Demand, Control and Support at Work Among Sick-Listed Patients with Neck or Back Pain: A Prospective Study

Purpose The main aim of this study was to assess changes in perceived demand, control and support at work of neck and back pain patients over 1 year. We also hypothesised that perceived changes in demand, control and support at work were associated with clinical improvement, reduced fear-avoidance beliefs and successful return to work. Methods Four hundred and five sick-listed patients referred to secondary care with neck or back pain were originally included in an interventional study. Of these, two hundred and twenty-six patients reported perceived psychosocial work factors at both baseline and 1-year follow-up, and they were later included in this prospective study. Changes in demand, control and support dimensions were measured by a total of nine variables. Results At the group level, no significant differences were found among the measured subscales. At the individual level, the regression analyses showed that decreases in fear-avoidance beliefs about work were consistently related to decreases in demand and increases in control, whereas decreases in disability, anxiety and depression were related to increases in support subscales. Conclusions The perception of demand, control and support appear to be stable over 1 year in patients with neck and back pain, despite marked improvement in pain and disability. Disability, anxiety, depression and fear-avoidance beliefs about work were significantly associated with the perception of the work environment, whereas neck and back pain were not. The published version is available at link.springer.co

Change in pain, disability and influence of fear-avoidance in a work-focused intervention on neck and back pain: a randomized controlled trial

Background Neck and back pain are among the most common causes of prolonged disability, and development of interventions with effect on pain, disability and return to work is important. Reduction of fear avoidance might be one mechanism behind improvement after interventions. The aim of the present study was to evaluate changes in pain and disability at the 12-month follow-up of patients with neck and back pain treated with a work-focused intervention compared to patients treated with standard interventions, and the influence of improvement fear avoidance beliefs during the interventions on pain, disability and return to work at 12-month follow-up. Methods 413 employed patients with back or neck pain referred to secondary care, and sick-listed between 4 weeks and 12 months, were randomized to a work-focused rehabilitation or control interventions. Follow-up was conducted 4 and 12 months after inclusion. The groups were compared (independent sample t-test) regarding differences in disability scores (Oswestry disability index/neck disability index) and pain (numeric rating scale) from baseline to 12-month follow-up. Changes in fear avoidance beliefs (FABQ) from baseline to 4 month follow-up were calculated, and the association between this change and return to work, pain and disability at 12 months were tested in stepwise multiple logistic regression models. Results Pain and, disability scores decreased to in both the work-focused and control intervention to 12-month follow-up, and there were no significant differences between the groups. FABQ decreased similarly in both groups to 4 month follow-up. The logistic regression model revealed an association between a reduced FABQ work score at 4 months and return to work within one year (adjusted OR 3.60, 95% CI 1.19 to 10.88). Reduced FABQ physical activity score at 4 months was associated with decreased disability after 12 months (adjusted OR (3.65. 95% CI 1.43 to 9.28). Conclusions Short work-focused rehabilitation had the same effect on pain and disability as control interventions. Reduction in FABQ-W score after treatment seems to be an important predictor for return to work in both groups

Apparent diffusion coefficient values in Modic changes – interobserver reproducibility and relation to Modic type

Background Modic Changes (MCs) in the vertebral bone marrow were related to back pain in some studies but have uncertain clinical relevance. Diffusion weighted MRI with apparent diffusion coefficient (ADC)-measurements can add information on bone marrow lesions. However, few have studied ADC measurements in MCs. Further studies require reproducible and valid measurements. We expect valid ADC values to be higher in MC type 1 (oedema type) vs type 3 (sclerotic type) vs type 2 (fatty type). Accordingly, the purpose of this study was to evaluate ADC values in MCs for interobserver reproducibility and relation to MC type. Methods We used ADC maps (b 50, 400, 800 s/mm2) from 1.5 T lumbar spine MRI of 90 chronic low back pain patients with MCs in the AIM (Antibiotics In Modic changes)-study. Two radiologists independently measured ADC in fixed-sized regions of interests. Variables were MC-ADC (ADC in MC), MC-ADC% (0% = vertebral body, 100% = cerebrospinal fluid) and MC-ADC-ratio (MC-ADC divided by vertebral body ADC). We calculated mean difference between observers ± limits of agreement (LoA) at separate endplates. The relation between ADC variables and MC type was assessed using linear mixed-effects models and by calculating the area under the receiver operating characteristic curve (AUC). Results The 90 patients (mean age 44 years; 54 women) had 224 MCs Th12-S1 comprising type 1 (n = 111), type 2 (n = 91) and type 3 MC groups (n = 22). All ADC variables had higher predicted mean for type 1 vs 3 vs 2 (p  50% of their mean value was less frequent for MC-ADC (9% of MCs) vs MC-ADC% and MC-ADC-ratio (17–20%). Conclusions The MC-ADC variable (highest mean ADC in the MC) had best interobserver reproducibility, discriminated between MC type groups, and may be used in further research. ADC values differed between MC types as expected from previously reported MC histology.publishedVersio

