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Predictors identified for non-return to work in patients with low back pain
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March 2013
Predictors identified for non-return to work in patients with low back pain
Study Type:Therapy
OE Level Evidence:2
Journal Level of Evidence:N/A
Expectations, perceptions, and physiotherapy predict prolonged sick leave in subacute low back pain
BMC Musculoskelet Disord. 2009 Nov 13;10:139.Did you know you're eligible to earn 0.5 CME credits for reading this report? Click Here
Synopsis
246 patients suffering from low back pain, who have been sick listed for 8-12 weeks, were randomized to receive a brief intervention program alone or a brief intervention in combination with physical exercise. The objective of this trial was to identify predictors for not returning to work (i.e. secondary analysis). At 3, 12 and 24 months, there were no differences in return to work between participants in each group. As such, both arms were pooled for analysis of predictors of not returning to work. Significant predictors included pain intensity while resting and during activity, negative expectations for return to work, perceived reduced ability to walk long distances, and having prior treatment from a physiotherapist before the trial.
Publication Funding Details
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Funding:
Non-Industry funded
Sponsor:
Norwegian Foundation for Health and Rehabilitation
Conflicts:
None disclosed
Was the allocation sequence adequately generated?
Was allocation adequately concealed?
Blinding Treatment Providers: Was knowledge of the allocated interventions adequately prevented?
Blinding Outcome Assessors: Was knowledge of the allocated interventions adequately prevented?
Blinding Patients: Was knowledge of the allocated interventions adequately prevented?
Was loss to follow-up (missing outcome data) infrequent?
Are reports of the study free of suggestion of selective outcome reporting?
Were outcomes objective, patient-important and assessed in a manner to limit bias (ie. duplicate assessors, Independent assessors)?
Was the sample size sufficiently large to assure a balance of prognosis and sufficiently large number of outcome events?
Was investigator expertise/experience with both treatment and control techniques likely the same (ie.were criteria for surgeon participation/expertise provided)?
Yes = 1
Uncertain = 0.5
Not Relevant = 0
No = 0
The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.
1/4
Randomization
1/4
Outcome Measurements
2/4
Inclusion / Exclusion
4/4
Therapy Description
3/4
Statistics
Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.
Why was this study needed now?
Low back pain is one of the most common causes for loss of work and is a large economic burden. Brief intervention (BI) programs, consisting of consultations and a short follow up, have been demonstrated to significantly reduce sick leave; however, a large proportion of patients still do not return to work. This study identified predictors of non-return to work in patients who participated in a BI program alone or in combination with exercise.
What was the principal research question?
What predictors for not returning to work are present in patients suffering from sub-acute low back pain undergoing a brief intervention program or a brief intervention program in combination with physical exercise?
Study Characteristics
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Population:
246 patient suffering from low back pain who have been sick listed for 8-12 weeks
Intervention:
Group 1: Brief intervention program comprised of two consultation and a short follow-up (n=122)
Comparison:
Group 2: Brief intervention program with an additional physical exercise program (n=124)
Outcomes:
Sick leave, return to work, predictors for non return to work, Hopkins Symptom check list (HSCL-25) for physiological ditress, fear-avoidance beliefs questionnaire, subjective health complaint inventory, Roland Morris Questionnaire, Brief Pain Inventory
Methods:
RCT; Multiple Centers Patient responses were merged for the predictor analysis using multiple logistic regression analysis; Secondary analysis
Time:
24 months (follow-up at 3, 12 and 24 months)
What were the important findings?
- No significant differences in return to work were observed between group 1 and group 2 at 3, 12, or 24 months
- Both groups were combined for regression analysis of predictors for non-return to work
- At 3 months, pain intensity while resting (OR= 5.6 95%CI= 1.7-19.0), perception of constant back strain while working (OR= 4.1; 95% CI= 1.5-11.5), negative expectations of return to work (OR=4.2; 95% CI= 1.7-10.2), and physical therapy prior to study participation (OR=3.3; 95% CI=1.3-8.3) predicted non-return to work
- At 12 months, perceived reduced ability to walk far due to complaints (OR= 2.6; 95% CI= 1.3-5.4), pain during activities (OR=2.4;95% CI= 1.1-5.1), and physical therapy prior to participation in the trial (OR 2.1; 95% CI=1.1-4.3) predicted non-return to work at 12 months
- At 24 months, age below 41 years was the only predictor of non-return to work (OR= 2.9; 95% CI= 1.4-6.0)
What should I remember most?
The addition of an exercise program to a brief intervention provided no significant improvements in patient return to work. Pooled regression analysis identified a number of predictors for non-return to work at different follow-up points. These included the pain intensity at rest, perception of constant back strain negative expectations of return to work, pain during activities, perceived reduced ability to walk, and age less than 41, and previous treatment by a physiotherapist.
How will this affect the care of my patients?
Return to work for patients suffering from sub-acute low back pain is dependent on a number of individual and cognitive factors, including negative expectations and perceptions of pain and disability. Previous physiotherapy treatment was also identified as a novel predictor for non return to work, an unexpected finding that deserves further investigation.
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