that one of the factors limiting the understanding of return to work (RTW) following work disability is the use of measurement tools that do not capture a complete picture of workers' RTW experiences. To facilitate the investigation of RTW, the current authors proposed a developmental conceptualization of RTW, which argues for an expanded awareness that encompasses four phases: off work, work reintegration, work maintenance and advancement. This paper reports on work undertaken with the aim of operationalizing the conceptualization.

METHODS

A review of the RTW and related literature, with databases searched including PubMed, EconLit, and PsycInfo. We began by extracting details of RTW instruments used by previous researchers. We then interpreted these within the context of the phases of RTW. Using the International Classification of Functioning, Disability, and Health (ICF) to inform our thinking and coding structure, we conceptualized phase-based RTW outcomes and categorized them as 'tasks and actions', 'contextual' or 'process driven'. Iteratively, we reviewed existing instruments for their use as measures of RTW. Where gaps in instrumentation were found, the wider vocational and career assessment literature was searched for instruments that could be adapted for use in RTW research.

RESULTS

Results indicate that, although numerous research instruments have been used to assess RTW, within the scientific literature some important dimensions of RTW lack instrumentation. In particular, we found that outcomes such as goal setting, motivation, expectation, job seeking, work maintenance, and career advancement require operationalization. Amongst the outcomes had been operationalized, we found considerable variation in conceptual development and application.

CONCLUSIONS

The lack of consistency and comprehensiveness of RTW measurement is one of the factors compromising the advancement of the field of RTW research. It is suggested that a more complete and psychometrically sound array of research instruments, grounded within a commonly adopted paradigm, would further the understanding of RTW and the factors affecting it.

Roles of safety climate and shift work on perceived injury risk: a multi-level analysis

This study evaluated the relationship between employees' work shift (i.e., day shift versus night shift) and perceptions of injury risk, and how the relationship is affected by company level safety climate and injury frequency. The results showed that night shift workers perceived a higher level of injury risk compared to day shift workers. Both company level safety climate and injury frequency played critical roles in predicting individual perceived work injury risk. Perception of injury risk of night shift workers was significantly lower when they perceived high-level rather than low-level safety climate. However, this pattern was not noticeable for day shift workers. These findings highlighted the importance of considering company level factors when attempting to understand the differences between day shift and night shift work on an individual's perception of injury risk.

Functional restoration programs for low back pain: a systematic review

BACKGROUND

In developed countries, chronic low back pain (LBP) is one the most common reasons for disability and work-time loss. Conventional treatments have not slowed the increasing prevalence of chronic LBP. Therefore, in a search for new solutions to the problem, functional restoration programs were developed.

OBJECTIVE

To synthesize the literature on the efficacy of functional restoration programs for LBP.

METHODS

We performed a systematic literature search of the MedLINE database using the keywords LBP, functional restoration, work-hardening program, exercise therapy, rehabilitation, aerobic, and cognitive behavioral therapy.

SYNTHESIS

The term "functional restoration" has been associated with a full-day multidisciplinary program lasting from 3 to 6 weeks. Results of most published controlled studies on the efficacy of functional restoration programs are positive regarding the return-to-work rate. Maintaining job status with the pre-injury employer is often best accomplished by the provision of suitable modified duties. Finally, results of functional restoration programs in terms of return-to-work rate probably depend strongly on the social security system of the country where the program was developed.

Agreement of a work-capacity assessment with the World Health Organisation International Classification of Functioning, Disability and Health pain sets and back-to-work predictors

The degree of agreement between a clinical multi-professional work-capacity assessment and the Comprehensive World Health Organisation International Classification of Functioning, Disability and Health (ICF) Core Sets for chronic pain and risk factors for no return to work was investigated. A review of data records and interviews with team members included measures of body function/structure, activities/participation and environmental factors. Predictors for return to work were reviewed. The team used eight different methods for data collection. Of the 29 categories concerning environmental factors, two were excluded; the methods used were more unstructured, e.g. interviews. The agreement with the 41 predictors of work resumption was high. The clinical work-capacity assessment agreed largely with the Comprehensive ICF Core Sets for the components body function, body structure, activities and participation. Nine categories out of 69 were not included. The clinical work-capacity assessment agreed largely with the Comprehensive ICF Core Sets for chronic pain conditions and with 40 predictors of work resumption. Clinically speaking, however, the current work-capacity assessment lacks on-the-job site evaluations and this most certainly affects reliability. The same is true for ICF, although the structure lacks proper coding for relevant factors found at work.