Amoxicillin did not Reduce Modic Change Oedema in Patients with Chronic Low Back pain - subgroup Analyses of a Randomised Trial (the AIM study)

Study Design. Exploratory subgroup analyses of a randomised trial [Antibiotics in Modic changes (AIM) study]. Objective. The aim was to assess the effect of amoxicillin versus placebo in reducing Modic change (MC) edema in patients with chronic low back pain. Summary of Background Data. The AIM study showed a small, clinically insignificant effect of amoxicillin on pain-related disability in patients with chronic low back pain and MC type 1 (edema type) on magnetic resonance imaging (MRI). Materials and Methods. A total of 180 patients were randomised to receive 100 days of amoxicillin or placebo. MC edema was assessed on MRI at baseline and one-year follow-up. Per-protocol analyses were conducted in subgroups with MC edema on short tau inversion recovery (STIR) or T1/T2-weighted MRI at baseline. MC edema reductions (yes/no) in STIR and T1/T2 series were analyzed separately. The effect of amoxicillin in reducing MC edema was analyzed using logistic regression adjusted for prior disk surgery. To assess the effect of amoxicillin versus placebo within the group with the most abundant MC edema on STIR at baseline (“STIR3” group), we added age, STIR3 (yes/no), and STIR3×treatment group (interaction term) as independent variables and compared the marginal means (probabilities of edema reduction). Results. Compared to placebo, amoxicillin did not reduce MC edema on STIR (volume/intensity) in the total sample with edema on STIR at baseline (odds ratio 1.0, 95% CI: 0.5, 2.0; n=141) or within the STIR3 group (probability of edema reduction 0.69, 95% CI: 0.47, 0.92 with amoxicillin and 0.61, 95% CI: 0.43, 0.80 with placebo; n=41). Compared with placebo, amoxicillin did not reduce MC edema in T1/T2 series (volume of the type 1 part of MCs) (odds ratio: 1.0, 95% CI: 0.5, 2.3, n=104). Edema declined in >50% of patients in both treatment groups. Conclusions. From baseline to one-year follow-up, amoxicillin did not reduce MC edema compared with placebo.publishedVersio

Amoxicillin did not Reduce Modic Change Oedema in Patients with Chronic Low Back pain - subgroup Analyses of a Randomised Trial (the AIM study)

Study Design. Exploratory subgroup analyses of a randomised trial (Antibiotics In Modic changes (AIM) study). Objective. To assess the effect of amoxicillin versus placebo in reducing Modic change (MC) oedema in patients with chronic low back pain (LBP). Summary of Background Data. The AIM study showed a small, clinically insignificant effect of amoxicillin on pain-related disability in patients with chronic LBP and MC type 1 (oedema type) on magnetic resonance imaging (MRI). Methods. A total of 180 patients were randomised to receive 100 days of amoxicillin or placebo. MC oedema was assessed on MRI at baseline and one-year follow-up. Per-protocol analyses were conducted in subgroups with MC oedema on short tau inversion recovery (STIR) or T1/T2-weighted MRI at baseline. MC oedema reductions (yes/no) in STIR and T1/T2-series were analysed separately. The effect of amoxicillin in reducing MC oedema was analysed using logistic regression adjusted for prior disc surgery. To assess the effect of amoxicillin versus placebo within the group with the most abundant MC oedema on STIR at baseline (‘STIR3’ group), we added age, STIR3 (yes/no), and STIR3×treatment group (interaction term) as independent variables and compared the marginal means (probabilities of oedema reduction). Results. Compared to placebo, amoxicillin did not reduce MC oedema on STIR (volume/intensity) in the total sample with oedema on STIR at baseline (odds ratio 1.0, 95% confidence interval (95%CI) [0.5, 2.0]; n=141) or within the STIR3 group (probability of oedema reduction 0.69, 95%CI [0.47, 0.92] with amoxicillin and 0.61, 95%CI [0.43, 0.80] with placebo; n=41). Compared with placebo, amoxicillin did not reduce MC oedema in T1/T2-series (volume of the type 1 part of MCs) (odds ratio 1.0, 95%CI [0.5, 2.3], n=104). Oedema declined in >50% of patients in both treatment groups. Conclusions. From baseline to one-year follow-up, amoxicillin did not reduce MC oedema compared with placebo. Level of Evidence. Level 2

The Norwegian version of the Copenhagen Psychosocial Questionnaire (COPSOQ III): Initial validation study using a national sample of registered nurses.

