New opioid prescription claims and their clinical indications: results from health administrative data in Quebec, Canada, over 14 years

OBJECTIVES

Describe new opioid prescription claims, their clinical indications and annual trends among opioid naïve adults covered by the Quebec's public drug insurance plan (QPDIP) for the fiscal years 2006/2007-2019/2020.

DESIGN AND SETTING

A retrospective observational study was conducted using data collected between 2006/2007 and 2019/2020 within the Quebec Integrated Chronic Disease Surveillance System, a linkage administrative data.

PARTICIPANTS

A cohort of opioid naïve adults and new opioid users was created for each study year (median number=2 263 380 and 168 183, respectively, over study period).

INTERVENTION

No.

MAIN OUTCOME MEASURE AND ANALYSES

A new opioid prescription was defined as the first opioid prescription claimed by an opioid naïve adult during a given fiscal year. The annual incidence proportion for each year was then calculated and standardised for age. A hierarchical algorithm was built to identify the most likely clinical indication for this prescription. Descriptive and trend analyses were performed.

RESULTS

There was a 1.7% decrease of age-standardised annual incidence proportion during the study period, from 7.5% in 2006/2007 to 5.8% in 2019/2020. The decrease was highest after 2016/2017, reaching 5.5% annual percentage change. Median daily dose and days' supply decreased from 27 to 25 morphine milligram equivalent/day and from 5 to 4 days between 2006/2007 and 2019/2020, respectively. Between 2006/2007 and 2019/2020, these prescriptions' most likely clinical indications increased for cancer pain from 34% to 48%, for surgical pain from 31% to 36% and for dental pain from 9% to 11%. Inversely, the musculoskeletal pain decreased from 13% to 2%. There was good consistency between the clinical indications identified by the algorithm and prescriber's specialty or user's characteristics.

CONCLUSIONS

New opioid prescription claims (incidence, dose and days' supply) decreased slightly over the last 14 years among QPDIP enrollees, especially after 2016/2017. Non-surgical and non-cancer pain became less common as their clinical indication.

Predictors of adverse outcomes in elders hospitalised for isolated orthopaedic trauma: a multicentre cohort study

BACKGROUND

Patients >64 years of age now represent more than 51% of injury hospitalisations in Canada. The tools used to identify older patients who could benefit the most from an interdisciplinary approach include complex parameters difficult to collect in the ED, which suggests that better tools with higher accuracy and using items that can be derived from routinely collected data are needed. We aimed to identify variables that are associated with adverse outcomes in older patients admitted to a trauma centre for an isolated orthopaedic injury.

METHODS

We conducted a multicentre retrospective cohort study between 1 April 2013 and 31 March 2019 on older patients hospitalised with a primary diagnosis of isolated orthopaedic injury (n=19 928). Data were extracted from the provincial trauma registry (Registre des traumatismes du Québec). We used multilevel logistic regression to estimate the associations between potential predictors and adverse outcomes (extended length of stay, mortality, complications, unplanned readmission and adverse discharge destination).

RESULTS

Increasing age, male sex, specific comorbidities, type of orthopaedic injuries, increasing number of comorbidities, severe orthopaedic injury, head injuries and admission in the year before the injury were all significant predictors of adverse outcomes.

CONCLUSION

We identified eight predictors of adverse outcomes in patients >64 years of age admitted to a trauma centre for orthopaedic injury. These variables could eventually be used to develop a clinical decision rule to identify elders who may benefit the most from interdisciplinary care.

Perceptions and Preoccupations of Patients and Physicians Regarding Use of Medical Cannabis as an Intervention Against Chronic Musculoskeletal Pain: Results from a Qualitative Study

Objective

Explore perceptions and preoccupations regarding use of medical cannabis against chronic musculoskeletal pain, among patients and physicians.

Design

Qualitative study using interviews with patients and physicians, based on the Theory of Planned Behavior (TPB).

Setting

The study was conducted in Quebec, Canada, in spring 2020.

Subjects

We included 27 adult patients and 11 physicians (GPs, anesthesiologists, psychiatrists, and a rheumatologist); the mean age of patients was 48.2 years; 59.3% of patients and 36.4% of physicians were women; 59.3% of patients used no medical cannabis at the time of study; 45.5% of physicians had never authorized it.

Methods

Semi-structured interviews were conducted, transcribed and for the qualitative analysis codes were developed in a hybrid, inductive and deductive approach. Guided by the TPB, facilitators and barriers, perceived benefits and harms, and perceived norms that may influence cannabis use or authorization were documented.

Results

Although medical cannabis is an interesting avenue for the relief of chronic musculoskeletal pain, doctors and patients agreed that it remained a last line option, due to the lack of scientific evidence regarding its safety and efficacy. The norms surrounding medical cannabis also play an important role in the social and professional acceptance of this therapeutic option.

Conclusion

Medical cannabis is seen as a last line option among interventions in the management of chronic pain, and attitudes and prior experiences play a role in the decision to use it. Study results may contribute to improved shared decision making between patients and physicians regarding this option.

Psychosocial Stressors at Work and Coronary Heart Disease Risk in Men and Women: 18-Year Prospective Cohort Study of Combined Exposures

BACKGROUND

Psychosocial stressors at work, like job strain and effort-reward imbalance (ERI), can increase coronary heart disease (CHD) risk. ERI indicates an imbalance between the effort and received rewards. Evidence about the adverse effect of combined exposure to these work stressors on CHD risk is scarce. This study examines the separate and combined effect of job strain and ERI exposure on CHD incidence in a prospective cohort of white-collar workers in Quebec, Canada.

METHODS

Six thousand four hundred sixty-five white-collar workers without cardiovascular disease (mean age, 45.3±6.7) were followed for 18 years (from 2000 to 2018). Job strain and ERI were measured with validated questionnaires. CHD events were retrieved from medico-administrative databases using validated algorithms. Marginal Cox models were used to calculate hazard ratios (HR) stratified by sex. Multiple imputation and inverse probability weights were applied to minimize potential threats to internal validity.

RESULTS

Among 3118 men, 571 had a first CHD event. Exposure to either job strain or ERI was associated with an adjusted 49% CHD risk increase (HR, 1.49 [95% CI, 1.07-2.09]). Combined exposure to job strain and ERI was associated with an adjusted 103% CHD risk increase (HR, 2.03 [95% CI, 1.38-2.97]). Exclusion of early CHD cases and censoring at retirement did not alter these associations. Among 3347 women, 265 had a first CHD event. Findings were inconclusive (passive job HR, 1.24 [95% CI, 0.80-1.91]; active job HR, 1.16 [95% CI, 0.70-1.94]; job strain HR, 1.08 [95% CI, 0.66-1.77]; ERI HR, 1.02 [95% CI, 0.72-1.45]).

CONCLUSIONS

In this prospective cohort study, men exposed to job strain or ERI, separately and in combination, were at increased risk of CHD. Early interventions on these psychosocial stressors at work in men may be effective prevention strategies to reduce CHD burden. Among women, further investigation is required.

Association between psychosocial work-related factors at midlife and arterial stiffness at older age in a prospective cohort of 1736 white-collar workers

OBJECTIVE

Arterial stiffness and exposure to psychosocial work-related factors increase the risk of developing cardiovascular disease. However, little is known about the relationship between psychosocial work-related factors and arterial stiffness. We aimed to examine this relationship.

DESIGN

Prospective cohort study.

SETTING

Public organisations in Quebec City, Canada.

PARTICIPANTS

The study included 1736 white-collar workers (women 52%) from 19 public organisations.

PRIMARY AND SECONDARY OUTCOME MEASURES

Association between psychosocial work-related factors from the job strain and effort-reward imbalance (ERI) models assessed at study baseline (1999-2001) with validated instruments and arterial stiffness assessed using carotid-femoral pulse wave velocity at follow-up, on average 16 years later (2015-2018). Generalised estimating equations were used to estimate differences in arterial stiffness between exposed and unexposed participants. Subgroup analyses according to sex, age, blood pressure (BP), cardiovascular risk score and employment status were conducted.

RESULTS

Among participants with high diastolic BP (≥90 mm Hg) at baseline, aged 47 on average, those exposed to high job strain had higher arterial stiffness (1.38 m/s (95% CI: 0.57 to 2.19)) at follow-up, 16 years later, following adjustment for a large set of potential confounders. The trend was similar in participants with high systolic BP (≥140 mm Hg) exposed to high job strain (0.84 m/s (95% CI: -0.35 to 2.03)). No association was observed for ERI in the total sample and counterintuitive associations were observed in subgroup analyses.

CONCLUSIONS

Job strain may have a long-term deleterious effect on arterial stiffness in people with high BP. Interventions at midlife to reduce job strain may mitigate arterial stiffness progression.

