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Businesses are struggling to re-open as the world continues to deal with the coronavirus 2019 (COVID-19) pandemic. The reopening of businesses will require employers to implement safe return-to-work strategies through evaluation, testing, work modifications, and development of appropriate workplace policies. There will be unique challenges along the way as no one approach will be ideal for all workplaces and industries. This document is intended to provide return-to-work guidance for both employers and the occupational and environmental medicine physicians who will be supporting businesses in implementing safe return-to-work strategies.

Objective Higher probability of developing severe COVID-19 has been associated with health risk factors and medical conditions which are common among workers globally. For at risk workers, return to work may require additional protective policies and procedures. Methods A review of the medical literature was conducted on health risk factors and medical conditions associated with increased COVID-19 morbidity and mortality, standardized measures for community COVID transmission, and occupation-specific risk. Results The relative risk of acquiring and the severity of COVID-19 for workers is associated with three pillars: individual risk, workplace risk, and community risk. Matrices were developed to determine a worker's individual risk based on these three pillars. Conclusions A practical decision tool is proposed for physicians evaluating and managing individual worker COVID-19 risk in the context of returning to work.

OBJECTIVES: This study investigated spinal pain-related absenteeism at age 17 as a potential precursor to work presenteeism at age 23. METHODS: A longitudinal study was performed with Raine Study Gen2 participants (n = 451). Spinal pain-related absenteeism from school/work was collected at the 17 year follow-up. Presenteeism (due to ill-health or any other reason) was collected quarterly during one year around the age of 23. Zero-inflated binominal regression analysis was conducted. RESULTS: Participants with adolescent spinal pain-related absenteeism reported higher work presenteeism in early adulthood than those without pain (155.7 h/y compared to 77.7 h/y), with an incident rate ratio (95% confidence interval) of 1.41 (1.04 to 1.92) after adjusting for sex, occupational class and multimorbidity count. CONCLUSIONS: Targeting factors associated with absenteeism behaviours during early life may have significant benefits for future work productivity.

Background The amount of time between key points in the work disability and workers' compensation process, referred to as lag times, has been shown to relate to work disability outcomes but little research has examined how this finding may differ based on the diagnosis associated with the cause of work disability. Objective To examine whether relationships between lag times in the work disability process and disability duration vary by diagnosis in a sample of workers' compensation claims. Methods Using workers' compensation claims, Analysis of Covariance was used to estimate differences in disability duration across three lag times (days from the date of injury to: reporting the injury, seeking medical care, and starting lost work time paid by the workers' compensation insurer) and injury diagnosis groups (Work-related Musculoskeletal Disorders (WRMSD) and fractures). Results WRMSD tended to have longer lag times than fractures, whereas disability duration tended to be longer for fractures than WRMSD. Overall, shorter lag times were associated with shorter disability duration, but the relationships varied across diagnosis groups, and greater variation in disability duration was observed for WRMSD compared to fractures. Conclusions The findings suggest the importance of responding to work-related injuries by reporting the injury, receiving medical care, and taking time off of work if necessary, in a timely fashion.

Objectives Spinal (ie, back and neck) pain often develops as early as during adolescence and can set a trajectory for later life. However, whether early-life spinal-pain-related behavioral responses of missing school/work are predictive of future work absenteeism is yet unknown. We assessed the association of adolescent spinal-pain-related work or school absenteeism with early adulthood work absenteeism in a prospective population-based cohort. Methods Six year follow-up data from the Western Australian Pregnancy Cohort (Raine) study were used (N=476; with a 54% response rate). At age 17, participants reported spinal pain (using the Nordic questionnaire) and adolescent spinal-pain-related work/school absenteeism (with a single item question). Annual total and health-related work absenteeism was assessed with the Health and Work Performance questionnaire distributed in four quarterly text messages during the 23rd year of age. We modelled the association of adolescent spinal-pain-related absenteeism with work absenteeism during early adulthood, using negative binomial regression adjusting for sex, occupation and comorbidities. Results Participants with adolescent low-back or neck pain with work/school absenteeism reported higher total work absenteeism in early adulthood [148.7, standard deviation (SD) 243.4 hours/year], than those without pain [43.7 (SD 95.2) hours/year); incidence rate ratio 3.4 (95% CI 1.2-9.2)]. Comparable findings were found when considering low-back and neck separately, and when considering health-related absenteeism. Conclusions We found a more than three-fold higher risk of work absenteeism in early adulthood among those with adolescent spinal-pain-related absenteeism, compared to those without. These findings suggest that, to keep a sustainable workforce, pain prevention and management should focus on pain-related behaviors as early as in adolescence.

