J. David Cassidy

Are workplace health promotion programs effective at improving presenteeism in workers? a systematic review and best evidence synthesis of the literature

BackgroundPresenteeism is highly prevalent and costly to employers. It is defined as being present at work, but limited in some aspect of job performance by a health problem.Workplace health promotion (WHP) is a common strategy used to enhance on-the-job productivity. The primary objective is to determine if WHP programs are effective in improving presenteeism. The secondary objectives are to identify characteristics of successful programs and potential risk factors for presenteeism.MethodsThe Cochrane Library, Medline, and other electronic databases were searched from 1990 to 2010. Reference lists were examined, key journals were hand-searched and experts were contacted. Included studies were original research that contained data on at least 20 participants (≥ 18 years of age), and examined the impacts of WHP programs implemented at the workplace. The Effective Public Health Practice Project Tool for Quantitative Studies was used to rate studies. Strong and moderate studies were abstracted into evidence tables, and a best evidence synthesis was performed. Interventions were deemed successful if they improved the outcome of interest. Their program components were identified, as were possible risk factors contributing to presenteeism.ResultsAfter 2,032 titles and abstracts were screened, 47 articles were reviewed, and 14 were accepted (4 strong and 10 moderate studies). These studies contained preliminary evidence for a positive effect of some WHP programs. Successful programs offered organizational leadership, health risk screening, individually tailored programs, and a supportive workplace culture. Potential risk factors contributing to presenteeism included being overweight, a poor diet, a lack of exercise, high stress, and poor relations with co-workers and management. Limitations: This review is limited to English publications. A large number of reviewed studies (70%) were inadmissible due to issues of bias, thus limiting the amount of primary evidence. The uncertainties surrounding presenteeism measurement is of significant concern as a source of bias.ConclusionsThe presenteeism literature is young and heterogeneous. There is preliminary evidence that some WHP programs can positively affect presenteeism and that certain risk factors are of importance. Future research would benefit from standard presenteeism metrics and studies conducted across a broad range of workplace settings.

Musculoskeletal Injuries and Pain in Dancers: A Systematic Review

OBJECTIVEnTo assemble and synthesize the best evidence on the epidemiology, diagnosis, prognosis, treatment, and prevention of musculoskeletal injuries and pain in dancers.nnnDATA SOURCESnMedline, CINAHL, PsycINFO, Embase, and other electronic databases were searched from 1966 to 2004 using key words such as dance, dancer, dancing, athletic injuries, occupational injuries, sprains and strains, and musculoskeletal diseases. In addition, the reference lists of relevant studies were examined, specialized journals were hand-searched, and the websites of major dance associations were scanned for relevant information.nnnSTUDY SELECTIONnCitations were screened for relevance using a priori criteria, and relevant studies were critically reviewed for scientific merit by the best evidence synthesis method. After 1865 abstracts were screened, 103 articles were reviewed, and 32 (31%) of these were accepted as scientifically admissible (representing 29 unique studies).nnnDATA EXTRACTIONnData from accepted studies were abstracted into evidence tables relating to the prevalence and associated factors, incidence and risk factors, diagnosis, treatment, economic costs, and prevention of musculoskeletal injuries and pain in dancers.nnnDATA SYNTHESISnThe scientifically admissible studies consisted of 15 (52%) cohort studies, 13 (45%) cross-sectional studies, and 1 (3%) validation study of a diagnostic assessment tool. There is a high prevalence and incidence of lower extremity and back injuries, with soft tissue and overuse injuries predominating. For example, lifetime prevalence estimates for injury in professional ballet dancers ranged between 40% and 84%, while the point prevalence of minor injury in a diverse group of university and professional ballet and modern dancers was 74%. Several potential risk factors for injury are suggested by the literature, but conclusive evidence for any of these is lacking. There is preliminary evidence that comprehensive injury prevention and management strategies may help decrease the incidence of future injury.nnnCONCLUSIONSnThe dance medicine literature is young and heterogeneous, limiting our ability to draw consistent conclusions. Nonetheless, the best available evidence suggests that musculoskeletal injury is an important health issue for dancers at all skill levels. Better quality research is needed in this specialized area. Future research would benefit from clear and relevant research questions being addressed with appropriate study designs, use of conceptually valid and clinically meaningful case definitions of injury and pain, and better reporting of studies in line with current scientific standards.

