Patrick Loisel

A population-based, randomized clinical trial on back pain management.

Study Design. Population‐based randomized clinical trial. Objectives. To develop and test a model of management of subacute back pain, to prevent prolonged disability. Summary of Background Data. The present management of back pain seems inadequate, and development of innovative models has been urged. Methods. A model for the treatment of subacute work‐related back pain has been developed and evaluated in a population‐based randomized clinical trial. Workers (n = 130) from eligible workplaces in the Sherbrooke area (N = 31), who had been absent from work for more than 4 weeks for back pain, were randomized, based on their workplace, in one of four treatment groups: usual care, clinical intervention, occupational intervention, and full intervention (a combination of the last two). The duration of absence from regular work and from any work was evaluated using survival analysis. Functional status and pain were compared at study entry and after 1 year of follow‐up. Results. The full intervention group returned to regular work 2.41 times faster than the usual care intervention group (95% confidence interval 1.19‐4.89; P = 0.01). The specific effect of the occupational intervention accounted for the most important part of this result, with a rate ratio of return to regular work of 1.91 (95% confidence interval = 1.18‐3.10; P < 0.01). Pain and disability scales demonstrated either a statistically significant reduction or a trend toward reduction in the three intervention groups, compared with the trend in the usual care intervention group. Conclusions. Close association of occupational intervention with clinical care is of primary importance in impeding progression toward chronicity of low back pain.

Randomised controlled trial of integrated care to reduce disability from chronic low back pain in working and private life

Objective To evaluate the effectiveness of an integrated care programme, combining a patient directed and a workplace directed intervention, for patients with chronic low back pain. Design Population based randomised controlled trial. Setting Primary care (10 physiotherapy practices, one occupational health service, one occupational therapy practice) and secondary care (five hospitals). Participants 134 adults aged 18-65 sick listed for at least 12 weeks owing to low back pain. Intervention Patients were randomly assigned to usual care (n=68) or integrated care (n=66). Integrated care consisted of a workplace intervention based on participatory ergonomics, involving a supervisor, and a graded activity programme based on cognitive behavioural principles. Main outcome measures The primary outcome was the duration of time off work (work disability) due to low back pain until full sustainable return to work. Secondary outcome measures were intensity of pain and functional status. Results The median duration until sustainable return to work was 88 days in the integrated care group compared with 208 days in the usual care group (P=0.003). Integrated care was effective on return to work (hazard ratio 1.9, 95% confidence interval 1.2 to 2.8, P=0.004). After 12 months, patients in the integrated care group improved significantly more on functional status compared with patients in the usual care group (P=0.01). Improvement of pain between the groups did not differ significantly. Conclusion The integrated care programme substantially reduced disability due to chronic low back pain in private and working life. Trial registration Current Controlled Trials ISRCTN28478651.

Improving return to work research

Background: Despite considerable multidisciplinary research on return to work (RTW), there has been only modest progress in implementation of study results, and little change in overall rates of work disability in developed countries. Methods: Thirty RTW researchers, representing over 20 institutions, assembled to review the current state of the art in RTW research, to identify promising areas for further development, and to provide direction for future investigations. Results and Conclusion: Six major themes were selected as priority areas: early risk prediction; psychosocial, behavioral and cognitive interventions; physical treatments; the challenge of implementing evidence in the workplace context; effective methods to engage multiple stakeholders; and identification of outcomes that are relevant to both RTW stakeholders and different phases of the RTW process. Understanding and preventing delayed RTW will require application of new concepts and study designs, better measures of determinants and outcomes, and more translational research. Greater stakeholder involvement and commitment, and methods to address the unique challenges of each situation are required.