Many clinical practice guidelines recommend similar approaches for the assessment and management of low back pain. Recommendations include use of a biopsychosocial framework to guide management with initial non-pharmacological treatment, including education that supports self-management and resumption of normal activities and exercise, and psychological programmes for those with persistent symptoms. Guidelines recommend prudent use of medication, imaging, and surgery. The recommendations are based on trials almost exclusively from high-income countries, focused mainly on treatments rather than on prevention, with limited data for cost-effectiveness. However, globally, gaps between evidence and practice exist, with limited use of recommended first-line treatments and inappropriately high use of imaging, rest, opioids, spinal injections, and surgery. Doing more of the same will not reduce back-related disability or its long-term consequences. The advances with the greatest potential are arguably those that align practice with the evidence, reduce the focus on spinal abnormalities, and ensure promotion of activity and function, including work participation. We have identified effective, promising, or emerging solutions that could offer new directions, but that need greater attention and further research to determine if they are appropriate for large-scale implementation. These potential solutions include focused strategies to implement best practice, the redesign of clinical pathways, integrated health and occupational interventions to reduce work disability, changes in compensation and disability claims policies, and public health and prevention strategies.

Background Although regional socioeconomic (SE) factors have been associated with worse health outcomes, prior studies have not addressed important confounders or work disability. Methods A national sample of 59 360 workers’ compensation (WC) cases to evaluate impact of regional SE factors on medical costs and length of disability (LOD) in occupational low back pain (LBP). Results Lower neighborhood median household incomes (MHI) and higher state unemployment rates were associated with longer LOD. Medical costs were lower in states with more workers receiving Social Security Disability, and in areas with lower MHI, but this varied in magnitude and direction among neighborhoods. Medical costs were higher in more urban, more racially diverse, and lower education neighborhoods. Conclusions Regional SE disparities in medical costs and LOD occur even when health insurance, health care availability, and indemnity benefits are similar. Results suggest opportunities to improve care and disability outcomes through targeted health care and disability interventions.

The aim of this study was to estimate the effect of spinal pain and mental ill-health conditions on work productivity in 22-year-old workers.A cross-sectional design using data from the Raine Study cohort (n = 867) including self-reported work productivity and self-report of health practitioner diagnosed medical conditions.Mean (median, 25th-percentile, 75th-percentile) annualized cost of health-related absenteeism was $AUD1899 ($0, $0, $1738) per worker. Annualized cost of presenteeism was $AUD10,674 ($6573, $4003, $13,087) per worker. Spinal pain and mental ill-health conditions were associated with increased health-related absenteeism, but not presenteeism.Work productivity loss in young workers is a substantial problem needing priority attention. Addressing spinal pain and mental ill-health may improve productivity of this important sector of the workforce.

PURPOSE: This study examined the impact of a Safe Resident Handling Program (SRHP) on length of disability and re-injury, following work-related injuries of nursing home workers. Resident handling-related injuries and back injuries were of particular interest. METHODS: A large national nursing home corporation introduced a SRHP followed by three years of training for 136 centers. Lost-time workers’ compensation claims (3 years pre-SRHP and 6 years post-SRHP) were evaluated. For each claim, length of first episode of disability and recurrence of disabling injury were evaluated over time. Differences were assessed using Chi square analyses and a generalized linear model, and “avoided” costs were projected. RESULTS: The SRHP had no impact on length of disability, but did appear to significantly reduce the rate of recurrence among resident handling-related injuries. As indemnity and medical costs were three times higher for claimants with recurrent disabling injuries, the SRHP resulted in significant “avoided” costs due to “avoided” recurrence. CONCLUSIONS: In addition to reducing overall injury rates, SRHPs appear to improve long-term return-to-work success by reducing the rate of recurrent disabling injuries resulting in work disability. In this study, the impact was sustained over years, even after a formal training and implementation program ended. Since back pain is inherently a recurrent condition, results suggest that SRHPs help workers remain at work and return-to-work.