Sensitivity and specificity of algorithms for the identification of nonspecific low back pain in medico-administrative databases

ABSTRACT

Identifying nonspecific low back pain (LBP) in medico-administrative databases is a major challenge because of the number and heterogeneity of existing diagnostic codes and the absence of standard definitions to use as reference. The objective of this study was to evaluate the sensitivity and specificity of algorithms for the identification of nonspecific LBP from medico-administrative data using self-report information as the reference standard. Self-report data came from the PROspective Québec Study on Work and Health , a 24-year prospective cohort study of white-collar workers. All diagnostic codes that could be associated with nonspecific LBP were identified from the International Classification of Diseases, Ninth and Tenth Revisions ( ICD-9 and ICD-10 ) in physician and hospital claims. Seven algorithms for identifying nonspecific LBP were built and compared with self-report information. Sensitivity analyses were also conducted using more stringent definitions of LBP. There were 5980 study participants with (n = 2847) and without (n = 3133) LBP included in the analyses. An algorithm that included at least 1 diagnostic code for nonspecific LBP was best to identify cases of LBP in medico-administrative data with sensitivity varying between 8.9% (95% confidence interval [CI] 7.9-10.0) for a 1-year window and 21.5% (95% CI 20.0-23.0) for a 3-year window. Specificity varied from 97.1% (95% CI 96.5-97.7) for a 1-year window to 90.4% (95% CI 89.4-91.5) for a 3-year window. The low sensitivity we found reveals that the identification of nonspecific cases of LBP in administrative data is limited, possibly due to the lack of traditional medical consultation.

Work-Related Psychosocial Factors and Global Cognitive Function: Are Telomere Length and Low-Grade Inflammation Potential Mediators of This Association?

The identification of modifiable factors that could maintain cognitive function is a public health priority. It is thought that some work-related psychosocial factors help developing cognitive reserve through high intellectual complexity. However, they also have well-known adverse health effects and are considered to be chronic psychosocial stressors. Indeed, these stressors could increase low-grade inflammation and promote oxidative stress associated with accelerated telomere shortening. Both low-grade inflammation and shorter telomeres have been associated with a cognitive decline. This study aimed to evaluate the total, direct, and indirect effects of work-related psychosocial factors on global cognitive function overall and by sex, through telomere length and an inflammatory index. A random sample of 2219 participants followed over 17 years was included in this study, with blood samples and data with cognitive function drawn from a longitudinal study of 9188 white-collar workers (51% female). Work-related psychosocial factors were evaluated according to the Demand-Control-Support and the Effort-Reward Imbalance (ERI) models. Global cognitive function was evaluated with the validated Montreal Cognitive Assessment (MoCA). Telomere length and inflammatory biomarkers were measured using standardised protocols. The direct and indirect effects were estimated using a novel mediation analysis method developed for multiple correlated mediators. Associations were observed between passive work or low job control, and shorter telomeres among females, and between low social support at work, ERI or iso-strain, and a higher inflammatory index among males. An association was observed with higher cognitive performance for longer telomeres, but not for the inflammatory index. Passive work overall, and low reward were associated with lower cognitive performance in males; whereas, high psychological demand in both males and females and high job strain in females were associated with a higher cognitive performance. However, none of these associations were mediated by telomere length or the inflammatory index. This study suggests that some work-related psychosocial factors could be associated with shorter telomeres and low-grade inflammation, but these associations do not explain the relationship between work-related psychosocial factors and global cognitive function. A better understanding of the biological pathways, by which these factors affect cognitive function, could guide future preventive strategies to maintain cognitive function and promote healthy aging.

Anxiety disorders in patients with noncardiac chest pain: association with health-related quality of life and chest pain severity

BACKGROUND

Patients with noncardiac chest pain (NCCP) report more severe symptoms and lowered health-related quality of life when they present with comorbid panic disorder (PD). Although generalized anxiety disorder (GAD) is the second most common psychiatric disorder in these patients, its impact on NCCP and health-related quality of life remains understudied. This study describes and prospectively compares patients with NCCP with or without PD or GAD in terms of (1) NCCP severity; and (2) the physical and mental components of health-related quality of life.

METHODS

A total of 915 patients with NCCP were consecutively recruited in two emergency departments. The presence of comorbid PD or GAD was assessed at baseline with the Anxiety Disorder Schedule for DSM-IV. NCCP severity at baseline and at the six-month follow-up was assessed with a structured telephone interview, and the patients completed the 12-item Short-Form Health Survey Version 2 (SF-12v2) to assess health-related quality of life at both time points.

RESULTS

Average NCCP severity decreased between baseline and the six-month follow-up (p < .001) and was higher in the patients with comorbid PD or GAD (p < .001) at both time points compared to those with NCCP only. However, average NCCP severity did not differ between patients with PD and those with GAD (p = 0.901). The physical component of quality of life improved over time (p = 0.016) and was significantly lower in the subset of patients with PD with or without comorbid GAD compared to the other groups (p < .001). A significant time x group interaction was found for the mental component of quality of life (p = 0.0499). GAD with or without comorbid PD was associated with a lower mental quality of life, and this effect increased at the six-month follow-up.

CONCLUSIONS

Comorbid PD or GAD are prospectively associated with increased chest pain severity and lowered health-related quality of life in patients with NCCP. PD appears to be mainly associated with the physical component of quality of life, while GAD has a greater association with the mental component. Knowledge of these differences could help in the management of patients with NCCP and these comorbidities.

THE ASSOCIATION BETWEEN SELF-REPORTED CIGARETTE SMOKING AND SPINAL PAIN IS NOT EXPLAINED BY SERUM COTININE LEVELS

PURPOSE

The aim of this study was to check if self-reported smoking is still associated with back pain above and beyond its association with cotinine, to test the hypothesis that the association of self-reported cigarette smoking with back pain is due to residual confounding.

METHODS

Secondary analyses of population-based cross-sectional data pertaining to 4,470 adults were conducted. In multivariate analyses examining the associations of self-reported smoking with several spinal pain outcomes (neck pain, low back pain, low back pain with pain below knee, self-reported diagnosis of arthritis/rheumatism, and related limitations), further adjustment for serum cotinine concentrations was made.

RESULTS

Self-reported cigarette smoking was associated with neck pain (adjusted Odds Ratio (_aOR) Regular smokers vs Non-smokers: 1.44; 95% Confidence Interval (CI): 1.14-1.82), low back pain (_aOR: 1.48; 95% CI: 1.24-1.78), low back pain with pain below knee (_aOR: 1.98; 95% CI: 1.42-2.76), as well as arthritis/rheumatism (_aOR: 1.33; 95% CI: 1.03-1.71), and related functional limitations (p<0.05). Further adjustment for serum cotinine concentrations brought about little change in the ORs or beta coefficients.

CONCLUSIONS

These results do not support the hypothesis that serum cotinine concentrations explain the well-known relationship between cigarette smoking and spinal pain.

Cross-cultural adaptation of Delphi definitions of low back pain prevalence in French (Delphi DOLBaPP-F)

Aim: The high heterogeneity in the definitions of low back pain encountered in the literature has led to the development of standardized definitions of this condition called “Delphi definitions of low back pain prevalence (Delphi DOLBaPP)” by a group of international researchers. In order to be widely used, these definitions need to be adapted according to the cultural and linguistic context. The aim of this work was to perform the cross-cultural adaptation of the Delphi DOLBaPP definitions in Quebecc French and to pre-test them among French-speaking adults. Methods: In order to enable practical use of the Delphi DOLBaPP definitions in different contexts, their presentation was adapted in the form of a questionnaire (referred to as the “Delphi DOLBaPP questionnaire”). The process of cross-cultural adaptation of the Delphi DOLBaPP questionnaire in French was conducted according to the most recognized recommendations for the cultural adaptation of measuring instruments. The resulting questionnaire and an evaluation form were then submitted to a sample of 82 adults. Results: A total of 41 participants (50.0%) reported low back pain. A high proportion of participants (89.0%) stated that it took them less than 5 minutes to complete the questionnaire. More than 62.0% of them did not find any question poorly worded or confusing. Nearly 80.0% of the participants found the questionnaire easy to understand. The cross-cultural adaptation process suggested minor modifications to the original Delphi DOLBaPP questionnaire. Conclusions: This study has produced a cross-cultural adaptation of the Delphi DOLBaPP questionnaire in Quebec French that will enable French-speaking populations to share the benefits of using standardized definitions of low back pain in epidemiological studies.

Psychosocial stressors at work and inflammatory biomarkers: PROspective Quebec Study on Work and Health

BACKGROUND

Chronic low-grade inflammation has been associated with high risk of several chronic diseases such as cardiovascular diseases, diabetes, depression, and dementia. As low-grade inflammation could be present long before the apparition of the disease, identifying modifiable risk factors could allow to act upstream. Psychosocial stressors at work have been suggested as modifiable risk factors of low-grade inflammation, but few longitudinal studies have evaluated the association between these stressors and inflammatory biomarkers, such as C-reactive protein (CRP) and interleukin-6 (IL-6).