Work status and chronic low back pain: exploring the International Classification of Functioning, Disability and Health

PURPOSE

Exploring which variables are related to work status in patients with chronic low back pain (CLBP), classified according to the International Classification of Functioning, Disability and Health (ICF).

METHOD

Ninety-two patients with CLBP filled out questionnaires inquiring after health status, impairments in body functions/structures, limitations in activities of daily living (ADL), participation in work, environmental and personal factors. Additionally, patients performed tests to measure physical fitness and performance of work-related activities. Univariate analyses were performed to investigate whether differences exist between working and non-working patients. Logistic linear regression analysis was performed to explain work status from the variables of functioning.

RESULTS

Non-working patients had a lower self-reported physical and mental health, lower physical fitness, more self-reported limitations in ADL, lower education, more depressive symptoms and higher psycho neuroticism than working patients. Self-reported physical and mental health and educational level correctly classified 84.5% of the patients as working or non-working. Performance of work-related activities was not significantly related with work-status.

CONCLUSIONS

The relation between work status and CLBP is multidimensional, as was illustrated by using the bio-psychosocial model of the ICF. Patients with a low educational level, a low self-reported physical or mental health were more likely to be non-working. Self-reported limitations and physical and mental health are more important in explaining work status than objective measurements of performance.

A study of factors influencing return to work after wrist or ankle fractures

BACKGROUND

Factors associated with time to return to work are poorly understood for occupational injuries, other than those to the back.

METHODS

Anonymized data on claims for work-related wrist or ankle fracture between 1/1/1998 and 12/31/2002 were identified in administrative data held by the Workers Compensation Board in Alberta, Canada. Bivariate and Cox regression analyses were used to identify factors associated with return to work.

RESULTS

Increased duration of temporary disability (TD) was associated with older age, female gender, work in construction and construction trade services, smaller company size, higher industry claim rates, a fall/jump from a height, ankle fracture, and greater medical aid costs in the 30 days following injury (used as a proxy for severity).

CONCLUSIONS

Factors associated with longer time off work were largely consistent with those reported following back injury. Median time to return to work was longer following ankle than wrist fracture. Although Workers' Compensation Board (WCB) administrative data provided information that could be used to identify factors affecting return to work, better information on injury severity would considerably enhance their research potential.

I get by with a little help from my friends: The interaction of chronic pain and organizational support on performance

The authors conducted three studies to examine the interactive effects of perceived organizational support (POS) and chronic pain on performance outcomes (i.e., effectiveness, work intensity, citizenship behavior, and task performance). After controlling for demographic factors, tenure variables, the number of subordinates, and main effects, the POS chronic pain interaction explained criterion variance for perceived effectiveness and citizenship behavior in Study 1; effectiveness, work intensity, and citizenship behavior in Study 2; and supervisor-rated task performance in Study 3. Higher levels of chronic pain were associated with lower levels of performance when coupled with low support, as hypothesized. Conversely, high levels of POS reduced the adverse effects of chronic pain on performance. Contributions, strengths and limitations, and future research directions are provided.

New low back pain in nurses: work activities, work stress and sedentary lifestyle

BACKGROUND

Low back pain is common among nurses. Previous studies have shown that the risk of low back pain increases rapidly with greater amounts of physical work and psychological stress, but is inversely related to leisure activities. However, these previous studies were predominantly retrospective in design and not many took account of three factors simultaneously.

AIMS

This 12-month prospective study examined the relationships between work activities, work stress, sedentary lifestyle and new low back pain.

METHODS

A total of 144 nurses from six Hong Kong district hospitals completed a face-to-face baseline interview, which was followed-up by a telephone interview. The main study measures were demographic characteristics, work activities, work stress, physical leisure activities and the nature of new low back pain during the 12-month follow-up period. Level of work stress, quality of relationships at work, level of enjoyment experienced at work, and work satisfaction were self-reported.