BackgroundEmployers are legally obligated to ensure the safety and health of employees, including the organizational and psychosocial working environment. The Copenhagen Psychosocial Questionnaire (COPSOQ III) covers multiple dimensions of the work environment. COPSOQ III has three parts: a) work environment b) conflicts and offensive behaviours and c) health and welfare. We translated all three parts into Norwegian and evaluated the statistical properties of the 28 work environment dimensions in part a), using a sample of registered nurses.MethodsThe original English version was translated into Norwegian and back translated into English; the two versions were compared, and adjustments made. In total, 86 of 99 items from the translated version were included in a survey to which 8804 registered nurses responded. Item response theory models designed for ordinal manifest variables were used to evaluate construct validity and identify potential redundant items. A standard confirmatory factor analysis was performed to verify the latent dimensionality established in the original version, and a more exploratory factor analysis without restrictions is included to determine dependency between items and to identify separable dimensions.ResultsThe measure of sampling adequacy shows that the data are well suited for factor analyses. The latent dimensionality in the original version is confirmed in the Norwegian translated version and the scale reliability is high for all dimensions except 'Demands for Hiding Emotions'. In this homogenous sample, eight of the 28 dimensions are found not to be separate dimensions as items covering these dimensions loaded onto the same factor. Moreover, little information is provided at the low and high ends of exposure for some dimensions in this sample. Of the 86 items included, 14 are found to be potential candidates for removal to obtain a shorter Norwegian version.ConclusionThe established Norwegian translation of COPSOQ III can be used in further research about working environment factors and health and wellbeing in Norway. The extended use of the instrument internationally enables comparative studies, which can increase the knowledge and understanding of similarities and differences between labour markets in different countries. This first validation study shows that the Norwegian version has strong statistical properties like the original, and can be used to assess work environment factors, including relational and emotional risk factors and resources available at the workplace

Registered nurses’ exposure to workplace aggression in Norway : 12-month prevalence rates, perpetrators, and current turnover intention

Background Identifying occupational health hazards among Registered Nurses (RNs) and other health personneland implementing effective preventive measures are crucial to the long-term sustainability of health services. Theobjectives of this study were (1) to assess the 12-month prevalence rates of exposure to workplace aggression,including physical violence, threats of violence, sexual harassment, and bullying; (2) to identify whether theperpetrators were colleagues, managers, subordinates, or patients and their relatives; (3) to determine whetherprevious exposure to these hazards was associated with RNs’ current turnover intention; and (4) to frame workplaceaggression from an occupational health and safety perspective.Methods The third version of the Copenhagen Psychosocial Questionnaire (COPSOQ III) was used to assess RNs’exposure to workplace aggression and turnover intention. A national sample of 8,800 RNs in Norway, representative ofthe entire population of registered nurses in terms of gender and geography, was analysed. Binary and ordinal logisticregression analyses were conducted, and odds for exposure and intention to leave are presented, with and withoutcontrols for RNs’ gender, age, and the type of health service they work in.Results The 12-month prevalence rates for exposure were 17.0% for physical violence, 32.5% for threats of violence,12.6% for sexual harassment, and 10.5% for bullying. In total, 42.6% of the RNs had experienced at least one of thesetypes of exposure during the past 12 months, and exposure to more than one of these hazards was common.Most perpetrators who committed physical acts and sexual harassment were patients, while bullying was usuallycommitted by colleagues. There was a strong statistical association between exposure to all types of workplaceaggression and RNs’ intention to leave. The strongest association was for bullying, which greatly increased the odds oflooking for work elsewhere.Conclusions Efforts to prevent exposure to workplace aggression should be emphasised to retain health personneland to secure the supply of skilled healthcare workers. The results indicate a need for improvements. To ensure thesustainability of health services, labour and health authorities should join forces to develop effective workplace

