Eli Molde Hagen

Does early intervention with a light mobilization program reduce long-term sick leave for low back pain?

Study Design. A controlled randomized clinical trial was performed. Objective. To investigate the effect of a light mobilization program on the duration of sick leave for patients with subacute low back pain. Summary of Background Data. Early intervention with information, diagnostics, and light mobilization may be a cost-effective method for returning patients quickly to normal activity. In this experiment, patients were referred to a low back pain clinic and given this simple and systematic program as an outpatient treatment. Methods. In this study, 457 patients sick-listed 8 to 12 weeks for low back pain, as recorded by the National Insurance Offices, were randomized into two groups: an intervention group (n = 237) and a control group (n = 220). The intervention group was examined at a spine clinic and given information and advice to stay active. The control group was not examined at the clinic, but was treated with conventional primary health care. Results. At 12-month follow-up assessment, 68.4% in the intervention group had returned to full-duty work, as compared with 56.4% in the control group. Conclusions. Early intervention with examination, information, and recommendations to stay active showed significant effects in reducing sick leave for patients with low back pain.

Comorbid subjective health complaints in low back pain

Study Design. Cross-sectional study. Objectives. To compare subjective health complaints in subacute patients with low back pain with reference values from a Norwegian normal population. Summary of Background Data. Comorbidity is common with nonspecific low back pain. We wanted to investigate if these complaints were specific or part of a more general unspecific condition comparable to subjective health complaints in the normal population. Materials and Methods. The study group consisted of 457 patients sick-listed 8 to 12 weeks for low back pain. All subjects filled out questionnaires. The subjective health complaints in the study group were compared with reference values from a Norwegian normal population using logistic regression analysis. Results. Compared with the normal reference population, the patients with low back pain had significantly more low back pain, neck pain, upper back pain, pain in the feet during exercise, headache, migraine, sleep problems, flushes/heat sensations, anxiety, and sadness/depression. The prevalence of pain in arms, pain in shoulders, and tiredness was also high, but not significantly higher than in the reference population. Conclusions. Our findings indicate that patients with low back pain suffer from what may be referred to as a “syndrome,” consisting of muscle pain located to the whole spine as well as to legs and head, and accompanying sleep problems, anxiety, and sadness/depression.

Does early intervention with a light mobilization program reduce long-term sick leave for low back pain: a 3-year follow-up study.

Study Design. A randomized clinical trial. Objectives. To evaluate long-term clinical and economical effects of a light mobilization program on the duration of sick leave for patients with subacute low back pain. Summary of Background Data. Twelve-month follow-up results from a previous study showed that early intervention with examination at a spine clinic, giving the patients information, reassurance, and encouragement to engage in physical activity as normal as possible had significant effect in reducing sick leave. At 12-month follow-up, 68.4% in the intervention group were off sick leave, as compared with 56.4% in the control group. Patients in this study were followed-up for a period of 3 years to investigate possible long-term effects. Materials and Methods. Four hundred fifty-seven patients placed on a sick list for 8 to 12 weeks for low back pain were randomized into two groups: an intervention group (n = 237) and a control group (n = 220). The intervention group was examined at a spine clinic and given information and advice to stay active. The control group was not examined at the clinic but was treated within the primary health care. Results. Over the 3 years of observation, the intervention group had significantly fewer days of sickness compensation (average 125.7 d/person) than the control group (169.6 d/person). This difference is mainly caused by a more rapid return to work during the first year. There was no significant difference for the second or third year. In particular, there is no increased risk for reoccurrence of illness from early return to work. At 6-month follow-up, patients in the intervention group were less likely to use bed rest and more likely to use stretching and walking to cope with their back pain compared with the control group. This effect diminished. At 12-month follow-up, the only significant difference between the groups was in the use of stretching. Economic returns of the intervention were calculated in terms of increases in the net present value of production for the society because of the reduction in number of days on sick leave. Net benefits accumulated over 3 years of treating the 237 patients in the intervention group amount to approximately

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

2,822 per person. Conclusions. For patients with subacute low back pain, a brief and simple early intervention with examination, information, reassurance, and encouragement to engage in physical activity as normal as possible had economic gains for the society. The effect occurred during the first year after intervention. There were no significant long-term effects of the intervention. The initial gain obtained during the first year does not lead to any increased costs or increased risks for reoccurrence of illness over the next 2 years.