Improving work participation for individuals with rheumatic and musculoskeletal diseases (RMDs), has gained increasing interest over the last 10 years. New approaches are based upon increasing adoption of a biopsychosocial approach to improving work participation, incorporating evidence that health professionals within multidisciplinary teams have a key and critical role. In particular, interaction between health professionals and employers, and rehabilitation services that are linked to the workplace are key elements for improving work participation for people with RMDs. This review outlines recent research that underpins approaches for health professionals to develop their role in improving work participation for people with RMDs based on recent research; it outlines how to measure work-related outcomes in clinical practice, models of work participation, and approaches for health professionals to improve work participation outcomes. The potential for developing the role of health professionals in future years is also outlined.

Low back pain is a very common symptom. It occurs in high-income, middle-income, and low-income countries and all age groups from children to the elderly population. Globally, years lived with disability caused by low back pain increased by 54% between 1990 and 2015, mainly because of population increase and ageing, with the biggest increase seen in low-income and middle-income countries. Low back pain is now the leading cause of disability worldwide. For nearly all people with low back pain, it is not possible to identify a specific nociceptive cause. Only a small proportion of people have a well understood pathological cause—eg, a vertebral fracture, malignancy, or infection. People with physically demanding jobs, physical and mental comorbidities, smokers, and obese individuals are at greatest risk of reporting low back pain. Disabling low back pain is over-represented among people with low socioeconomic status. Most people with new episodes of low back pain recover quickly; however, recurrence is common and in a small proportion of people, low back pain becomes persistent and disabling. Initial high pain intensity, psychological distress, and accompanying pain at multiple body sites increases the risk of persistent disabling low back pain. Increasing evidence shows that central pain-modulating mechanisms and pain cognitions have important roles in the development of persistent disabling low back pain. Cost, health-care use, and disability from low back pain vary substantially between countries and are influenced by local culture and social systems, as well as by beliefs about cause and effect. Disability and costs attributed to low back pain are projected to increase in coming decades, in particular in low-income and middle-income countries, where health and other systems are often fragile and not equipped to cope with this growing burden. Intensified research efforts and global initiatives are clearly needed to address the burden of low back pain as a public health problem.

Low back pain is the leading worldwide cause of years lost to disability and its burden is growing alongside the increasing and ageing population.1 Because these population shifts are more rapid in low-income and middle-income countries, where adequate resources to address the problem might not exist, the effects will probably be more extreme in these regions. Most low back pain is unrelated to specific identifiable spinal abnormalities, and our Viewpoint, the third paper in this Lancet Series,2,3 is a call for action on this global problem of low back pain.

