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Study Design: Prospective inception cohort study., Objective: To investigate prospectively whether pain-related fear predicts future perceived disability and participation in patients with acute low back pain (LBP)., Summary of Background Data: There are indications that fear of movement/(re)injury, as measured by the Tampa Scale for Kinesiophobia, is present early in an episode of LBP, and that it might be a predictor of future perceived disability and participation., Methods: A cohort of 555 patients with acute LBP included by general practitioners and physical therapists in primary care settings was followed for 6 months., Results: Results indicate that baseline fear of movement/(re)injury was predictive of future perceived disability and, to a lesser extent (and together with duration and radiation), of participation., Conclusions: The results suggest that interventions aimed at reducing pain-related fear in the acute stage of LBP might prevent restrictions of activity and participation because of pain, and might be a way of preventing the transition from acute to chronic LBP.

Study Design: To establish outcome, 253 workers with subacute and chronic low back conditions were assessed with a comprehensive multimethod biopsychosocial protocol at baseline, 3 days after the initial examination, and 3 months later., Objective: To validate empirically a biopsychosocial model for prediction of occupational low back disability., Summary of Background Data: Costs of low back occupational disability continue to spiral despite stabilization of low back injury rates. An empirically based model to predict occupational disability in workers with low back injuries is required., Methods: Workers with subacute low back injuries (4-6 weeks after injury, n = 192) and those with chronic back pain (6-12 months after injury, n = 61) were the study participants. The biopsychosocial protocol included five groups of variables: 1) sociodemographic, 2) medical, 3) psychosocial, 4) pain behavior, and 5) workplace-related factors. Predictive validity was investigated through a 3-month follow-up assessment, at which time the return to work outcome was determined. Stepwise logistic regression models were developed to predict work status., Results: The final integrated model consisted of variables from a wide biopsychosocial spectrum: vitality, health transition, feeling that job is threatened due to injury, expectations of recovery, guarding behavior, perception of severity of disability, time to complete walk, and right leg typical sciatica., Conclusions: The "winning" variables identified in the integrated model are dominated by cognitions, which are accompanied by disability behaviors. A cognitive-behavioral model with an adaptation-oriented rather than a pathology-oriented focus is favored for early intervention with high-risk workers since cognitions are amenable to change.

Study Design: Randomized control post-test only., Objectives: To investigate the reliability and validity of the EPIC Lift Capacity test's indicators of sincere effort., Summary of Background Data: The EPIC Lift Capacity test (ELC) (Employment Potential Improvement Corp., Santa Ana, CA) is a functional evaluation tool used to identify physical limitations involved in lifting and manual materials handling. Identification of insincere effort is an integral component of such functional testing because of the potential secondary gain issues surrounding the various populations typically involved in this form of testing. The purpose of this study was to determine the sensitivity and specificity of the "indicators of sincere effort" of the EPIC Lift Capacity test when used on a previously injured population typical of subjects for which the test is designed., Methods: Subjects consisted of 41 volunteers (age 22 to 58 years) with a previously diagnosed musculoskeletal pathology of the spine or extremities. Volunteers were randomized into either the control group, instructed to give a sincere maximum effort, or the experimental group, instructed to give an insincere effort at 50% of their perceived maximum effort. All tests were administered by certified clinical evaluators according to the standardized EPIC Lift Capacity test protocol.-, Results: Overall accuracy in identifying participants' level of effort was 86.84%. The indicators of valid effort exhibited both high positive (94.44%) and negative (80.00%) predictive values. The indicators of valid effort accounted for 94.9% of the total variance in the determination of the subjects' overall effort level. Interrater reliability for agreement of subjects' overall effort was good (interclass correlation coefficient = 0.82)., Conclusions: Through use of standardized indicators of sincere effort, certified EPIC Lift Capacity test evaluators were able to predict sincerity of effort with a high degree of reliability and validity. The rater's systematicobservational evaluation of effort was shown to be the single best indicator of sincere effort.

Study Design: Randomized controlled trial., Objective: To test the ability of an educational pamphlet to improve recovery in terms of pain, work status, and health care utilization after occupational low back injury., Background: Low back pain and disability persist as occupational health problems of epidemic proportions. Because interventions based on biomechanical models have had limited impact, recent educational approaches to preventing back problems have stressed psychosocial recovery issues., Methods: A pamphlet was developed by compiling activity resumption, self-care, and attitudinal advice from recent publications. The pamphlet was sent at random to half of all consenting workers reporting back pain within 11 days of occupational injury between 7/96 and 6/97. Three and 6 months later, back pain, work status, health care use, and pamphlet impact outcomes were assessed through structured telephone interviews., Results: Of the 726 eligible workers, 486 consented to participate. Consenters and nonconsenters and intervention and control groups were similar in initial demographic variables. The pamphlet had no statistically significant impact at the 0.05 significance level on pain severity or reduction, health care visits, or work absence. Of the 229 pamphlet recipients, 129 thought it had provided useful information, but only 25 thought it had helped them return to work more quickly., Conclusions: In this trial, a pamphlet stressing psychosocial recovery issues did not prevent or reduce postinjury pain, health care use, or work absence.