Predictors and Modifiers of Treatment Effect Influencing Sick Leave in Subacute Low Back Pain Patients

BackgroundBrief intervention programs for subacute low back pain (LBP) result in significant reduction of sick leave compared to treatment as usual. Although effective, a substantial proportion of the patients do not return to work. This study investigates predictors of return to work in LBP patients participating in a randomized controlled trial comparing a brief intervention program (BI) with BI and physical exercise.MethodsPredictors for not returning to work was examined in 246 patients sick listed 8-12 weeks for low back pain. The patients had participated in a randomized controlled trial, with BI (n = 122) and BI + physical exercise (n = 124). There were no significant differences between the two intervention groups on return to work. The groups were therefore merged in the analyses of predictors. Multiple logistic regression analysis was used to identify predictors for non return to work at 3, 12, and 24 months of follow-up.ResultsAt 3 months of follow-up, the strongest predictors for not returning to work were pain intensity while resting (OR = 5.6; CI = 1.7-19), the perception of constant back strain when working (OR = 4.1; CI = 1.5-12), negative expectations for return to work (OR = 4.2; CI = 1.7-10), and having been to a physiotherapist prior to participation in the trial (OR = 3.3; CI = 1.3-8.3). At 12 months, perceived reduced ability to walk far due to the complaints (OR = 2.6; CI = 1.3-5.4), pain during activities (OR = 2.4; CI = 1.1-5.1), and having been to a physiotherapist prior to participation in the trial (OR = 2.1; CI = 1.1-4.3) were the strongest predictors for non return to work. At 24 months age below 41 years (OR = 2.9; CI = 1.4-6.0) was the only significant predictor for non return to work.ConclusionIt appears that return to work is highly dependant on individual and cognitive factors. Patients not returning to work after the interventions were characterized by negative expectations, perceptions about pain and disability, and previous physiotherapy treatment. This is the first study reporting that previous treatment by physiotherapists is a risk factor for long-term sick leave. This has not been reported before and is an interesting finding that deserves more scrutiny.

Adding a physical exercise programme to brief intervention for low back pain patients did not increase return to work

Study Design. Modifying effects in multivariate analyses of a randomized controlled trial. Objectives. To identify prognostic factors for the effect of a brief intervention (“modifiers”) at a spine clinic on return to work in patients with subacute low back pain. Summary of Background Data. A previous study of a brief intervention showed significant reduction of sick leave, compared with usual primary healthcare treatment. Randomized controlled trials give data only on the group as an average. Identifying prognostic factors that interact with the treatment (“modifiers”) may identify specific groups requiring this or other types of treatment. Methods. A total of 457 patients who had been sick-listed 8 to 12 weeks for low back pain were randomized into an intervention group (spine clinic with medical examination, information, reassurance, encouragement to engage in physical activity, n = 237), and a control group (primary health care, n = 220). All subjects filled out questionnaires. Logistic regression and tests for interaction were used to identify prognostic factors and modifiers for return to work in the two groups, at 3 and 12 months of follow-up. Results. At 3 months of follow-up, the strongest modifying effect on return to work was the perception of constant back strain when working and beliefs about reduced ability to work. At 12 months, gastrointestinal complaints were the strongest modifier for the effect of the intervention. Conclusion. The spine clinic intervention seems to have a main effect on work absenteeism via interacting with the concerns of being unable to work.

Protocol for the Cognitive Interventions and Nutritional Supplements (CINS) trial: A randomized controlled multicenter trial of a brief intervention (BI) versus a BI plus cognitive behavioral treatment (CBT) versus nutritional supplements for patients with long-lasting muscle and back pain

Aims: To investigate if a standardised physical exercise programme given in addition to a brief intervention at a spine clinic had an effect on return to work. Methods: A total of 246 patients sick-listed 8—12 weeks for non-specific low back pain were offered a brief intervention programme at the spine clinic with examination, information, reassurance, and encouragement to engage in physical activity as normal as possible, before they were randomised into an intervention group (n = 124) and a control group (n = 122). Patients in the intervention group participated in a physical exercise programme at the spine clinic. Results: During the 2-year follow-up, there were no significant differences between the groups on sick leave, pain, use of analgesics, psychological distress, coping strategies, fear-avoidance beliefs, self-reported disability, or walking distances. However, both groups increased return to work, reported less pain and better function, and reduced fear-avoidance beliefs for physical activity during the follow-up period. Fear-avoidance beliefs for work were not changed. Conclusions: A physical exercise programme for low back pain patients given after a brief intervention at a spine clinic did not have any additional effect on sick leave or fear-avoidance beliefs. Both groups reported less pain, better physical function, and increased return to work during follow-up. The treatment at the spine clinic did not contain a vocational rehabilitation programme directed towards individual work-related problems, which might explain no change in fear-avoidance beliefs for work.