OBJECTIVE

This longitudinal study evaluate the associations between exposure to psychosocial stressors at work and CRP and IL-6, separately and combined into an inflammatory index.

METHODS

Data came from a cohort of 9188 white-collar workers recruited in 1991-1993 (T1) and followed-up after 8 (T2, 1999-2000) and 24 (T3, 2015-2018) years. Participants included in this study were randomly selected at T3 for serum biomarkers studies (n = 2557). CRP and IL-6 were measured using standardized protocols. Psychosocial stressors at work were assessed at T2 according to recognized models: Karasek's Demand-Control-Support model and Siegrist's Effort-Reward Imbalance (ERI) model, using validated questionnaires. High job strain was defined by an exposure to high psychological demand combined with low job control, and iso-strain was defined by an exposure to high job strain combined with low social support at work. ERI was defined by an imbalance between psychological demand and social, economic, and organizational reward. Several covariates were considered including sociodemographic, anthropometric, and lifestyle characteristics, and comorbidities. Prevalence ratios (PRs) and 95% confidence interval (CI) for the highest quartile of CRP, IL-6 and inflammatory index at T3 according to psychosocial stressors at work measured at T2 were calculated using generalized estimating equations. Multiple imputation and inverse probability of censoring weighting were done.

RESULTS

In men, an association was observed between exposure to iso-strain and the inflammatory index (PR of 1.42 (95% CI: 1.06;1.90)), mainly among men aged less than 65 years (PR of 2.00 (95% CI: 1.37;2.92)). In this same age group, associations with inflammatory biomarkers were also observed among men with exposure to ERI, and among women with exposure to low reward at work or moderate social support at work.

CONCLUSION

These results suggest that psychosocial stressors at work may increase low-grade inflammation. However, further studies are needed to corroborate these results and to clarify the potential differences between men and women. As these stressors are frequent and modifiable, their reduction is important for public health and could play a role in the primary prevention of chronic diseases.

Cannabis against chronic musculoskeletal pain: a scoping review on users and their perceptions

Background

Chronic musculoskeletal pain (CMP) may lead to reduced physical function and is the most common cause of chronic non-cancer pain. Currently, the pharmacotherapeutic options against CMP are limited and frequently consist of pain management with non-steroidal anti-inflammatories, gabapentinoids, or opioids, which carry major adverse effects. Although the effectiveness of medical cannabis (MC) for CMP still lacks solid evidence, several patients suffering from it are exploring this therapeutic option with their physicians.

Objectives

Little is known about patients’ perceptions of their MC treatment for CMP. We aimed to increase this knowledge, useful for healthcare professionals and patients considering this treatment, by conducting a scoping literature review, following guidance by Arksey and O’Malley, to describe the views and perceptions of adult patients who had consumed MC to relieve chronic CMP.

Methods

Databases (PUBMED, EMBASE, Web of Science) and websites were searched using combinations of controlled and free vocabulary. All studies and study designs reporting on patients’ perceptions regarding MC against CMP were considered. Studies had to include adult patients reporting qualitatively or quantitatively, i.e., through questionnaires, on MC use to treat CMP or other non-cancer pain, since studies reporting exclusively on perceptions regarding CMP were very rare. Study characteristics were extracted and limitations of the study quality were assessed. The review includes patients’ demographic characteristics, patterns of MC use, perceived positive and negative effects, use of alcohol or other drugs, reported barriers to CM use, and funding sources of the studies.

Results

Participants of the 49 included studies reported that MC use helped them to reduce CMP and other chronic non-cancer pain, with only minor adverse effects, and some reported improved psychological well-being.

In the included studies, men represent between 18 and 88% of the subjects. The mean age of participants in these studies (42/49) varied between 28.4 and 62.8 years old. The most common route of administration is inhalation.

Conclusion

MC users suffering from CMP or other chronic non-cancer pain perceived more benefits than harms. However, the information from these studies has several methodological limitations and results are exploratory. These user-reported experiences must thus be examined by well-designed and methodologically sound clinical or observational studies, particularly regarding CMP, where reports are very scarce.

Supplementary Information

The online version contains supplementary material available at 10.1186/s42238-021-00096-8.

Cumulative exposure to psychosocial stressors at work and global cognitive function: the PROspective Quebec Study on Work and Health

OBJECTIVES

Psychosocial stressors at work have been proposed as modifiable risk factors for mild cognitive impairment (MCI). This study aimed to evaluate the effect of cumulative exposure to psychosocial stressors at work on cognitive function.

METHODS

This study was conducted among 9188 white-collar workers recruited in 1991-1993 (T1), with follow-ups 8 (T2) and 24 years later (T3). After excluding death, losses to follow-up and retirees at T2, 5728 participants were included. Psychosocial stressors at work were measured according to the Karasek's questionnaire. Global cognitive function was measured with the Montreal Cognitive Assessment. Cumulative exposures to low psychological demand, low job control, passive job and high strain job were evaluated using marginal structural models including multiple imputation and inverse probability of censoring weighting.

RESULTS

In men, cumulative exposures (T1 and T2) to low psychological demand, low job control or passive job were associated with higher prevalences of more severe presentation of MCI (MSMCI) at T3 (Prevalence ratios (PRs) and 95% CIs of 1.50 (1.16 to 1.94); 1.38 (1.07 to 1.79) and 1.55 (1.20 to 2.00), respectively), but not with milder presentation of MCI. In women, only exposure to low psychological demand or passive job at T2 was associated with higher prevalences of MSMCI at T3 (PRs and 95% CI of 1.39 (0.97 to 1.99) and 1.29 (0.94 to 1.76), respectively).

CONCLUSIONS

These results support the deleterious effect of a low stimulating job on cognitive function and the cognitive reserve theory. Psychosocial stressors at work could be part of the effort for the primary prevention of cognitive decline.

Tools Appraisal of Organizational Factors Associated with Return-to-Work in Workers on Sick Leave Due to Musculoskeletal and Common Mental Disorders: A Systematic Search and Review

Purpose The objective of this study was to identify organizational factors that are predictive of return-to-work (RTW) among workers with musculoskeletal (MSD) and common mental disorders (CMD), and to subsequently catalogue and characterize the questionnaires (tools) used to measure them. Methods A systematic search on PubMed, Web of Science and PsycINFO library databases and grey literature was conducted. First, a list of organizational factors predictive of RTW for the two populations considered was built. Second, the questionnaires used to measure these factors were retrieved. Third, we looked in the scientific literature for studies on the psychometric properties and practical relevance of these questionnaires. Results Among the factors retained, perceived social support from supervisor and co-workers, work accommodations, and job strain were identified as common RTW factors. Other risk/protective factors, and associated tools, specifically targeting either people with MSD or CMD were also analysed. Conclusions Researchers and practitioners are often uncertain of which tools to use to measure organizational factors which can facilitate or hinder RTW. This study provides an evaluation of the tools measuring predictive organizational RTW factors in people with MSD and CMD. The identified tools can be used in everyday practice and/or research.

Epidemiology and prognostic implications of panic disorder and generalized anxiety disorder in patients with coronary artery disease: rationale and design for a longitudinal cohort study

Background

Anxiety is associated with poorer prognosis in patients with coronary artery disease (CAD). Due to their severity and chronic course, anxiety disorders, particularly generalized anxiety disorder (GAD) and panic disorder (PD), are of considerable interest and clinical importance in this population. This study has two main objectives: (1) to estimate the prevalence and incidence of GAD and PD in patients with CAD over a 2-year period and (2) to prospectively assess the association between PD or GAD and adverse cardiac events, treatment adherence, CAD-related health behaviors, quality of life and psychological distress.

Design/Method

This is a longitudinal cohort study in which 3610 participants will be recruited following a CAD-related revascularization procedure. They will complete an interview and questionnaires at 5 time points over a 2-year period (baseline and follow-ups after 3, 6, 12 and 24 months). The presence of PD or GAD, adherence to recommended treatments, health behaviors, quality of life and psychological distress will be assessed at each time point. Data regarding mortality and adverse cardiac events will be collected with a combination of interviews and review of medical files.

Discussion

This study will provide essential information on the prevalence and incidence of anxiety disorders in patients with CAD and on the consequences of these comorbidities. Such data is necessary in order to develop clear clinical recommendations for the management of PD and GAD in patients with CAD. This will help improve the prognosis of patients suffering from both conditions.

Effect of thermal therapy and exercises on acute low back pain: a protocol for a randomized controlled trial

BACKGROUND

Low back pain (LBP) is the first cause of years lived with disability worldwide. This is due to the development of chronic pain. Thus, it is necessary to identify the best therapeutic approaches in the acute phase of LBP to limit the transition to chronic pain. Superficial heat presents the highest level of evidence for short-term reduction in pain and disability in acute LBP. Physical activity is also recommended to avoid transition to chronic LBP, but there is a lack of evidence to determine its effect to reduce acute LBP. Also, the long-term effects of these interventions are unknown. This is a protocol for a randomized controlled trial (RCT) to determine the short and long-term effects of wearable continuous low-level thermal therapy, in combination with exercises or not, on disability and pain.