Workplace injury and illness is a serious concern in today's work environment. The estimated annual direct and indirect cost of workplace injury and illness is approximately $250 billion, a total greater than the annual cost of cancer.1 Most of these costs result from injuries/illnesses that require time away from work or work restriction.1 Unsurprisingly, workplace injuries/illnesses that require a greater amount of time out of work or limitation while at work tend to be more costly.2–5 As such, there is interest in better understanding the factors related to the length of disability and how to best manage the work-disability process. Age has been consistently shown to relate to the experience of workplace injury/illness and the length of disability. Research has found that the length of disability increases with age, as does the likelihood of experiencing work-disability recurrence. In addition, the chances of never achieving a return to work (RTW) increase with age.6–13 There are several potential reasons for the relationship between age and RTW outcomes that include biological changes associated with aging, which might delay recovery after injury/illness, older workers might sustain more serious injuries/illnesses, and there is a higher incidence of comorbidities with age that might further complicate recovery.14,15 In addition, it has been suggested that older workers might have reduced access to rehabilitation services, older workers might also be less satisfied with their rehabilitation services, employers might not encourage older workers to RTW, and older workers might be in industries and occupations with fewer opportunities for accommodation that might facilitate RTW.8,15 Despite the research on the relationship between age and the length of disability, research also has demonstrated that the length of disability decreases with increasing tenure.6,9,16–18 The relationship between tenure and the length of disability might be due to several factors including the increase in work experience at a given company that can help workers to better navigate the RTW system at an organization, workers with longer lengths of tenure might also have greater organization attachment and more positive supervisor interactions both of which can make the RTW process easier, and more accommodations might be available to workers with higher tenure. The reverse directions of the relationships between age and the length of disability and tenure and the length of disability are somewhat surprising as age and tenure have traditionally been very closely related.19 As such, it might be expected that a positive relationship between age and the length of disability would translate to a positive relationship between tenure and the length of disability; however, this is not the case. These findings raise questions including the following: Are age and tenure independently related to the length of disability? Is one of the relationships stronger than the other? Is there nonlinearity in these relationships? and Do age and tenure interact in their relationship with length of disability? Few studies have systematically examined models involving age, tenure, and the length of disability. Several studies have, however, included age and tenure in predictive models either as covariates or as variables included in larger multivariate models. Findings indicate that both explain unique variance in work-disability outcomes.6,9,20,21 In the majority of previous work, age and tenure have been included in models with only linear terms or in some cases as categorical variables, despite speculation about possible nonlinearity in the relationships.15,22 There has been only one previous study that has considered nonlinearity in both relationships. In this study, the age/work-disability relationship was found to be linear; however, an inverted u-shaped relationship was found between tenure and certified sickness absence. Previous research has not yet examined nonlinearity in the relationships with disability resulting from work-related injury/illness specifically. In addition, research has not examined whether the relationship with the length of disability is stronger for age than tenure, or vice versa. Regarding the possible interaction between age and tenure, again there is limited research. A few studies have examined the interaction between age and tenure with the risk of experiencing a workplace injury/illness. One study found that in younger railway workers, the risk of injury increased with tenure.23 Another study found that in older health care workers, the risk of injury was the lowest for new hires.24 Other research has focused on the interaction in relation to the length of disability. In a study of workers in the fruit and vegetable packing industry, the number of days off work following an accident was found to be similar across tenure levels for middle-aged workers, whereas for older workers the number of days off decreased with tenure.25 A final study found different patterns for the interaction between age and tenure with the length of certified sickness absence among two groups of workers. For homecare workers with high tenure, age was positively associated with the length of certified absence, whereas there was no association with age for homecare workers with low tenure. In contrast, for residential care workers, the positive relationship between age and certified absence was stronger for low- and medium-tenure workers than for high-tenure workers.15 These studies focused on single industries, raising questions about the generalizability of the findings. This is an especially important time to examine relationships among age, tenure, and the length of disability. The demographic makeup of the United States workforce has been changing drastically over the last several decades. In 1990, roughly 12% of the workforce was comprised of workers age 55 and older. That number is expected to grow to over 25% by 2020.26 This has heightened concerns for employers about the potential impact of the aging workforce in regards to the cost and length of disability for older employees.27 At the same time that the workforce is aging, the typical career trajectory is also changing. Traditionally, individuals entered the workforce after school and then remained with a single employer for their entire careers. As a result, as age increased, tenure on the job also increased; however, research indicates that this trend might be changing.28 Individuals now change organizations, and sometimes careers, several times throughout their working years.29,30 This has led to shorter average lengths of tenure, especially for men at older ages. For example, the median tenure for male workers aged 55 to 64 years fell from 15.3 years in 1983 to 9.5 years in 2006.31 Based on previous research, it is unclear whether and how age and tenure might interact in their relationship with the length of disability; however, there are a few potential directions this interaction might take. First, work-related experience generally increases with tenure. As such, this experience might serve as a protective factor against the age-related changes that result in an increase in the length of disability as age increases. If this were the case, the length of disability might be shorter for older workers with higher tenure compared with those with lower tenure. On the contrary, workers who have been with their employer longer might feel increased job security, which could result in individuals taking a longer time to RTW as they do not feel the need to rush back to work to keep their jobs. Accordingly, older workers with higher tenure might have longer disability durations than those with lower tenure. The current study aimed to address these possibilities. The changing demographic makeup of the US workforce and the changing nature of career trajectories make this an important time to conduct research aimed at gaining an understanding of how age and tenure might interact to influence work disability. The goal of the present study is to explore the relationship between age and tenure with the length of disability following a work-related injury/illness to better understand the complex interplay among these factors.