Early Patient Screening and Intervention to Address Individual-Level Occupational Factors (“Blue Flags”) in Back Disability

Objective To develop a consensus plan for research and practice to encourage routine clinician screening of occupational factors associated with long-term back disability. Methods A 3-day conference workshop including 21 leading researchers and clinicians (the “Decade of the Flags Working Group”) was held to review the scientific evidence concerning clinical, occupational, and policy factors in back disability and the development of feasible assessment and intervention strategies. Results The Working Group identified seven workplace variables to include in early screening by clinicians: physical job demands, ability to modify work, job stress, workplace social support or dysfunction, job satisfaction, expectation for resuming work, and fear of re-injury. Five evaluation criteria for screening methods were established: reliability, predictive performance, feasibility, acceptability, and congruence with plausible interventions. An optimal screening method might include a stepped combination of questionnaire, interview, and worksite visit. Future research directions include improving available assessment methods, adopting simpler and more uniform conceptual frameworks, and tying screening results to plausible interventions. Discussion There is a clear indication that occupational factors influence back disability, but to expand clinician practices in this area will require that patient screening methods show greater conceptual clarity, feasibility, and linkages to viable options for intervention.

Twenty-five years with the biopsychosocial model of low back pain-is it time to celebrate? A report from the twelfth international forum for primary care research on low back pain.

Study Design. An integrated review of current knowledge about the biopsychosocial model of back pain for understanding etiology, prognosis, and interventions, as presented at the plenary sessions of the XII International Forum on LBP Research in Primary Care (Denmark; October 17–19, 2012). Objective. To evaluate the utility of the model in reference to rising rates of back pain-related disability, by identifying (a) the most promising avenues for future research in biological, psychological, and social approaches, (b) promising combinations of all 3 approaches, and (c) obstacles to effective implementation of biopsychosocial-based research and clinical practice. Summary of Background Data. The biopsychosocial model of back pain has become a dominant model in the conceptualization of the etiology and prognosis of back pain, and has led to the development and testing of many interventions. Despite this back pain remains a leading source of disability worldwide. Methods. The review is a synthesis based on the plenary sessions and discussions at the XII International Forum on LBP Research in Primary Care. The presentations included evidence-based reviews of the current state of knowledge in each of the 3 areas (biological, psychological, and social), identification of obstacles to effective implementation and missed opportunities, and identification of the most promising paths for future research. Results. Although there is good evidence for the role of biological, psychological, and social factors in the etiology and prognosis of back pain, synthesis of the 3 in research and clinical practice has been suboptimal. Conclusion. The utility of the biopsychosocial framework cannot be fully assessed until we truly adopt and apply it in research and clinical practice. Level of Evidence: N/A

Interorganizational collaboration in occupational rehabilitation: perceptions of an interdisciplinary rehabilitation team.

Introduction: Various obstacles to and facilitators of collaboration between an interdisciplinary work rehabilitation team and the stakeholders (workers, insurers, physicians, and employers) exist, but are not well characterized. Methods: An observational study was conducted, using videotapes of interdisciplinary team discussions of ongoing cases involving 22 workers absent from work due to musculoskeletal disorders. The actions taken and strategies adopted by the team in an effort to overcome the obstacles to collaboration were studied. Results: Various factors influence collaboration between the rehabilitation team and the stakeholders. In general, stakeholder endorsement of the teams therapeutic principles and confidence in their approach emerged as particularly important factors. Diverse strategies, most often, education and awareness-raising, were used by the team to foster collaboration among the parties. Conclusions: This study provides greater insight into the factors affecting collaboration among a rehabilitation team, an injured worker and other stakeholders. The results may improve understanding of the actions taken by rehabilitation teams and help to optimize their practices.

Discriminative and predictive validity assessment of the Quebec Task Force Classification

Study Design. A prospective cohort study of workers with low back pain who had been absent from work for more than 4 weeks was conducted. Objective. To assess the discriminative and predictive validity of the Quebec Task Force Classification for workers during the subacute phase of disability from back pain. Summary of Background Data. The Quebec Task Force Classification was designed for clinical decision making, prognosis establishment, quality of care evaluation, and scientific research in low back pain. Methods. For this study, 104 workers absent from work because of back pain were classified according to the first four categories of the Quebec Task Force Classification 4 weeks after their first day of work absence. They then were randomized into four treatment groups: standard care (control), clinical–rehabilitation intervention, occupational intervention, and the Sherbrooke model (a combination of the clinical–rehabilitation and occupational interventions). Functional status, pain level, and work status were assessed at baseline and after 1 year. Duration of full compensation and back-related costs were calculated over a mean follow-up period of 6.5 years. The discriminative validity of the Quebec Task Force Classification was evaluated using Kendall tau correlation coefficients. Predictive validity was evaluated using logistic regression analyses. Age, gender, comorbidities, body mass index, and treatment group were considered as potential confounders. Results. Significant but low correlation coefficients were found between Quebec Task Force Classification categories and functional status scores at baseline. Subjects classified as having distal radiating pain (categories 3 and 4) at baseline were more likely to have a lower functional status, higher pain level, and no return to regular work at the 1-year follow-up evaluation. They also were more likely to accumulate more days of full compensation and to cost more after a mean follow-up period of 6.5 years. Conclusion. The Quebec Task Force Classification demonstrated good predictive ability by discriminating between subjects with and those without distal radiating pain.