METHODS/DESIGN

Sixty-nine participants with acute LBP will be randomly assigned to one of three intervention programs: 1) thermal therapy, 2) thermal therapy + exercises, and 3) control. The interventions will be applied for 7 continuous days. The primary outcome will be disability and secondary outcomes will be pain intensity, pain-related fear, self-efficacy, number of steps walked and perception of change. The evaluators will be blinded to the interventions, and participants will be blinded to other groups' interventions. Primary and secondary outcomes will be compared between intervention groups.

DISCUSSION

This study will provide new evidence about acute LBP treatments, to limit transition to chronicity. This will be the first study to measure the long-term effects of wearable continuous low-level thermal therapy, combined or not to exercises.

TRIAL REGISTRATION

This RCT has been retrospectively registered on ClinicalTrials.gov ( NCT03986047 ) on June 14th, 2019.

Outcomes and prognosis of diabetic foot ulcers treated by an interdisciplinary team in Canada

The aim of this study was to determine the wound healing outcomes of patients with a plantar diabetic foot ulcer (DFU) treated with an interdisciplinary team approach, and to identify associated variables. A retrospective observational cohort study of 140 adult patients, with a plantar DFU, treated between 2012 and 2018 at a wound care clinic of a University affiliated hospital was conducted. Predictive and explicative analyses were conducted with logistic multivariate methods and with a Receiver Operating Characteristics curve. The best predictor of wound healing at 3 months was a 41.8% wound size reduction at 4 weeks (AUC: 0.86; sensitivity: 83.1%; specificity: 67.2%, positive predictive value: 72.8%; negative predictive value: 78.9%; positive and negative likelihood ratios: 2.53 and 0.25, respectively). Main baseline variables independently associated with this predictor were: a monophasic Doppler waveform (OR 7.52, 95% CI [2.64–21.39]), cigarette smoking (OR 4.7, 95% CI [1.44–15.29]), and male gender (OR 3.58, 95% CI [1.30–9.87]). The health care provider should be cautious and intensify its management of DFUs particularly with patients of male gender; smoking, having a monophasic waveform with a hand‐held Doppler, and not achieving a minimal 41.8% wound area reduction at 4 weeks of treatment.

Quality of Diabetic Foot Ulcer Care: Evaluation of an Interdisciplinary Wound Care Clinic Using an Extended Donabedian Model Based on a Retrospective Cohort Study

OBJECTIVES

Diabetic foot ulcer (DFU), a serious complication of diabetes, is associated with increased morbidity and mortality and presents a substantial socioeconomic burden. However, DFU quality of care has been insufficiently studied. Therefore, the aim of this study was to evaluate the quality of DFU care at an interdisciplinary wound care clinic in Canada, based on an extended Donabedian model: structure, process and outcome quality indicators combined with patient characteristics.

METHODS

This was a retrospective cohort study of 140 adult patients with diabetes who were treated between 2012 and 2018 at a wound care clinic in a university-affiliated hospital in the Québec City area of Canada. Twenty-two internationally recognized quality-of-care indicators were identified from the literature. Data were collected from medical files, and the results were used to document the selected quality-of-care indicators.

RESULTS

The principal indicators regarding structure and process were met, and outcome indicators were influenced by study population characteristics, particularly peripheral artery disease and critical limb ischemia. Moreover, this study highlights that quality-of-care indicators are essential when evaluating DFU outcomes, as structure and process indicators can also affect wound healing outcomes.

CONCLUSIONS

This study suggests that DFU care at a Canadian wound care clinic, with an interdisciplinary approach, meets most quality-of-care indicators. The socioeconomic burden of DFUs for patients, health-care organizations and policymakers, and the paucity of quality and performance evaluations, call for more studies evaluating DFU care.

Physical activity and disability in patients with noncardiac chest pain: a longitudinal cohort study

BACKGROUND

Noncardiac chest pain (NCCP) is one of the leading reasons for emergency department visits and significantly limits patients' daily functioning. The protective effect of physical activity has been established in a number of pain problems, but its role in the course of NCCP is unknown. This study aimed to document the level of physical activity in patients with NCCP and its association with NCCP-related disability in the 6 months following an emergency department visit.

METHODS

In this prospective, longitudinal, cohort study, participants with NCCP were recruited in two emergency departments. They were contacted by telephone for the purpose of conducting a medical and sociodemographic interview, after which a set of questionnaires was sent to them. Participants were contacted again 6 months later for an interview aimed to assess their NCCP-related disability.

RESULTS

The final sample consisted of 279 participants (57.0% females), whose mean age was 54.6 (standard deviation = 15.3) years. Overall, the proportion of participants who were physically active in their leisure time, based on the Actimètre questionnaire criteria, was 22.0%. Being physically active at the first measurement time point was associated with a 38% reduction in the risk of reporting NCCP-related disability in the following 6 months (ρ = .047). This association remained significant after controlling for confounding variables.

CONCLUSIONS

Being physically active seems to have a protective effect on the occurrence of NCCP-related disability in the 6 months following an emergency department visit with NCCP. These results point to the importance of further exploring the benefits of physical activity in this population.

Incidence of shoulder pain in 40 years old and over and associated factors: A systematic review

BACKGROUND

Shoulder pain is one of the most frequent musculoskeletal complaints, and its prevalence and consequences increase with age. However, little is known about the incidence of shoulder pain among aging adults. We conducted this review to estimate the incidence of shoulder pain in ageing adults and its associated factors.

DATABASES AND DATA TREATMENT

We conducted a systematic review of cohort studies in which the incidence of shoulder pain and associated factors were explored in adults aged 40 years and over. PubMed, Embase, and Web of Science databases were consulted.

RESULTS

We retrieved 3332 studies and included six, of which five were prospective cohort studies and one was retrospective. For adults aged 45-64 years, the annual cumulative incidence was 2.4%. The incidence density was estimated at 17.3 per 1,000 person-years for adults in the 45-64 years age group, at 12.8 per 1000 person-years for those in the 65-74 years group and at 6.7 per 1000 person-years among those aged 75 years and over. Occupational factors, notably physical demands of work, were associated with the incidence of shoulder pain. Non-occupational factors were also linked to the occurrence of shoulder pain.

CONCLUSION

Few studies have estimated the incidence of shoulder pain and associated factors among ageing adults. From this systematic review, we conclude that studies on the incidence of shoulder pain are scarce, and that both occupational and non-occupational factors could be associated with the onset of shoulder pain among adults 40 years and over. This very limited evidence calls for more studies on this topic.

SIGNIFICANCE

Shoulder pain is one of the most frequent musculoskeletal complaints, and its prevalence and consequences increase with age. However, since the prevalence of a recurring condition is determined by its incidence and the number and duration of episodes, it is important to have valid incidence estimates and to conduct aetiological studies on incidence measures to untangle risk factors of the occurrence of shoulder pain from those affecting the duration and number of episodes . In this systematic review, we sought to estimate the incidence of shoulder pain in ageing adults along with its associated factors. This work could lead to better interventions to prevent shoulder pain in older individuals.

Incidence of panic disorder in patients with non-cardiac chest pain and panic attacks

This study documented the 6-month incidence of panic disorder and its predictors in emergency department patients with panic attacks and non-cardiac chest pain. The assessment included a validated structured interview to identify panic attacks and questionnaires measuring the potential predictors of panic disorder. Presence of panic disorder was assessed 6 months later. The incidence of panic disorder was 10.1 percent ( n = 14/138). Anxiety sensitivity was the only significant predictor of the incidence of panic disorder (odds ratio = 1.06; 95% confidence interval = 1.01–1.12). Patients with panic attacks and non-cardiac chest pain are at an elevated risk for panic disorder. This vulnerability appears to increase with anxiety sensitivity.

The Revised-Panic Screening Score for emergency department patients with noncardiac chest pain

OBJECTIVES

We sought to reduce the 90% rate of missed diagnoses of panic-like anxiety (panic attacks with or without panic disorder) among emergency department patients with low risk noncardiac chest pain by validating and improving the Panic Screening Score (PSS).

METHOD

A total of 1,102 patients with low risk noncardiac chest pain were prospectively and consecutively recruited in two emergency departments. Each patient completed a telephone interview that included the PSS, a brief 4-item screening instrument, new candidate predictors of panic-like anxiety, and the Anxiety Disorder Interview for the Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition to identify panic-like anxiety.

RESULTS

The original 4-item PSS demonstrated a sensitivity of 51.8% (95% CI [48.4, 57.0]) and a specificity of 74.8% (95% CI [71.3, 78.1]) for panic-like anxiety. Analyses prompted the development of the Revised-PSS; this 6-item instrument was 19.1% (95% CI [12.7, 25.5]) more sensitive than the original PSS in identifying panic-like anxiety in this sample (χ2(1, N = 351) = 23.89 p < .001) while maintaining a similar specificity (χ2(1, N = 659) = 0.754, p = .385; 0.4%, 95% CI [-3.6, 4.5]). The discriminant validity of the Revised-PSS proved stable over the course of a 10-fold cross-validation.