OBJECTIVE: The aim of this study is to examine the associations between lag times following occupational low back injury and the length of work disability. METHODS: In a retrospective cohort study using workers' compensation claims, random effects Tobit models were used to explore how disability length relates to three lag times: the number of days from the date of injury to reporting the injury, the number of days from the date of injury to medical care, and the number of days from the date of injury to initiating work disability. RESULTS: In general, shorter lag times for each of the different lags were related to shorter lengths of disability. CONCLUSIONS: Decreasing the length of the lag times in reporting injuries, receiving medical care, and missing work may help to decrease the length of work disability for workers after low back injury.This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially. http://creativecommons.org/licenses/by-nc-nd/4.0. Language: en

Study design Retrospective cohort study using medical claims data. Objective To document the extent of geographic variation in utilization of magnetic resonance imaging (MRI) for working-age patients early in the course of acute, disabling low back pain (LBP); to identify potential factors associated with the most extreme variations. Summary of background data Although guidelines discourage MRI in acute uncomplicated LBP, this practice is highly prevalent. Geographic variation in radiologic testing is common, and may indicate problems with access or quality of care, yet this has not been studied in working-age patients with LBP (a frequent cause for acute care visits). Methods All cases of acute, disabling LBP with onset between 1/1/2002 and 12/31/2007 were selected from a large workers' compensation data source. Detailed information from medical bills was used to identify persons who received early MRI (within 30 days of onset), classify cases by LBP severity, and exclude those with concurrent injuries or diseases, and/or prior LBP disability. Individual predictors included age, gender, job tenure, and industry. State-level predictors included economic, physician supply and practice variables, workers compensation system features, and MRI testing location. Generalized linear mixed models were constructed to evaluate within- and between-state variability, selecting the six highest and six lowest MRI utilization states. Results State rates of early MRI scanning varied from 6.0% to 58.4%. In the 12 selected most extreme states, non-hospital MRI sites and lower state median income were associated with higher rates of early MRIs, explaining 84% of between-state variation, and 12.5% of all observed variability. Inter-state differences in MRI rates were greatest for lower-severity cases. Higher severity diagnoses were more common in high utilization states. Conclusions Between-state inappropriate early MRI variability is largely explained by rate of non-hospital MRI sites and state median income. Potential solutions include efforts to address inappropriate referral patterns based on private MRI facility ownership, and to improve quality of communication with low-income patients. Level of evidence 4.

OBJECTIVE The aim of this study was to describe the process by which a group of subject matter experts in the area of return to work developed a resource tool to provide clinical decision support (CDS) for primary care clinicians. METHODS A common musculoskeletal disorder, low back pain (LBP), was selected, pertinent literature reviewed, and specific recommendations for action in the clinical setting developed. RESULTS Primary care practitioners (PCPs) are routinely expected to create work activity prescriptions. The knowledge base for a CDS tool that could be embedded in electronic health records has been developed. CONCLUSION Improved clinical support should help prevent and manage work limitations associated with LBP not caused by work. The proposed decision support should reduce administrative burden and stimulate PCPs to explore the role of occupation and its demands on patients.

Supplemental Digital Content is Available in the Text. Magnetic resonance imaging (MRI) without clear indications led to a cascade of subsequent diagnostic and invasive services, which occurred within 6 months after imaging. Early MRI was significantly associated with a large and sustained escalation in medical costs, even after grouping by severity and controlling for pain and demographic covariates., Study Design. Retrospective cohort study. Objective. To compare type, timing, and longitudinal medical costs incurred after adherent versus nonadherent magnetic resonance imaging (MRI) for work-related low back pain. Summary of Background Data. Guidelines advise against MRI for acute uncomplicated low back pain, but is an option for persistent radicular pain after a trial of conservative care. Yet, MRI has become frequent and often nonadherent. Few studies have documented the nature and impact of medical services (including type and timing) initiated by nonadherent MRI. Methods. A longitudinal, workers' compensation administrative data source was accessed to select low back pain claims filed between January 1, 2006 and December 31, 2006. Cases were grouped by MRI timing (early, timely, no MRI) and subgrouped by severity (“less severe,” “more severe”) (final cohort = 3022). Health care utilization for each subgroup was evaluated at 3, 6, 9, and 12 months post-MRI. Multivariate logistic regression models examined risk of receiving subsequent diagnostic studies and/or treatments, adjusting for pain indicators and demographic covariates. Results. The adjusted relative risks for MRI group cases to receive electromyography, nerve conduction testing, advanced imaging, injections, and surgery within 6 months post-MRI risks in the range from 6.5 (95% CI: 2.20–19.09) to 54.9 (95% CI: 22.12–136.21) times the rate for the referent group (no MRI less severe). The timely and early MRI less severe subgroups had similar adjusted relative risks to receive most services. The early MRI more severe subgroup cases had generally higher adjusted relative risks than timely MRI more severe subgroup cases. Medical costs for both early MRI subgroups were highest and increased the most over time. Conclusion. The impact of nonadherent MRI includes a wide variety of expensive and potentially unnecessary services, and occurs relatively soon post-MRI. Study results provide evidence to promote provider and patient conversations to help patients choose care that is based on evidence, free from harm, less costly, and truly necessary. Level of Evidence: N/A