Cognitive Interventions and Nutritional Supplements (The CINS Trial): A Randomized Controlled, Multicenter Trial Comparing a Brief Intervention with Additional Cognitive Behavioral Therapy, Seal Oil, and Soy Oil for Sick-Listed Low Back Pain Patients

BackgroundBrief intervention programs are clinically beneficial, and cost efficient treatments for low back pain, when offered at 8-12 weeks, compared with treatment as usual. However, about 30% of the patients do not return to work. The European Guidelines for treatment of chronic low back pain recommends Cognitive Behavioral Therapy (CBT), but conclude that further research is needed to evaluate the effectiveness of CBT for chronic low back pain.Methods/DesignThe aim of the multicenter CINS trial (Cognitive Interventions and Nutritional Supplements) is to compare the effectiveness of 4 different interventions; Brief Intervention, Brief Intervention and CBT, Brief Intervention and nutritional supplements of seal oil, and Brief Intervention and nutritional supplements of soy oil. All participants will be randomly assigned to the interventions. The nutritional supplements will be tested in a double blind design. 400 patients will be recruited from a population of chronic low back pain patients that have been sick listed for 2-10 months. Four outpatient clinics, located in different parts of Norway, will participate in recruitment and treatment of the patients.The Brief Intervention is a one session cognitive, clinical examination program based on a non-injury model, where return to normal activity and work is the main goal, and is followed by two booster sessions. The CBT is a tailored treatment involving 7 sessions, following a detailed manual. The nutritional supplements consist of a dosage of 10 grams of either soy or seal oil (capsules) per day for 3 months, administered in a double blind design. All patients will be followed up with questionnaires after 3, 6 and 12 months, while sick leave data will be collected up to at least 24 months after randomization. The primary outcome of the study is sick leave and will be based on register data from the National Insurance Administration. Secondary outcomes include self-reported data on disability, pain, and psychological variables.ConclusionsTo our knowledge, the CINS trial will be the largest, randomized trial of psychological and nutritional interventions for chronic low back pain patients to date. It will provide important information regarding the effectiveness of CBT and seal oil for chronic low back pain patients.Trial Registrationhttp://www.clinicaltrials.gov, with registration number NCT00463970.

Vermindert vroegtijdige interventie met een licht mobiliseringsprogramma het langdurig ziekteverzuim bij lage-rugpijn?

Study Design. A randomized controlled trial. Objective. The aim of this study was to evaluate whether a tailored and manualized cognitive behavior therapy (CBT) or nutritional supplements of seal oil and soy oil had any additional benefits over a brief cognitive intervention (BI) on return to work (RTW). Summary of Background Data. Brief intervention programs are clinically beneficial and cost-effective for patients with low back pain (LBP). CBT is recommended for LBP, but evidence on RTW is lacking. Seal oil has previously been shown to have a possible effect on muscle pain, but no randomized controlled trials have so far been carried out in LBP patients. Methods. Four hundred thirteen adults aged 18 to 60 years were included. Participants were sick-listed 2 to 10 months due to LBP. Main outcome was objectively ascertained work participation at 12-month follow-up. Participants were randomly assigned to BI (n = 100), BI and CBT (n = 103), BI and seal oil (n = 105), or BI and soy oil (n = 105). BI is a two-session cognitive, clinical examination program followed by two booster sessions, while the CBT program is a tailored, individual, seven-session manual-based treatment. Results. At 12-month follow-up, 60% of the participants in the BI group, 50% in the BI and CBT group, 51% in the BI and seal oil group, and 53% in the BI and soy oil group showed reduced sick leave from baseline, and had either partly or fully RTW. The differences between the groups were not statistically significant (&khgr;2 = 2.54, P = 0.47). There were no significant differences between the treatment groups at any of the other follow-up assessments either, except for a significantly lower sick leave rate in the BI group than the other groups during the first 3 months of follow-up (&khgr;2 = 9.50, P = 0.02). Conclusion. CBT and seal oil had no additional benefits over a brief cognitive intervention on sick leave. The brief cognitive intervention alone was superior in facilitating a fast RTW. Level of Evidence: 2

A multi-state model for sick-leave data applied to a randomized control trial study of low back pain

Does early intervention with a light mobilization program reduce long-term sick leave for low back pain? [Spine 2000;25(15):1973-6]