CONCLUSIONS

The Revised-PSS has significant potential for improving identification of panic-like anxiety in emergency department patients with low risk noncardiac chest pain and promoting early access to treatment. External validation and impact analysis of the Revised-PSS are warranted prior to clinical implementation. (PsycINFO Database Record

Which Characteristics are Associated with the Timing of the First Healthcare Consultation, and Does the Time to Care Influence the Duration of Compensation for Occupational Back Pain?

Purpose To identify the characteristics associated with the timing of the first healthcare consultation and to measure the impact of that timing on the duration of the first episode of compensation for occupational back pain following the injury. Methods We analyzed data from a cohort of workers with compensated back pain in 2005 in Ontario obtained from the Workplace Safety and Insurance Board. Cox multivariable survival models were performed to identify factors associated with the time to care and to measure its association with the length of the first episode of 100 % compensation. Results Among the 5520 claims analyzed, 93.7 % of workers accessed care within the first week (average = 2.1 days; median = 1 day). Time to care was shorter for males, for workers who had received previous compensation and for those with access to an early return to work program. Age, number of employees in the company and personal earnings were positively associated with the time to care. More severe nature of injury, employers doubt about the work-relatedness of the injury and consulting a physiotherapist as the first healthcare provider were also associated with longer time to care. Considering potential confounders, longer time to care was significantly associated with a delay in the end of the first episode of compensation (hazard ratio = 0.98; P < 0.001). Conclusion Temporal access to a source of care is not problematic for the vast majority of Ontarian workers who receive compensation for occupational back pain; however, for the minority of workers who do not rapidly access care, the timing of the first healthcare consultation is a significant predictor of the duration of the first episode of compensation.

Association Between the Type of First Healthcare Provider and the Duration of Financial Compensation for Occupational Back Pain

Objective To compare the duration of financial compensation and the occurrence of a second episode of compensation of workers with occupational back pain who first sought three types of healthcare providers. Methods We analyzed data from a cohort of 5511 workers who received compensation from the Workplace Safety and Insurance Board for back pain in 2005. Multivariable Cox models controlling for relevant covariables were performed to compare the duration of financial compensation for the patients of each of the three types of first healthcare providers. Logistic regression was used to compare the occurrence of a second episode of compensation over the 2-year follow-up period. Results Compared with the workers who first saw a physician (reference), those who first saw a chiropractor experienced shorter first episodes of 100 % wage compensation (adjusted hazard ratio [HR] = 1.20 [1.10-1.31], P value < 0.001), and the workers who first saw a physiotherapist experienced a longer episode of 100 % compensation (adjusted HR = 0.84 [0.71-0.98], P value = 0.028) during the first 149 days of compensation. The odds of having a second episode of financial compensation were higher among the workers who first consulted a physiotherapist (OR = 1.49 [1.02-2.19], P value = 0.040) rather than a physician (reference). Conclusion The type of healthcare provider first visited for back pain is a determinant of the duration of financial compensation during the first 5 months. Chiropractic patients experience the shortest duration of compensation, and physiotherapy patients experience the longest. These differences raise concerns regarding the use of physiotherapists as gatekeepers for the worker's compensation system. Further investigation is required to understand the between-provider differences.

Physical Activity and Exercise Interventions in the Workplace Impacting Work Outcomes: A Stakeholder-Centered Best Evidence Synthesis of Systematic Reviews

Background:

The prevention of work disability is beneficial to employees and employers, and mitigates unnecessary societal costs associated with social welfare. Many service providers and employers have initiated workplace interventions designed to reduce unnecessary work disability.

Objective:

To conduct a best-evidence synthesis of systematic reviews on workplace interventions that address physical activities or exercise and their impact on workplace absence, work productivity or financial outcomes.

Methods:

Using a participatory research approach, academics and stakeholders identified inclusion and exclusion criteria, built an abstraction table, evaluated systematic review quality and relevance, and interpreted the combined findings. A minimum of two scientists participated in a methodological review of the literature followed by a consensus process.

Results:

Stakeholders and researchers participated as a collaborative team. 3363 unique records were identified, 115 full text articles and 46 systematic reviews were included, 18 assessed the impact of physical fitness or exercise interventions. 11 focused on general workers rather than workers who were absent from work at baseline; 16 of the reviews assessed work absence, 4 assessed productivity and 6 assessed financial impacts.

Conclusion:

The strongest evidence supports the use of short, simple exercise or fitness programs for both workers at work and those absent from work at baseline. For workers at work, simple exercise programs (1–2 modal components) appear to provide similar benefits to those using more complex multimodal interventions. For workers off-work with subacute low back pain, there is evidence that some complex exercise programs may be more effective than simple exercise interventions, especially if they involve workplace stakeholder engagement, communication and coordination with employers and other stakeholders. The development and utilization of standardized definitions, methods and measures and blinded evaluation would improve research quality and strengthen stakeholder-centered guidance.

Psychosocial work factors and social inequalities in psychological distress: a population-based study

Background

Mental health problems (MHP) are the leading cause of disability worldwide. The inverse association between socioeconomic position (SEP) and MHP has been well documented. There is prospective evidence that factors from the work environment, including adverse psychosocial work factors, could contribute to the development of MHP including psychological distress. However, the contribution of psychosocial work factors to social inequalities in MHP remains unclear. This study evaluates the contribution of psychosocial work factors from two highly supported models, the Demand-Control-Support (DCS) and the Effort-Reward Imbalance (ERI) models to SEP inequalities of psychological distress in men and women from a population-based sample of Quebec workers.

Methods

Data were collected during a survey on working conditions, health and safety at work. SEP was evaluated using education, occupation and household income. Psychosocial work factors and psychological distress were assessed using validated instruments. Mean differences (MD) in the score of psychological distress were estimated separately for men and women.

Results

Low education level and low household income were associated with psychological distress among men (MD, 0.56 (95% CI 0.06; 1.05) and 1.26 (95% CI 0.79; 1.73) respectively). In men, the contribution of psychosocial work factors from the DCS and the ERI models to the association between household income and psychological distress ranged from 9% to 24%. No clear inequalities were observed among women.

Conclusions

These results suggest that psychosocial work factors from the DCS and the ERI models contribute to explain a part of social inequalities in psychological distress among men. Psychosocial factors at work are frequent and modifiable. The present study supports the relevance of targeting these factors for the primary prevention of MHP and for health policies aiming to reduce social inequalities in mental health.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4014-4) contains supplementary material, which is available to authorized users.

Intervention study on psychosocial work factors and mental health and musculoskeletal outcomes

Organizations are facing ever-stiffer competition in the current globalized economy, and employees are consequently being exposed to increasingly adverse psychosocial work factors. Psychosocial work factors, also called psychosocial stressors, refer to all organizational factors and interpersonal relationships in the workplace that may affect workers' health. Two well-defined and internationally recognized theoretical models are used to assess these factors: the Karasek demand-latitude-support model and the Siegrist effort-reward imbalance model. The Karasek and Siegrist models reflect specific components of the work environment for which there is empirical evidence of a deleterious effect on health. Preventive interventions targeting these factors are conducted in workplaces. However, few studies have rigorously documented these interventions and their effectiveness in reducing adverse work factors and improving health outcomes. Most previous intervention studies were limited by (1) a short follow-up that may not have provided sufficient time for effects to appear, (2) small sample sizes (N ≤ 100) that limited the statistical power and the possibility of detecting results and (3) rare assessment of the Siegrist model. The current paper presents the overall design and the main results of an intervention study on psychosocial work factors and related mental health and musculoskeletal outcomes. The study integrated (1) a development phase that aimed at identifying the changes needed to reduce psychosocial factors in the target population and the best ways to bring about these changes, (2) an implementation phase that systematically documented how the intervention was carried out and (3) an effectiveness phase that evaluated whether the intervention was successful in reducing adverse psychosocial work factors and health problems. In addition, the study used repeated measurements of psychosocial work factors and health indicators at baseline and six and 30 months post-intervention to assess short- and medium-term effects of the intervention.

A closer look at the relationships between panic attacks, emergency department visits and non-cardiac chest pain

This study examined the prevalence of emergency department visits prompted by panic attacks in patients with non-cardiac chest pain. A validated structured telephone interview was used to assess panic attacks and their association with the emergency department consultation in 1327 emergency department patients with non-cardiac chest pain. Patients reported at least one panic attack in the past 6 months in 34.5 per cent (95% confidence interval: 32.0%–37.1%) of cases, and 77.1 per cent (95% confidence interval: 73.0%–80.7%) of patients who reported panic attacks had visited the emergency department with non-cardiac chest pain following a panic attack. These results indicate that panic attacks may explain a significant proportion of emergency department visits for non-cardiac chest pain.