Risk classification of patients referred to secondary care for low back pain

Background Nonspecific low back pain is characterized by a wide range of possible triggering and conserving factors, and initial screening needs to scope widely with multilevel addressment of possible factors contributing to the pain experience. Screening tools for classification of patients have been developed to support clinicians. The primary aim of this study was to assess the criterion validity of STarT Back Screening Tool (STarT Back) against the more comprehensive Örebro Musculoskeletal Pain Questionnaire (ÖMPSQ), in a Norwegian sample of patients referred to secondary care for low back pain. Secondary aims were to assess risk classification of the patients, as indicated by both instruments, and to compare pain and work characteristics between patients in the different STarT Back risk categories. Methods An observational, cross-sectional survey among patients with low back pain referred to outpatient secondary care assessment at Trondheim University Hospital, Norway. Cohen’s Kappa coefficient, Pearson’s r and a Bland-Altman plot were used to assess criterion validity of STarT Back against ÖMPSQ. Furthermore, linear regression was used to estimate mean differences with 95% CI in pain and work related variables between the risk groups defined by the STarT Back tool. Results A total of 182 persons participated in the study. The Pearsons correlation coefficient for correspondence between scores on ÖMPSQ and STarT Back was 0.76. The Kappa value for classification agreement between the instruments was 0.35. Risk group classification according to STarT Back allocated 34.1% of the patients in the low risk group, 42.3% in the medium risk, and 23.6% in the high risk group. According to ÖMPSQ, 24.7% of the participants were allocated in the low risk group, 28.6% in the medium risk, and 46.7% in the high risk group. Patients classified with high risk according to Start Back showed a higher score on pain and work related characteristics as measured by ÖMPSQ. Conclusion The correlation between score on the screening tools was good, while the classification agreement between the screening instruments was low. Screening for work factors may be important in patients referred to multidisciplinary management in secondary care

Risk classification of patients referred to secondary care for low back pain

Abstract Background Nonspecific low back pain is characterized by a wide range of possible triggering and conserving factors, and initial screening needs to scope widely with multilevel addressment of possible factors contributing to the pain experience. Screening tools for classification of patients have been developed to support clinicians. The primary aim of this study was to assess the criterion validity of STarT Back Screening Tool (STarT Back) against the more comprehensive Örebro Musculoskeletal Pain Questionnaire (ÖMPSQ), in a Norwegian sample of patients referred to secondary care for low back pain. Secondary aims were to assess risk classification of the patients, as indicated by both instruments, and to compare pain and work characteristics between patients in the different STarT Back risk categories. Methods An observational, cross-sectional survey among patients with low back pain referred to outpatient secondary care assessment at Trondheim University Hospital, Norway. Cohen’s Kappa coefficient, Pearson’s r and a Bland-Altman plot were used to assess criterion validity of STarT Back against ÖMPSQ. Furthermore, linear regression was used to estimate mean differences with 95% CI in pain and work related variables between the risk groups defined by the STarT Back tool. Results A total of 182 persons participated in the study. The Pearsons correlation coefficient for correspondence between scores on ÖMPSQ and STarT Back was 0.76. The Kappa value for classification agreement between the instruments was 0.35. Risk group classification according to STarT Back allocated 34.1% of the patients in the low risk group, 42.3% in the medium risk, and 23.6% in the high risk group. According to ÖMPSQ, 24.7% of the participants were allocated in the low risk group, 28.6% in the medium risk, and 46.7% in the high risk group. Patients classified with high risk according to Start Back showed a higher score on pain and work related characteristics as measured by ÖMPSQ. Conclusion The correlation between score on the screening tools was good, while the classification agreement between the screening instruments was low. Screening for work factors may be important in patients referred to multidisciplinary management in secondary care

The Fear Avoidance Beliefs Questionnaire (FABQ) Does it really measure fear beliefs?

Study Design. A cohort study with 12 months of follow-up. Objective. To assess (1) the unidimensionality of the Fear-Avoidance Beliefs Questionnaire (FABQ) and (2) whether single questions in the FABQ predict future sickness absence as well as the whole scale. Summary of Background Data. The fear-avoidance model is a leading model in describing the link between musculoskeletal pain and chronic disability. However, reported measurement properties have been inconsistent regarding the FABQ. Methods. Individuals (n = 722) sick listed due to musculoskeletal, unspecified or common mental health disorders undergoing rehabilitation was included. A Rasch analysis was applied to evaluate the measurement properties of FABQ and its two subscales (physical activity and work). Linear regression was used to assess how well single items predicted future sickness absence. Results. The Rasch analysis did not support the FABQ or its two subscales representing a unidimensional construct. The 7-point scoring of the items was far too fine meshed and in the present population the data only supported a yes or no or a 3-point response option. The items were invariant to age, whereas two of the items revealed sex differences. The item “I do not think that I will be back to my normal work within 3 months” was the best predictor of future sickness absence. Adding the item “I should not do my regular work with my present pain” improved the prediction model slightly. Conclusion. The FABQ is not a good measure of fear-avoidance beliefs about work or physical activity, and the predictive property of the FABQ questionnaire is most likely related to expectations rather than fear. Based on these results we do not recommend using the FABQ to measure fear-avoidance beliefs