RESULTS

Fifty-six (38.9%) nurses reported experiencing new low back pain. Sedentary leisure time activity was not associated with new low back pain. Being comparatively new on a ward (adjusted relative risk 2.90), working in bending postures (adjusted relative risk 2.76) and poor work relationships with colleagues (adjusted relative risk 2.52) were independent predictors of new low back pain.

CONCLUSION

The findings of this study suggest that low back pain is a common problem in the population of nurses in Hong Kong. Being comparatively new on a ward, bending frequently during work and having poor work relationships with colleagues are independent predictors of new low back pain. Training for high-risk work activities and ergonomic assessment of awkward work postures are essential. Moreover, relaxation and team-building workshops for nurses, especially those who are less experienced in the type of work on their current ward, are recommended.

Réadaptation du lombalgique à l’effort

Mediocre functional prognosis In industrialised countries, chronic low back pain is the most common cause of disability and work stoppage. Conventional treatments have not reduced the impact of chronic low back pain. Hence new solutions have been searched for. FUNCTIONAL RESTORATION PROGRAMS: These programs consist in heavy and expensive multidisciplinary treatment schedules, lasting from 3 to 6 weeks. The key concepts of these programs are acceptance of pain, treatment of the problem by the patients themselves and a progression contract. POSITIVE RESULTS: Controlled studies published on the percentage of patients returning to work are positive. Maintenance of a job-attached status to the pre-injury employer is often best accomplished by the provision of suitable modified duties. Finally, results of functional restoration programs in term of return-to-work rate probably strongly depend on the social security system of the country in which such programs have been developed.

Work conditioning, work hardening and functional restoration for workers with back and neck pain

BACKGROUND

Physical conditioning programs, variously called work conditioning, work hardening and functional restoration/exercise programs, aim to improve work status and function. Previous attempts have been made to evaluate the efficacy of work-oriented back pain management programs, but none have focused exclusively on work or functional outcomes.

OBJECTIVES

To compare the effectiveness of physical conditioning programs with management strategies that do not include physical conditioning programs, for workers with back and neck pain, in reducing time lost from work and increasing functional status.

SEARCH STRATEGY

We searched the following databases to 31 May 2000: MEDLINE from 1966, EMBASE from 1980, CINAHL from 1982, Biomedical Collection: I (from 1993), II (from 1995), III (from 1995), IV (from 1995), PsycINFO from 1967, the Cochrane Central Register of Controlled Trials, PEDro.

SELECTION CRITERIA

Randomized controlled trials (RCTs) that studied adults with work disability related to back or neck pain, who were included in physical conditioning programs.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed trial quality. Where data could be pooled, a meta-analysis was performed using RevMan. For continuous outcomes, we nominated a saving of 10 sick days as the smallest treatment effect that would be clinically worthwhile. For dichotomous outcomes, we considered that an intervention that affected less than one in 10 people would not be clinically worthwhile.

MAIN RESULTS

Eighteen RCTs were identified in 20 publications. Twenty-three relevant contrasts were investigated. There is evidence that physical conditioning programs that include a cognitive-behavioural approach can reduce the number of sick days lost at 12 months follow-up by an average of 45 days, when compared to general practitioner usual care or advice, for workers with chronic back pain. For work-related outcomes, there is little evidence for or against the efficacy of specific exercises that are not accompanied by a cognitive-behavioural approach, in reducing sick days lost due to back pain, for workers with either acute or chronic back pain.

REVIEWER'S CONCLUSIONS

Physical conditioning programs that include a cognitive-behavioural approach plus intensive physical training (specific to the job or not) that includes aerobic capacity, muscle strength and endurance, and coordination; are in some way work-related; and are given and supervised by a physiotherapist or a multidisciplinary team, seem to be effective in reducing the number of sick days for some workers with chronic back pain, when compared to usual care. However, there is no evidence of their efficacy for acute back pain.

Educational achievement and chronic pain disability: mediating role of pain-related cognitions

OBJECTIVE

This study examined the relation between level of educational achievement (LOE) and the clinical morbidity associated with chronic pain.

SETTING

a multidisciplinary pain rehabilitation program located within a university hospital.