Inter-Professional Practices of Private-Sector Physiotherapists for Low Back Pain Management: Who, How, and When?

Purpose: Although there have been increasing demands for health care providers to take part in inter-professional practices in recent years, very little attention has been paid to the actualization of such practices in the private sector. This study describes private-sector physiotherapists' inter-professional practices regarding low back pain (LBP) management and identifies organizational and provider-level variables associated with the intensity of such practices. Method: A total of 327 randomly selected physiotherapists were surveyed in the province of Quebec. Data were analyzed using descriptive and multiple regression analyses. Results: Physiotherapists reported frequent interactions with other physiotherapists (daily/weekly for 52.6%), family physicians (51.0%), and physiotherapy (PT) assistants (45.2%), but infrequent interactions with psychologists (3.6%), neurosurgeons (0.9%), and chiropractors (0.3%). Frequently reported means of interactions were written and oral messages sent through clients (55.1% and 24.1%, respectively), face-to-face unplanned discussions (41.9%), and faxed or mailed letters (23.2%). Variables associated with the intensity of inter-professional practices (mean of 6.7 [SD 1.7] out of 10 on the Intensity of Interprofessional Practices Questionnaire for Private Sector Physiotherapists) were related to physiotherapists' clientele, social activities with other providers, and perceptions of inter-professional practices as well as organizational models, vision, and provision of PT training. Conclusions: There is room to improve inter-professional practices with private-sector physiotherapists involved in managing LBP. Targets for action include physiotherapists and their workplaces.

Workers' characteristics associated with the type of healthcare provider first seen for occupational back pain

BACKGROUND

Few studies have compared the factors that drive patients' decision to choose a chiropractor, physician or physiotherapist as their first healthcare provider for occupational back pain. The purpose of this study is to identify characteristics associated with the choice of first healthcare provider seen for acute uncomplicated occupational back pain.

METHODS

We analyzed data collected by the Workplace Safety and Insurance Board from a cohort of workers with compensated back pain in 2005 in Ontario (Canada). Multivariable logistic regression models were created to identify factors associated with the type of first healthcare provider seen (chiropractor, physician, or physiotherapist). Adjustments to the final models were evaluated using the area under the receiver-operating characteristics curve (ROC).

RESULTS

According to the 5520 analyzed claims, 85.3 % of the patients saw a physician, 11.4 % saw a chiropractor, and 3.2 % saw a physiotherapist. Longer job tenure (odds ratio (OR) = 1.02, P = 0.004), higher gross personal income (OR = 1.06, P = 0.018), mixed-manual job (OR = 1.35, P = 0.004) and previous similar injury (OR = 1.60, P < 0.001) increased the odds of seeing a chiropractor rather than a physician, while the size of the community (>500,000 inhabitants) and the availability of an early return to work program in the workplace (OR = 0.77, P = 0.035) decreased it. The odds of seeing a physiotherapist rather than a physician increased with increasing age (OR = 1.19, P = 0.019), previous similar injury (OR = 1.71, P < 0.001) and severity of injury (OR = 2.03, P = 0.010). Increased age (OR = 1.28, P = 0.008) and size of community (>1,500,000 inhabitants; OR = 2.58, P = 0.002) increased the odds of seeing a physiotherapist rather than a chiropractor, while holding a mixed-manual job significantly decreased those odds (OR = 0.63, P = 0.044). The area under the ROC curve of our multivariable models varied from 0.62 to 0.64.

CONCLUSION

The type of first healthcare provider sought for occupational back pain is influenced by injury-and work-related factors and by the worker's age, income and community size. Contrary to previous studies, the workers who first sought a physician did not have higher odds of having a severe injury.

Determinants and predictors of absenteeism and return-to-work in workers with shoulder disorders

BACKGROUND

Shoulder disorders lead to substantial productivity loss and determinants and predictors of sick leave are poorly known.

OBJECTIVE

To perform a systematic review on determinants and predictors of sick leave and delayed return-to-work (RTW) in workers with shoulder disorders.

METHODS

A systematic literature search was conducted and we included studies on workers with shoulder disorders that contained information on determinants or predictors for sick leave or RTW, The risk of bias of included studies was evaluated with a validated tool.

RESULTS

Eight studies were included and four had a high risk of bias. The only determinants that were found significantly associated with delayed RTW or sickness absence in more than one study were an atraumatic history, disease severity and previous sickness absence. A clinical prediction rule was developed to predict sick leave in one study and included the following predictors: a longer duration of sick leave prior to consultation, higher shoulder pain, strain/overuse in usual activities and psychological complaints.

CONCLUSION

Several determinants or predictors were identified in the present review, but there is currently inconsistent evidence on the role of any determinants or predictors of work absence or delayed RTW for workers with a shoulder disorder. More methodologically sound studies are needed.

Efficacy of exercise therapy in workers with rotator cuff tendinopathy: a systematic review

Objective:

To perform a systematic review of randomized controlled trials (RCTs) on the efficacy of therapeutic exercises for workers suffering from rotator cuff (RC) tendinopathy.

Methods:

A literature search in four bibliographical databases (Pubmed, CINAHL, EMBASE, and PEDro) was conducted from inception up to February 2015. RCTs were included if participants were workers suffering from RC tendinopathy, the outcome measures included work-related outcomes, and at least one of the interventions under study included exercises. The methodological quality of the studies was evaluated with the Cochrane Risk of Bias Assessment tool.

Results:

The mean methodological score of the ten included studies was 54.4%±17.2%. Types of workers included were often not defined, and work-related outcome measures were heterogeneous and often not validated. Three RCTs of moderate methodological quality concluded that exercises were superior to a placebo or no intervention in terms of function and return-to-work outcomes. No significant difference was found between surgery and exercises based on the results of two studies of low to moderate methodological quality. One study of low methodological quality, comparing a workplace-based exercise program focusing on the participants' work demands to an exercise program delivered in a clinical setting, concluded that the work-based intervention was superior in terms of function and return-to-work outcomes.

Conclusion:

There is low to moderate-grade evidence that therapeutic exercises provided in a clinical setting are an effective modality to treat workers suffering from RC tendinopathy and to promote return-to-work. Further high quality studies comparing different rehabilitation programs including exercises in different settings with defined workers populations are needed to draw firm conclusions on the optimal program to treat workers.

Mental Health Interventions in the Workplace and Work Outcomes: A Best-Evidence Synthesis of Systematic Reviews

Background:

Mental health issues in the workplace are a growing concern among organizations and policymakers, but it remains unclear what interventions are effective in preventing mental health problems and their associated organizational consequences. This synthesis reports on workplace mental health interventions that impact absenteeism, productivity and financial outcomes.

Objective:

To determine the level of evidence supporting mental health interventions as valuable to work outcomes.

Methods:

Databases were searched for systematic reviews between 2000 and 2012: Medline, EMBASE, the Cochrane Database of Systematic Reviews, DARE, CINAHL, PsycINFO and TRIP. Grey literature searches included health-evidence.ca, Rehab+, National Rehabilitation Information Center (NARIC), and Institute for Work and Health. The assessment of articles for inclusion criteria and methodological quality was conducted independently by two or more researchers, with differences resolved through consensus.

Results:

The search resulted in 3363 titles, of which 3248 were excluded following title/abstract review, with 115 articles retrieved for full-text review. 14 articles finally met the inclusion criteria and are summarized in this synthesis.

Conclusion:

There is moderate evidence for the effectiveness of workplace mental health interventions on improved workplace outcomes. Certain types of programs, such as those incorporating both mental and physical health interventions, multicomponent mental health and/or psychosocial interventions, and exposure in vivo containing interventions for particular anxiety disorders had a greater level of research evidence to support their effectiveness.

Reliability, validity, and responsiveness of a Canadian French adaptation of the Western Ontario Rotator Cuff (WORC) index

STUDY DESIGN

Clinical measurement.

PURPOSE

Several questionnaires assess symptoms and functional limitations following shoulder disorders, but few are available in French. The purposes were to translate and culturally adapt the Western Ontario Rotator Cuff (WORC) index into Canadian French and to evaluate its validity, reliability and responsiveness.

METHODS

In accordance with standard procedure, the WORC original version was translated and cross-culturally adapted into Canadian French (WORC-CF). Then, 87 patients with rotator cuff (RC) disorders completed the WORC-CF on three occasions: baseline, two days later to evaluate reliability, and four weeks later to evaluate responsiveness.

RESULTS

Cross-cultural adaptation was performed without problems with content or language. WORC-CF was found to be reliable (Intraclass Correlation Coefficient = 0.96), valid (high correlation with Disability of the Arm, Shoulder and Hand [DASH]) and responsive (Standardized Response Mean = 1.54).

CONCLUSION

WORC-CF can now be used to assess functional impairment in patients with RC disorders.

LEVEL OF EVIDENCE

Not applicable.