Objectives We investigated multiple trajectories of the probability of reporting health-related productivity loss over a 20-year period among adults aged 25–44 years and explored differences among the trajectories in demographic and personal characteristics and employment outcomes in midlife. Methods A latent class growth analysis of health-related productivity loss was estimated on 12 waves of data from the National Longitudinal Survey of Youth (NLSY79) (N=5699), an ongoing nationally representative longitudinal survey of Americans. Waves 1–5 were collected annually at ages 25–29 years. Waves 6–12 were collected biennially at ages 30–44 years. Productivity loss was measured as “health fully preventing a person from working” or “health limiting the amount of kind of work a person could do”. Differences among trajectories were assessed using analyses of variance (ANOVA) and Chi-square tests. Results A five-group trajectory model for productivity loss was identified: (i) no risk, (ii) low risk, (iii) high risk, (iv) increasing risk at early ages, and (v) increasing risk at later ages. At the first wave, after the waves used for the trajectory model in which respondents were approximately age 45 years, the no- and low-risk groups worked the most weeks and hours per week and had the highest percentages of participants employed ≥10 weeks compared to the high-risk and early-/late-onset increasing-risk groups, all of which had the lowest levels of mastery, self-esteem, education, and socioeconomic status. Conclusions There are several developmental patterns of productivity loss, with some trajectories being associated with lower work participation in midlife. These high risk patterns may be indicative of individuals needing intervention to prevent premature work withdrawal.

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.

To reduce a full psychosocial test battery to a brief screening questionnaire to triage return-to-work strategies among patients with low back pain (LBP).Workers (N = 496) with acute, work-related LBP completed multiple psychosocial measures at intake, then a 3-month follow-up of pain, function, and work status. A sensitivity analysis was conducted to reduce the number of items while maintaining scale reliability, preserving associations with outcomes, and maintaining separation between patient subgroups.The pool of items was trimmed from 129 to 46 items, describing elements of emotional distress, pain beliefs, organizational support, and activity limitation. A confirmatory cluster analysis replicated previous findings of three risk subgroups: distressed, avoidant, and lacking employer support.The reduced measure is a reliable and valid screening measure that can be used to identify early intervention needs among working adults with LBP.

Purpose To examine individual and area-level socioeconomic factors that predict the onset of work restriction in employed persons with lower limb joint pain. Methods Population-based prospective cohort study. Adults were aged 50–59, reported hip, knee, foot pain or a combination and maintained employment through 3 year follow-up (n = 716). Work restriction was measured as inability to participate in work as desired. Multi-level logistic regression was used to assess the associations of work restriction onset with baseline factors: health (severity of knee pain/functional limitation, comorbidity, anxiety, depression, cognitive impairment, abnormal weight), demographic socio-economic, environment and area-level employment deprivation. Results 108 (15.1 %) reported the onset of work restriction over 3 years. Severe lower limb joint pain and functional limitation, number of affected body sites and area employment deprivation were independently associated with onset. Significant interactions indicated a greater effect of area employment deprivation on older and more depressed workers. Conclusions Results suggest that effectively preventing work disability in those with OA will require both condition-specific interventions to decrease pain and maintain function, and providing alternative employment opportunities for those with progressive functional limitations. Results in older workers are particularly concerning, as retirement ages are expected to increase in the general population.