Back pain and work

Low back pain is a leading cause of work disability and constitutes a significant socioeconomic burden worldwide. In an attempt to stem the serious consequences of long-term disability, a new approach for back pain in primary care is being disseminated. It mainly focusses on identifying the relationship between pain/disability and work, recognising important workplace and psychosocial issues, providing patients reassuring messages about activity, facilitating the return to work process and engaging other resources as needed. This article examines current expert opinion and available evidence on work issues for effective back pain management. In general, return to work, if safe, is beneficial for recovery and well-being. Some cases might require physicians to actively communicate with employers, claims managers and others in order to achieve safe and sustained return to work, while in most instances, simple efforts to identify and discuss work issues directly with the patient can lead to better work outcomes.

From evidence to community practice in work rehabilitation: the Quebec experience.

BackgroundThe causes of prolonged disability due to back pain are multiply determined, involving medical, social, and environmental factors. Possible solutions to the problem of prolonged back pain disability have emerged from recent research but few efforts have been made to transfer evidence-based programs to large community settings. ObjectiveThis article describes three phases of the process of transfer of evidence from rehabilitation research to community practice in the province of Quebec. Methods and ResultsPhase A: Based on literature review and expert knowledge, the Sherbrooke model was developed and assessed through a population-based, randomized clinical trial. Results at 1-year follow-up showed quicker return to regular work and improvement of quality of life; the 6-year follow-up showed the cost-effectiveness of the method.Phase B: Based on the Sherbrooke model experience and recent evidence, a new program addressing the disability paradigm was developed and implemented in the province of Quebec (Canada). Results at 1- and 3-year follow-ups showed that only 24% of workers were not working owing to their musculoskeletal disorder. The program is presently being tested through a population-based, randomized clinical trial in a population of construction workers.Phase C: To implement the program at a provincial level, a network for management, research and education in work rehabilitation was developed. An external assessment is presently planned to evaluate return to work and economic outcomes and quality of implementation of the program in various settings.

Development and validation of competencies for return to work coordinators.

Introduction Return to work (RTW) coordinators are a key element in programs that facilitate RTW of injured or ill workers, yet little research documents the competencies required for success in this role. Methods Competencies were defined as knowledge, skills, attitudes, and behaviors. Eight focus groups were conducted with 75 experienced RTW coordinators to identify 904 individual competencies. These were subsequently reduced to 234 unique items through affinity mapping, and sorted into eight groups: administration, individual personal attributes, information gathering, communication, professional credibility, evaluation, problem-solving, and conflict management. A subset of 100 items, including 88 items most often cited, were incorporated in an Internet-based survey that sampled a broad range of RTW coordinators from three countries. Results Eighty-three of the questionnaire items were rated 4 or 5 (very important or essential) by over half of the 148 respondents. There were no differences in affinity group mean ratings by country, employer, profession, or type of clients. The highest-rated items reflect general personal characteristics, or specific skills related to coordinating among all involved with the RTW process. RTW coordinators with nursing backgrounds provided slightly higher ratings for items related to medical knowledge, but otherwise their ratings were similar to non-nurses. Conclusions These findings indicate a consensus across a wide range of RTW coordinators, and results can be applied to improve coordinator selection, training, and development. Certain key competencies may be well-established individual attributes, and others may be best developed through mentorship. Most of these competencies are probably best evaluated by direct observation.