Study Design: Cross-sectional design., Objectives: To investigate the correlation between degeneration in the lumbar spine and self-reported disability and pain levels in patients with and without a history of trauma., Summary of Background Data: The link between lumbar spine degeneration and low back pain remains controversial, as does the correlation between trauma and spinal degeneration., Methods: Radiographic and questionnaire data were collected from 172 consecutive patients with low back pain. Back pain severity was measured using two scales: one for pain over the entire episode and one for pain during the previous week. All patients also completed the Revised Oswestry Disability Questionnaire before radiography was performed. Further questions concerning the chronicity of symptoms and trauma were included., Results: Controlling for age, patients with low back pain with a history of trauma had a statistically significant increase in the severity of facet degeneration (P < 0.02) compared with nontrauma patients with low back pain. However, there was no difference in disability and pain scores between the trauma and nontrauma patients or between the genders. A weak correlation between pain severity ratings and the number of levels of degeneration and the severity of the degeneration at the disc and facets was noted., Conclusions: Patients with low back pain with a history of trauma had more severe facet arthrosis than do nontrauma patients with low back pain, but there were no differences in pain and disability. There was a weak correlation between the quantity and severity of lumbar degeneration with pain levels, but not with disability scores. These findings are discussed in the light of recent reports regarding the cervical spine.

Study Design: A retrospective cohort study of Michigan workers' compensation cases involving back injuries in 1986 and 1987 with incidence and outcome data., Objective: To determine claim rates by age, gender, and industry or occupation for compensable back injuries and to investigate the relation between occupation and return to work., Summary of Background Data: The cohort of 24,094 Michigan workers' compensation cases from 1986 and 1987 in which claimants were compensated for back injuries was reviewed. Compensation eligibility requires more than 7 days' disability after injury., Methods: Claim rates for back injuries by age, gender, and industry or occupation using employment data interpolated from 1980 and 1990 Census 1% Public Use Microdata Samples. Cox proportional hazards analysis was performed for return to work in the first 8 weeks after injury, with occupation coded at the three-digit level., Results: All-age claim rates for Michigan compensable back injuries by occupation ranged between 0.03% and 1.7% annually (0.39% for all cases) and were generally higher in women in white collar occupations and in men in blue collar occupations. The claim rate peaked in men in the 25-34 year range, with the highest rates in manual labor occupations. The peak claim rates by age were less marked in women, tending to occur broadly throughout the 25-44-year range. Similar all-age values were recorded by industry. The male-to-female risk ratio over all occupations does not vary by age and is approximately 1.4:1. As the classification of occupation became more detailed, large differences in risk were documented within major occupation groups. The highest risk in this study was approximately 6% annually for 25-44 year old men in driver-sales (beverage truck drivers and delivery workers). Only 7 of 40 occupation categories showed a significant relative hazard for return to work in the first 8 weeks after injury, and these were blue collar occupations with earlier return than the reference sales category. For Michigan compensable back injuries, a rough estimate of the true annual incidence of new claims is 94% of the reported claim rate., Conclusions: The relative risk of compensable back injury is generally higher for females in white collar occupations, higher for males in blue collar occupations and approximately equal in service occupations. Although the risk of back injury is related to occupation, the same occupational factors do not operate as a barrier to return to work.

The exponential increase in occupational low back pain disability is a problem that is not being addressed adequately in clinical practice. The notion of achieving primary control through ergonomic intervention, based on biomechanics principles, has so far been unhelpful. The traditional secondary prevention strategies of rest and return to restricted work duties are seemingly suboptimal. Biomechanics/ergonomic considerations may be related to the first onset of low back pain, but there is little evidence that secondary control based solely on these principles will influence the risk of recurrence or progression to chronic disability. More promising in this respect are programs that take account of the psychosocial influences surrounding disability. Work organizational issues are clearly important, but so also is the behavior of clinicians. The balance of the available evidence suggests that clinicians generally should adopt a proactive approach to rehabilitation by recommending, whenever possible, early return to normal rather than restricted duties as well as complementary psychosocial advice if the issue of chronic disability is to be successfully tackled.