PATIENTS

Two hundred ninety-nine consecutive patients with chronic spinal pain, average age 39.6 years (SD = 10.7) and with an average duration of pain of 41.9 months (SD = 51.6).

OUTCOME MEASURES

Age, duration of pain, sex, and compensation and litigation status were controlled for in the statistical analysis because each was found to be significantly associated with LOE. Pain intensity was assessed by the McGill Pain Questionnaire. Affective distress was assessed by the Global Severity Index from the Brief Symptom Inventory. Severity of depressive symptoms was derived from scores from the Center for Epidemiological Studies-Depression Scale. Pain beliefs and pain coping strategies were assessed by the Survey of Pain Attitudes and the Coping Strategies Questionnaire, respectively. Finally, self-report of pain-related disability was assessed by the Pain Disability Index.

RESULTS AND CONCLUSIONS

After controlling for relevant covariates, LOE was unrelated to pain intensity, severity of depressive symptoms, or affective distress, but was inversely related to self-reported disability. Persons with lower LOEs possessed a greater belief that pain is a "signal of harm," unrelated to emotional experience, disabling and uncontrollable. They also endorsed more passive and maladaptive coping strategies, including a tendency to catastrophize about their pain. Path analysis indicated that, after controlling for the influence of both the belief that pain is a "signal of harm" and catastrophizing on the association between LOE and disability, this relation loses statistical significance. These results suggest that pain-related cognitions mediate the relation between LOE and pain disability and that persons with lower LOEs are more likely to develop maladaptive pain beliefs and coping strategies.

Refractory chronic pain

Refractory chronic pain is a significant public health problem and frustrating to everyone affected by it. All physicians can participate in the care of these patients, but psychiatrists should take a leading role in their care. A comprehensive approach offers hope and increases the opportunities for successful treatment. Each perspective of an interdisciplinary formulation has a unique logic that defines specific methods for designing treatment for the patient with refractory chronic pain. The patient does not have to fit into one theoretic approach or model to receive and accept treatment. The patient's diagnoses are based on the formulation, which then directs treatment along rational directions. The linkages and interactions of a patient's diagnoses can then be investigated within a framework that includes the entire person and not just his or her biochemistry. If a patient's suffering persists, other factors must be considered that may have been overlooked before the treatment plan is abandoned or modified. Usually these factors are within one of the perspectives initially thought to be less important. A new combination of approaches is then required to treat the patient successfully. The perspectives appreciate not only that the patient is struggling through important life events but also that he is a person composed of vulnerabilities and strengths, having made many choices and afflicted by diseases.

Self-care techniques for acute episodes of low back pain

Guidelines recommend minimal medical intervention for acute non-specific low back pain. However, patients often request strategies to reduce symptoms and recover quickly. Self-care techniques that do not contradict current evidence-based recommendations may be suggested. Self-care techniques can reduce costs and iatrogenic complications that can occur with medical treatment. They may also increase the patient's perception of control and improve long-term outcome. A shift in paradigm for the health care provider and the patient is required for self-care to be successful. These issues, as well as self-care approaches such as medication, exercises, modalities and mind-body techniques are discussed. Practice points for each approach are given.

Employment-related factors in chronic pain and chronic pain disability

BACKGROUND

Disability is a multifactorial phenomenon. Social scientists suggest that nonclinical factors, including age, education, and job status, correlate with disability.

OBJECTIVE

Do employment-related factors predict chronic pain and/or chronic pain disability?

METHODOLOGY

The literature search identified 15 observational studies to provide the evidence about this question.

RESULTS

Review topics included job satisfaction, type of work, modified work and work autonomy, other employment-related factors, and socioeconomic status. Most subjects in the studies had low back pain. The studies used return to work as an outcome predicting chronic pain disability.

CONCLUSIONS

Lack of modified work and lack of work autonomy predicted chronic pain disability (level 2). There was limited evidence (level 3) that lack of job satisfaction, perception of difficult job conditions and demands, heavy physical demands of the job, private rather than public employment, and lower socioeconomic group predict chronic pain disability. The number of years employed varied as a predictor in different studies (level 4b).