Social Support and Supervisory Quality Interventions in the Workplace: A Stakeholder-Centered Best-Evidence Synthesis of Systematic Reviews on Work Outcomes

Background:

There is controversy surrounding the impact of workplace interventions aimed at improving social support and supervisory quality on absenteeism, productivity and financial outcomes.

Objective:

To determine the value of social support interventions for work outcomes.

Methods:

Databases were searched for systematic reviews between 2000 and 2012 to complete a synthesis of systematic reviews guided by the PRISMA statement and the IOM guidelines for systematic reviews. Assessment of articles for inclusion and methodological quality was conducted independently by at least two researchers, with differences resolved by consensus.

Results:

The search resulted in 3363 titles of which 3248 were excluded following title/ abstract review, leaving 115 articles that were retrieved and underwent full article review. 10 articles met the set inclusion criteria, with 7 focusing on social support, 2 on supervisory quality and 1 on both. We found moderate and limited evidence, respectively, that social support and supervisory quality interventions positively impact workplace outcomes.

Conclusion:

There is moderate evidence that social support and limited evidence that supervisory quality interventions have a positive effect on work outcomes.

Validation of a New Tool to Measure Physiotherapists' Interprofessional Practices

Interprofessional collaboration is recommended in health systems everywhere, but research on its measurement is needed. This psychometric study assessed the construct validity, internal consistency, and test-retest reliability of the Intensity of Interprofessional Practices Questionnaire for Private-Sector Physiotherapists (IIPQ-PT). A random sample of 303 physiotherapists (PTs) completed the 12-item questionnaire, and a subsample of 103 completed it a second time 2 weeks later. Exploratory factor analyses revealed a one-factor solution for the instrument. IIPQ-PT scores showed respectively fair and moderate relationships with the percentage of low back pain clients for whom PTs reported interactions with other professionals (0.30; 95% CI 0.19-0.40; p<0.001) and perceived degree of interactions (0.58; 95% CI 0.50-0.65; p<0.001). The IIPQ-PT had high internal consistency (Cronbach's a= 0.86; 95% CI 0.83-0.88) and good test-retest reliability (ICC=0.69; 95% CI 0.57-0.78). The minimum detectable difference for a 95% CI was 2.52. Although further study of this instrument is warranted, our results are promising for its future use. The IIPQ-PT may prove useful to evaluate the effectiveness of interventions aiming to improve interprofessional practices and to measure the effects of such practices on service users, providers, and the health system.

Efficacy of transcutaneous electrical nerve stimulation for rotator cuff tendinopathy: a systematic review

OBJECTIVE

To perform a systematic review on the efficacy of transcutaneous electrical nerve stimulation (TENS) for the treatment of rotator cuff tendinopathy in adults.

METHODS

A literature search was conducted in four databases (CINAHL, Embase, PubMed and PeDRO) for randomised controlled trials published from date of inception until April 2015, comparing the efficacy of TENS for the treatment of rotator cuff tendinopathy with placebo or any other intervention. Risk of bias was evaluated using the Cochrane risk of bias tool. Results were summarised qualitatively.

RESULTS

Six studies were included in this review. The mean methodological score was 49% (standard deviation 16%), indicating an overall high risk of bias. One placebo-controlled trial reported that a single TENS session provided immediate pain reduction for patients with rotator cuff tendinopathy, but did not follow the participants in the short, medium or long term. Two trials that compared ultrasound therapy with TENS reported discrepancy and contradictory results in terms of pain reduction and shoulder range of motion. Corticosteroid injections were found to be superior to TENS for pain reduction in the short term, but the differences were not clinically important. Other studies included in this review concluded that TENS was not superior to heat or pulsed radiofrequency.

CONCLUSION

Due to the limited number of studies and the overall high risk of bias of the studies included in this review, no conclusions can be drawn on the efficacy of TENS for the treatment of rotator cuff tendinopathy. More methodologically sound studies are needed to document the efficacy of TENS. Until then, clinicians should prefer other evidence-based rehabilitation interventions proven to be efficacious to treat patients with rotator cuff tendinopathy.

Chiropractors' characteristics associated with their number of workers' compensation patients

STUDY DESIGN

A cross-sectional survey.

OBJECTIVE

The purpose of this study was to identify characteristics of Canadian doctors of chiropractic (DCs) associated with their number of workers' compensation patients.

SUMMARY OF BACKGROUND DATA

It has been previously hypothesized that DCs that treat a relatively high volume of workers' compensation cases may have different characteristics than the general chiropractic community.

METHODS

Secondary data analyses were performed on data collected in the 2011 survey of the Canadian Chiropractic Resources Databank (CCRD). The CCRD survey included 81 questions concerning the practice and concerns of DCs. Of the 6,533 mailed questionnaires, 2,529 (38.7%) were returned. Of these, 652 respondents did not meet our inclusion criteria, and our final study sample included 1,877 respondents. Bivariate analyses were conducted between predetermined independent variables and the annual number of workers' compensation patients. A negative binomial multivariate regression was performed to identify significant factors associated with the number of workers' compensation patients.

RESULTS

On average, DCs received 10.3 (standard deviation (SD) = 17.6) workers' compensation cases and nearly one-third did not receive any such cases. The type of clinic (other than sole provider), practice area population (smaller than 500,000), practice province (other than Quebec), number of practice hours per week, number of treatments per week, main sector of activity (occupational/ industrial), care provided to patients (electrotherapy, soft-tissue therapy), percentage of patients with neuromusculoskeletal conditions, and percentage of patients referred by their employer or a physician were associated with a higher annual number of workers' compensation cases.

CONCLUSION

Canadian DCs who reported a higher volume of workers' compensation patients had practices oriented towards the treatment of injured workers, collaborated with other health care providers, and facilitated workers' access to care.

THE EFFICACY OF TAPING FOR ROTATOR CUFF TENDINOPATHY: A SYSTEMATIC REVIEW AND META-ANALYSIS

BACKGROUND

Rotator cuff (RC) tendinopathy is a highly prevalent musculoskeletal disorder. Non-elastic taping (NET) and kinesiology taping (KT) are common interventions used by physiotherapists. However, evidence regarding their efficacy is inconclusive.

OBJECTIVE

To examine the current evidence on the clinical efficacy of taping, either NET or KT, for the treatment of individuals with RC tendinopathy.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

A literature search was conducted in four bibliographical databases to identify randomized controlled trials (RCT) that compared NET or KT to any other intervention or placebo for treatment of RC tendinopathy. Internal validity of RCTs was assessed with the Cochrane Risk of Bias tool. A qualitative or quantitative synthesis of evidence was performed.

RESULTS

Ten trials were included in the present review on overall pain reduction or improvement in function. Most RCTs had a high risk of bias. There is inconclusive evidence for NET, either used alone or in conjunction with another intervention. Based on pooled results of two studies (n=72), KT used alone resulted in significant gain in pain free flexion (MD: 8.7 ° 95%CI 8.0 ° to 9.5 °) and in pain free abduction (MD: 10.3 ° 95%CI 9.1 ° to 11.4 °). Based on qualitative analyses, there is inconclusive evidence on the efficacy of KT when used alone or in conjunction with other interventions on overall pain reduction or improvement in function.

CONCLUSION

Although KT significantly improved pain free range of motion, there is insufficient evidence to formally conclude on the efficacy of KT or NET used alone or in conjunction with other interventions in patients with RC tendinopathy.

LEVEL OF EVIDENCE

Therapy, level 1a.

Adrenal inhibition following a single dose of etomidate in intubated traumatic brain injury victims

Background:

Etomidate is frequently used to intubate traumatic brain injury (TBI) victims, even though it has been linked to adrenal insufficiency (AI) in some populations. Few studies have explored the risk of prolonged etomidateinduced AI among TBI victims.

Objective:

To determine the risk and the length of AI induced by etomidate in patients intubated for moderate and severe TBI.

Methods:

Participants in this observational study were moderate to severe intubated TBI victims aged ≥ 16 years. The anesthetic used (etomidate versus others) was determined solely by the treating emergency physician. Adrenocorticotropic hormone (ACTH) stimulation tests (250 µg) were performed 24, 48, and 168 hours after intubation. AI was defined as an increase in serumcortisol 1 hour post–ACTH test (delta cortisol) of less than 248.4 nmol/L.

Results:

Forty subjects (participation 42.6%) underwent ACTH testing. Fifteen received etomidate, and 25 received another anesthetic. There were no statistically significant differences between groups as to the cumulative incidence of AI at any measurement time. However, at 24 hours, exploratory post hoc analyses showed a significant decrease in delta cortisol (adjusted means: etomidate group: 305.1 nmol/L, 95% CI 214.7–384.8 versus other anesthetics: 500.5 nmol/L, 95% CI 441.8–565.7). This decrease was not present at 48 and 168 hours.