How well are you recovering? The association between a simple question about recovery and patient reports of pain intensity and pain disability in whiplash-associated disorders

Purpose: There is potential value in developing a brief assessment tool for assessing recovery after musculoskeletal injuries. Our goal was to investigate the association between a one-item global self-assessment of recovery and commonly used measures of recovery status. Method: We followed a cohort of 6,021 adults with acute whiplash-associated disorders for six months. Pain, depression, work status and physical health were assessed at baseline and follow-up. The question “How do you feel you are recovering from your injury?” (six response options from “all better” to “getting much worse”) and functional limitations were administered at follow-up. Results: Responses to the recovery question was associated with our other indices of recovery. Those “all better” had the lowest pain intensity, pain-related limitations, depression and work disability, and the best general physical health. Incrementally poorer recovery ratings on the recovery question were associated with greater pain, functional limitations and depression, poorer physical health and being off work, although “no improvement” and “getting a little worse” were similar. Recovery categories also reflected different degrees of actual improvements over the preceding follow-up period. Conclusions: Our findings suggest that a single recovery question is a useful tool for conducting brief global assessments of recovery of musculoskeletal injuries. Implications for Rehabilitation Musculoskeletal injuries are common sources of disability and pain. Having a quick and easy way of tracking patient recovery helps clinicians to be quickly responsive in modifying aspects of rehabilitation as required. A brief question “How are you recovering from your injuries?” with response options ranging from “all better” to “quite a bit worse,” performed well when compared with other indices of recovery. This brief question can help guide decisions about intensity and type of rehabilitation in treatment of musculoskeletal injuries.

Are Modic changes prognostic for recovery in a cohort of patients with non-specific low back pain?

BackgroundThere is evidence for an association between Modic type 1 and pain in patients with low back pain (LBP), but little knowledge about its effect on clinical outcomes.Purpose(1) To assess the prevalence of Modic changes, (2) to determine if Modic changes influence the clinical course of LBP, and (3) to identify prognostic factors for recovery.Study design/settingProspective clinical cohort study, with a 1-year follow-up. The treatment consisted of brief intervention and instruction in stretching.Patient’s sampleTwo hundred and sixty-nine patients with chronic low back pain.Outcome measuresSocio-demographic variables, education, profession, self-reported measures, degenerative changes on MRI.MethodsLinear growth model and Cox regression analysis.ResultsFive percent had a normal MRI, 14 and 50% had Modic 1 and Modic 2 changes. Modic changes were not significant covariates for the clinical course of pain, function or fear avoidance beliefs. Education was a strong prognostic factor for recovery.ConclusionsModic changes did not influence the clinical course of back pain and were not prognostic factors for recovery. Education was strongly associated with recovery.

A Population-Based Case-Series of Ontario Patients Who Develop a Vertebrobasilar Artery Stroke After Seeing a Chiropractor