Formal education and back pain: a review

OBJECTIVES

To summarise the scientific evidence on the relation between educational status and measures of the frequency and the consequences of back pain and of the outcomes of interventions among back pain patients, and to outline possible mechanisms that could explain such an association if found.

DESIGN

Sixty four articles published between 1966 and 2000 that documented the association of formal education with back pain were reviewed.

MAIN RESULTS

Overall, the current available evidence points indirectly to a stronger association of low education with longer duration and/or higher recurrence of back pain than to an association with onset. The many reports of an association of low education with adverse consequences of back pain also suggest that the course of a back pain episode is less favourable among persons with low educational attainment. Mechanisms that could explain these associations include variations in behavioural and environmental risk factors by educational status, differences in occupational factors, compromised "health stock" among people with low education, differences in access to and utilisation of health services, and adaptation to stress. Although lower education was not associated with the outcomes of interventions in major studies, it is difficult, in light of the current limited available evidence, to draw firm conclusions on this association.

CONCLUSION

Scientific evidence supports the hypothesis that less well educated people are more likely to be affected by disabling back pain. Further study of this association may help advance our understanding of back pain as well as understanding of the relation between socioeconomic status and disease as a general phenomenon.

Prediction of "intent", "discrepancy with intent", and "discrepancy with nonintent" for the patient with chronic pain to return to work after treatment at a pain facility

OBJECTIVE

We previously determined that "intent" to return to work post pain facility treatment is the strongest predictor for actual return to work. The purposes of the present study were the following: to identify variables predicting "intent"; to predict membership in the "discrepant with intent" group [those chronic pain patients (CPPs) who do intend to return to work but do not]; and to predict membership in the "discrepant with nonintent" group (those CPPs who do not intend to return to work but do).

DESIGN

A total of 128 CPPs completed a series of rating scales and yes/no questions relating to their preinjury job perceptions and a question relating to "intent" to return to the same type of preinjury job post-pain facility treatment. These CPPs were part of a grant study for prediction of return to work, and therefore their work status was determined at 1, 3, 6, 12, 18, 24, and 30 months posttreatment. Preinjury job perceptions and other demographic variables were utilized using stepwise discriminant analysis to identify variables predicting "intent" and predicting membership in the "discrepant with intent" and "discrepant with nonintent" groups.

SETTING

Pain facility (multidisciplinary pain center).

PATIENTS

Consecutive low back pain CPPs, mean age 41.66+/-9.54 years, with the most frequent highest educational status being high school completion (54.7%) and 60.2% being worker compensation CPPs.

RESULTS

"Intent" was predicted by (in decreasing order of probability) postinjury job availability variables, job characteristic variables, and a litigation variable. "Discrepant with intent" was predicted by (in decreasing order of probability) for the 1-month follow-up time point, postinjury job availability variables, pain variables, a litigation variable, and a function perception variable, and for the final follow-up time point, pain variables only. "Discrepant with nonintent" was predicted by (in order of decreasing probability) for the 1-month follow-up time point, a job availability variable, a demographic variable, and a functional perception variable, and for the final follow-up time point a pain variable and a job availability variable. The percentage of CPPs correctly classified by each of these analyses was as follows: "intent" 81.25%, "discrepant with intent" 87.01% (at 1-month follow-up) and 74.03% (final follow-up), "discrepant with nonintent" 92.16% (at 1-month follow-up) and 75.00% (final follow-up).

CONCLUSIONS

CPPs intentions of returning to their preinjury jobs are mainly determined by job availability and job characteristic variables but surprisingly not by pain variables. However, the results with "discrepant with intent" and "discrepant with nonintent" groups indicate that actual return to work is determined by an interaction between job availability variables and pain variables with pain variables predominating for long-term outcome.

Predictors of efficacy in treatment of chronic low back pain

The investigation of predictors for therapy outcome in patients with chronic low back pain date back to the early 1970s. Numerous well controlled prospective longitudinal studies have confirmed the predominant predictive power of several psychological factors, which are in addition to objective work related, medical and sociodemographic variables. Studies published in the review period have reported markedly improved methodological standards. Further progress is seen with the enhanced search for predictors of working situation in chronic low back pain patients. Finally, there is a shift toward the investigation of predictors for efficacy of primary care in acute and subchronic low back pain patients.