Conclusion:

In TBI victims, although a single dose of etomidate does not increase the cumulative incidence of AI as defined, it seems to decrease the adrenal response to an ACTH test for 24 hours. The clinical impacts of this finding remain to be determined.

Job demand and control interventions: a stakeholder-centered best-evidence synthesis of systematic reviews on workplace disability

BACKGROUND

Physical and psychological job demands in combination with the degree of control a worker has over task completion, play an important role in reducing stress. Occupational stress is an important, modifiable factor affecting work disability. However, the effectiveness of reducing job demands or increasing job control remains unclear, particularly for outcomes of interest to employers, such as absenteeism or productivity.

OBJECTIVE

This systematic review reports on job demand and control interventions that impact absenteeism, productivity and financial outcomes.

METHODS

A stakeholder-centered best-evidence synthesis was conducted with researcher and stakeholder collaboration throughout. Databases and grey literature were searched for systematic reviews between 2000 and 2012: Medline, EMBASE, the Cochrane Database of Systematic Reviews, DARE, CINAHL, PsycINFO, TRIP, health-evidence.ca, Rehab+, National Rehabilitation Information Center (NARIC), and Institute for Work and Health. Articles were assessed independently by two researchers for inclusion criteria and methodological quality. Differences were resolved through consensus.

RESULTS

The search resulted in 3363 unique titles. After review of abstracts, 115 articles were retained for full-text review. 11 articles finally met the inclusion criteria and are summarized in this synthesis. The best level of evidence we found indicates that multimodal job demand reductions for either at-work or off-work workers will reduce disability-related absenteeism.

CONCLUSION

In general, the impacts of interventions that aim to reduce job demands or increase job control can be positive for the organization in terms of reducing absenteeism, increasing productivity and cost-effectiveness. However, more high quality research is needed to further assess the relationships and quantify effect sizes for the interventions and outcomes reviewed in this study.

Psychometric properties of self-reported questionnaires for the evaluation of symptoms and functional limitations in individuals with rotator cuff disorders: a systematic review

PURPOSE

To conduct a systematic review of the psychometric properties (reliability, validity and responsiveness) of self-report questionnaires used to assess symptoms and functional limitations of individuals with rotator cuff (RC) disorders.

METHODS

A systematic search in three databases (Cinahl, Medline and Embase) was conducted. Data extraction and critical methodological appraisal were performed independently by three raters using structured tools, and agreement was achieved by consensus. A descriptive synthesis was performed.

RESULTS

One-hundred and twenty articles reporting on 11 questionnaires were included. All questionnaires were highly reliable and responsive to change, and showed construct validity; seven questionnaires also shown known-group validity. The minimal detectable change ranged from 6.4% to 20.8% of total score; only two questionnaires (American Shoulder and Elbow Surgeon questionnaire [ASES] and Upper Limb Functional Index [ULFI]) had a measurement error below 10% of global score. Minimal clinically important differences were established for eight questionnaires, and ranged from 8% to 20% of total score.

CONCLUSION

Overall, included questionnaires showed acceptable psychometric properties for individuals with RC disorders. The ASES and ULFI have the smallest absolute error of measurement, while the Western Ontario RC Index is one of the most responsive questionnaires for individuals suffering from RC disorders.

IMPLICATIONS FOR REHABILITATION

All included questionnaires are reliable, valid and responsive for the evaluation of individuals with RC disorders. As all included questionnaires showed good psychometric properties for the targeted population, the choice should be made according to the purpose of the evaluation and to the construct being evaluated by the questionnaire. The WORC, a RC-specific questionnaire, appeared to be more responsive. It should therefore be used to evaluate change in time. If the evaluation is time-limited, shorter questionnaires or short versions should be considered (such as Quick DASH or SST).

Diagnostic accuracy of ultrasonography, MRI and MR arthrography in the characterisation of rotator cuff disorders: a systematic review and meta-analysis

Background

Different diagnostic imaging modalities, such as ultrasonography (US), MRI, MR arthrography (MRA) are commonly used for the characterisation of rotator cuff (RC) disorders. Since the most recent systematic reviews on medical imaging, multiple diagnostic studies have been published, most using more advanced technological characteristics. The first objective was to perform a meta-analysis on the diagnostic accuracy of medical imaging for characterisation of RC disorders. Since US is used at the point of care in environments such as sports medicine, a secondary analysis assessed accuracy by radiologists and non-radiologists.

Methods

A systematic search in three databases was conducted. Two raters performed data extraction and evaluation of risk of bias independently, and agreement was achieved by consensus. Hierarchical summary receiver-operating characteristic package was used to calculate pooled estimates of included diagnostic studies.

Results

Diagnostic accuracy of US, MRI and MRA in the characterisation of full-thickness RC tears was high with overall estimates of sensitivity and specificity over 0.90. As for partial RC tears and tendinopathy, overall estimates of specificity were also high (>0.90), while sensitivity was lower (0.67–0.83). Diagnostic accuracy of US was similar whether a trained radiologist, sonographer or orthopaedist performed it.

Conclusions

Our results show the diagnostic accuracy of US, MRI and MRA in the characterisation of full-thickness RC tears. Since full thickness tear constitutes a key consideration for surgical repair, this is an important characteristic when selecting an imaging modality for RC disorder. When considering accuracy, cost, and safety, US is the best option.

Standardised method for reporting exercise programmes: protocol for a modified Delphi study

INTRODUCTION

Exercise is integral to health across the lifespan and important for people with chronic health conditions. A systematic review of exercise trials for chronic conditions reported suboptimal descriptions of the evaluated interventions and concluded that this hinders interpretation and replication. The aim of this project is to develop a standardised method for reporting essential exercise programme details being evaluated in clinical trials.

METHODS AND ANALYSIS

A modified Delphi technique will be used to gain consensus among international exercise experts. We will use three sequential rounds of anonymous online questionnaires to refine a standardised checklist. A draft checklist of potentially relevant items was developed based on the results of a systematic review of exercise systematic reviews. An international panel of experts was identified by exercise systematic review authorship, established international profile in exercise research and practice and by peer referral. In round 1, the international panel of experts will be asked to rate the importance of each draft item and provide additional suggestions for revisions or new items. Consensus will be considered reached if at least 70% of the panel strongly agree/disagree that an item should be included or excluded. Where agreement is not reached or there are suggestions for altered or new items, these will be taken to round 2 together with an aggregated summary of round 1 responses. Following the second round, a ranking of item importance will be made to rationalise the number of items. The final template will be distributed to panel members for approval.

ETHICS AND DISSEMINATION

Ethics approval was received from The Cabrini Institute Ethics Committee, Melbourne, Australia (HREC 02-07-04-14). We plan to use a stepwise process to develop and refine a standardised and internationally agreed template for explicit reporting of exercise programmes. The template will be generalisable across all types of exercise interventions. The findings will be disseminated through peer-reviewed publications and conference presentations.

Cross-cultural adaptation of the delphi definitions of low back pain prevalence (German DOLBaPP)

BACKGROUND

Assessed dimensions of low back pain (LBP) vary in prevalence studies. This may explain the heterogeneity in frequency estimates. To standardize definitions of LBP, an English consensus with 28 experts from 12 countries developed the "Delphi Definitions of Low Back Pain Prevalence" (DOLBaPP). The optimal definition and the shorter minimal definition with the related questionnaires for online, paper, and face-to-face use and telephone surveys are suitable for population-based studies. The definitions have to be adapted to different languages and cultures to provide comparable frequency estimates. The objective was to culturally adapt and pre-test the English definitions and corresponding Delphi DOLBaPP questionnaire forms into German.

METHODS

The German DOLBaPP adaptation was conducted using the systematic approach suggested by Beaton et al. A pre-test of the Delphi DOLBaPP optimal paper questionnaire including an additional evaluation form was conducted in a sample of 121 employees (mainly office workers). In order to evaluate the comprehensibility, usability, applicability, and completeness of the adapted questionnaire, response to the questionnaire and 6 closed evaluation questions were analyzed descriptively. Qualitative methods were used for the 3 open questions of the evaluation form.

RESULTS

The cultural adaptation of the DOLBaPP for a German-speaking audience required little linguistic adaptation. Conceptual equivalence was difficult for the expression "low back pain". The expert committee considered the face validity of the pre-final version of the related Delphi DOLBaPP questionnaires as good. In the pre-test, most participants (95%) needed less than 5 minutes to fill in the optimal Delphi DOLBaPP questionnaire. They were generally positive regarding length, wording, diagram, and composition. All subjects with LBP (n=61 out of 121 - 50.4%) answered the questions on functional limitation, sciatic pain, frequency and duration of symptoms as well as pain severity.

CONCLUSION

The results indicate that the cross-cultural German adaptation of the DOLBaPP Definitions and the corresponding questionnaires was successful. The definitions can be used in epidemiological studies to measure the prevalence of LBP. Some critical issues were raised regarding the general features of the Delphi DOLBaPP questionnaires. Future research is needed to evaluate these instruments.