PURPOSEnThe current evidence suggests that association between chiropractic care and vertebrobasilar artery (VBA) stroke is not causal. Rather, recent epidemiological studies suggest that it is coincidental and reflects the natural history of the disorder. Because neck pain and headaches are symptoms that commonly precede the onset of a VBA stroke, these patients might seek chiropractic care while their stroke is in evolution. However, very little is known about the characteristics of these patients. In fact, only small clinical case series and physician surveys have described the characteristics of chiropractic patients who later develop a VBA stroke. To date, no population-based study has described this group of patients. Therefore, the objective of our study is to describe the characteristics of Ontario VBA stroke patients who consulted a chiropractor within the year before their stroke.nnnMETHODSnWe conducted a population-based case series using administrative health care records of all Ontario residents hospitalized with VBA stroke between April 1, 1993, and March 31, 2002. Three databases were deterministically linked to extract the relevant information. We describe the demographic, health care utilization, and comorbidities of VBA patients.nnnRESULTSnNinety-three VBA stroke cases consulted a chiropractor during the year before their stroke. The mean age was 57.6 years (SD, 16.1), and 50% were female. Most cases had consulted a medical doctor during the year before their stroke, and 75.3% of patients had at least one cerebrovascular comorbidity. The 3 most common comorbidities were neck pain and headache (prevalence, 66.7%; 95% confidence interval [CI], 57.0%-76.3%), diseases of the circulatory system (prevalence, 63.4%; 95% CI, 54.8%-74.2%), and diseases of the nervous system and sense organs (prevalence, 47.3%; 95% CI, 38.7%-58.1%).nnnCONCLUSIONSnOur population-based analysis suggests that VBA stroke patients who consulted a chiropractor the year before their stroke are older than previously documented in clinical case series. We did not find that women were more commonly affected than men. Moreover, we found that most patients had at least one cardio- or cerebrovascular comorbidity. Our analysis suggests that relying on case series or surveys of health care professionals may provide a biased view of who develops a VBA stroke.

Pain-Related Emotions in Early Stages of Recovery in Whiplash-Associated Disorders: Their Presence, Intensity, and Association With Pain Recovery

Objective: Psychological factors such as depression affect recovery after whiplash-associated disorders. This study examined the prevalence of pain-related emotions, such as frustration, anger, and anxiety, and their predictive value for postcrash pain recovery during a 1-year follow-up. Methods: A population-based prospective cohort study design was used. Self-reported pain-related depression, anxiety, fear, anger, and frustration were assessed using 100-mm visual analog scales (VASs) at 6 weeks after crash in 2986 persons with traffic-related whiplash-associated disorder. Multivariable logistic regression was used to assess the relationship between the intensity of these pain-related emotions and pain recovery at 4 and 12 months after crash. Pain was measured at all time points on a 100-mm VAS, and pain recovery was defined as a score of 10 or lower. Results: Pain-related frustration was the most intense, with a mean score of 52. Only 3% of the cohort reported having no pain-related frustration, and 4% reported no pain-related anxiety. Multivariable logistic regression models revealed that each pain-related emotion increased the risk of failing to recover (odds ratios for each point increase on the 100-mm VAS), ranging from 1.011 to 1.015. Specifically, with each 10-point increase in pain-related emotion, the odds of failing to achieve pain recovery at 4 months was increased by 14% (p < .001) for depression, 15% (p < .001) for anxiety, 11% (p < .001) for fear, 12% (p < .001) for anger, and 11% (p < .001) for frustration. Conclusions: These findings suggest that it may be beneficial for health care providers to address emotional status related to pain in the first few weeks after a whiplash injury.WAD = whiplash-associated disorder; VAS = visual analog scale

Transdisciplinary Teamwork: The Experience of Clinicians at a Functional Restoration Program

Introduction This research explored the experience of clinicians during the transition from working as an interdisciplinary team to providing a transdisciplinary model of care in a functional restoration program (FRP) for clients with chronic disabling musculoskeletal pain. Methods This qualitative study used a grounded theory approach to data collection and analysis. In depth interviews were conducted to gather data and analysis was performed by the coding of emergent themes. Results Three major themes were identified that contributed towards building a successful transdisciplinary team: the client population; opportunities for communication with colleagues; and an organizational structure that supports transdisciplinary teamwork. Conclusions Transdisciplinary teams with multiple health care providers are suitable for treating patients with complex needs and with injuries that are chronic in nature. However, transdisciplinary teamwork requires input from an organizational level and from a communication level to effectively contribute to both clinician satisfaction and to improved coordination in patient care.

Delayed recovery in patients with whiplash-associated disorders

BACKGROUNDnPrognosis of whiplash injury has been found to be related to a number of sociodemographic, treatment and clinical factors. In the current study, we attempt to identify several novel prognostic factors for delayed recovery in whiplash-associated disorders (WADs), using a validated and reliable measure of recovery.nnnPATIENTS AND METHODSnRetrospective review of a large database of a national network of physiotherapy and rehabilitation service providers in Canada yielded 5581 individuals injured in motor vehicle collisions. Cases were grouped into 3 cohorts based on time lapsed between injury date and initial presentation. Acute (n=3075), early chronic (n=958) and chronic (n=1548) patient cohorts were compared regarding treatment outcome and relative distribution of 29 prognostic factors. Outcome was defined by a minimally important clinical change (10%) on a previously validated disability questionnaire between initial and discharge rehabilitation visits.nnnRESULTSnAnalysis demonstrated positive outcomes to be proportionally fewer in the chronic cohort (52.1%) relative to the early chronic (61.4%), which was in turn lower than the acute cohort (72.3%). Furthermore, individuals presenting with chronic pain were more likely to: (1) be female; (2) present with lower limb pain or nonorganic signs; (3) have returned to work; (4) have retained a lawyer; or (5) have undergone previous spinal surgery, and were less likely to: (1) present with neck or midback pain; (2) live in Ontario or Nova Scotia; or (3) have modified duties upon return to work. Acute, early chronic and chronic cohorts were also found to differ in the distribution of several other prognostic factors at initial clinical visit.nnnCONCLUSIONSnRecovery in whiplash-associated disorder appears to be multifactorial with both medical and non-injury related factors influencing outcome. Further characterisation of these factors may prove invaluable in guiding future clinical treatment and referral practices.

Prognosis of patients with whiplash-associated disorders consulting physiotherapy: development of a predictive model for recovery

BackgroundPatients with whiplash-associated disorders (WAD) have a generally favourable prognosis, yet some develop longstanding pain and disability. Predicting who will recover from WAD shortly after a traffic collision is very challenging for health care providers such as physical therapists. Therefore, we aimed to develop a prediction model for the recovery of WAD in a cohort of patients who consulted physical therapists within six weeks after the injury.MethodsOur cohort included 680 adult patients with WAD who were injured in Saskatchewan, Canada, between 1997 and 1999. All patients had consulted a physical therapist as a result of the injury. Baseline prognostic factors were collected from an injury questionnaire administered by Saskatchewan Government Insurance. The outcome, global self-perceived recovery, was assessed by telephone interviews six weeks, three and six months later. Twenty-five possible baseline prognostic factors were considered in the analyses. A prediction model was built using Cox regression. The predictive ability of the model was estimated with concordance statistics (c-index). Internal validity was checked using bootstrapping.ResultsOur final prediction model included: age, number of days to reporting the collision, neck pain intensity, low back pain intensity, pain other than neck and back pain, headache before collision and recovery expectations. The model had an acceptable level of predictive ability with a c-index of 0.68 (95% CI: 0.65, 0.71). Internal validation showed that our model was robust and had a good fit.ConclusionsWe developed a model predicting recovery from WAD, in a cohort of patients who consulted physical therapists. Our model has adequate predictive ability. However, to be fully incorporated in clinical practice the model needs to be validated in other populations and tested in clinical settings.

The economic cost of return to work: an employer's perspective.

BACKGROUNDnAlthough return-to-work (RTW) interventions have been shown to be cost-effective, most previous economic analyses have focused on the insurers perspective. Employers can also incur costs when supporting the RTW of their employees.nnnOBJECTIVEnTo identify a key set of items for estimating the costs of RTW interventions from the employers perspective, and to identify and value the costs and consequences of a RTW intervention.nnnPARTICIPANTSnEmployers with knowledge of the economic costs of RTW.nnnMETHODSnA survey of 10 workplaces with RTW programs was conducted. The survey consisted of semi-structured interviews with a human resources or occupational health and safety representative from each enrolled workplace.nnnRESULTSnThe interviews were reviewed and from them key items were identified for estimating the costs of RTW interventions from the employers perspective. Employers identified the following costs: medical, equipment, training and education, wage replacement and productivity, and claims administration when assisting an employees RTW.nnnCONCLUSIONSnEven in a jurisdiction with workers compensation insurance, employers incur costs associated with RTW programs. It is important to consider these costs, from the perspective of the employer, when studying the cost-effectiveness of RTW interventions or programs.