Introduction One possibility for reducing the disabling effects of low back pain (LBP) is to identify subgroups of patients who might benefit from different disability prevention strategies. The aim of this study was to test the ability to discern meaningful patient clusters for early intervention based on self-reported concerns and expectations at the time of an initial medical evaluation. Methods Workers seeking an initial evaluation for acute, work-related LBP (N = 496; 58 % male) completed self-report measures comprising of 11 possible risk factors for chronicity of pain and disability. Outcomes of pain, function, and return-to-work were assessed at 3-month follow-up. A K-means cluster analysis was used to derive patient subgroups based on risk factor patterns, and then these subgroups were compared with respect to 3-month outcomes. Results Eight of the 11 measures showed significant associations with functional recovery and return-to-work, and these were entered into the cluster analysis. A 4-cluster solution met criteria for cluster separation and interpretability, and the four clusters were labeled: (a) minimal risk (29 %), (b) workplace concerns (26 %); (c) activity limitations (27 %); and (d) emotional distress (19 %). Functional outcomes were best in the minimal risk group, poorest in the emotional distress group, and intermediate in the other two groups. A global severity index at baseline also showed highest overall risk in the emotional distressed group. Conclusions Patterns of early disability risk factors from this study suggest patients have differential needs with respect to overcoming emotional distress, resuming normal activity, and obtaining workplace support. Classifying patients in this manner may improve the cost-benefit of early intervention strategies to prevent long-term sickness absence and disability due to LBP.

Objectives This study aimed to determine whether a multi-faceted model of management of work related musculoskeletal disorders reduced compensation claim costs and days of compensation for injured workers. Methods An intervention including early reporting, employee centred case management and removal of barriers to return to work was instituted in 16 selected companies with a combined remuneration over $337 million. Outcomes were evaluated by an administrative dataset from the Victorian WorkCover Authority database. A ‘quasi experimental’ pre–post design was employed with 492 matched companies without the intervention used as a control group and an average of 21 months of post-intervention follow-up. Primary outcomes were average number of days of compensation and average cost of claims. Secondary outcomes were total medical costs and weekly benefits paid. Results Information on 3,312 claims was analysed. In companies where the intervention was introduced the average cost of claims was reduced from $6,019 to $3,913 (estimated difference $2,329, 95 % CI $1,318–$3,340) and the number of days of compensation decreased from 33.5 to 14.1 (HR 0.77, 95 % CI 0.67–0.88). Medical costs and weekly benefits costs were also lower after the intervention (p

To assess the effect of body mass index (BMI) on pain and function outcomes in the acute and subacute stages of work-related low back pain (LBP).A prospective cohort of working-age patients (410 male, 197 female) with recent onset LBP (≤14 days' duration) provided height and weight as part of a study of prognostic factors for back disability. Self-reported pain, functional limitation, and work status were assessed at 1- and 3-month follow-ups.BMI (kg/m) was used to categorize participants as normal (31%), overweight (40%), or obese (29%). In prediction analyses, outcomes of pain, functional limitation, and return to work showed no significant variation (P0.05) by BMI, with or without controlling for potential confounds.BMI is not a useful prognostic factor during the acute and subacute stages of work-related LBP.

Study design Synthesis and analysis of presentation and discussion highlights, with a focus on emerging trends and promising new directions in primary care research on low back pain (LBP). Objective To present a summary of findings, themes, and insights from the Tenth International Forum on Primary Care Research on Low Back Pain, a meeting of researchers designed to share the latest concepts, methods, and results of research on LBP diagnosis, treatment, and disability prevention. Summary of background data Earlier Forum meetings have developed several common themes and general conclusions. These are contrasted with the presentations and discussions at the 10th International Forum. Results Major themes included concerns about the epidemic of chronic, disabling LBP, associated treatments, iatrogenesis, and the "LBP medical industrial complex"; the variability and complexity of outcomes and how their importance differed across patients in defining recovery and recurrence; the power of nonspecific effects, expectations, and therapeutic alliance; and the challenges of identifying important therapeutic subgroups. New research addressed early risk factor screening and linked intervention, nonmedical approaches to reframe the LBP problem and avoid unnecessary care, cognitive and behavioral aspects of LBP, and ways to train clinicians to implement these innovations. More appropriate use of longitudinal designs and a greater focus on implementation research was called for. Conclusion Although the field of primary care LBP research often seems to progress slowly, the Forum highlighted several important, promising developments that could substantially improve LBP research and primary care practice.

Introduction In an earlier study, Gatchel et al. (J Occup Rehabil 13:1–9, 2003) demonstrated that participants at high risk for developing chronic low back pain disability (CLBPD), who received a biopsychosocial early intervention treatment program, displayed significantly more symptom improvement, as well as cost savings, relative to participants receiving standard care. The purpose of the present study was to expand on these results by examining whether the addition of a work-transition component would further strengthen the effectiveness of this early intervention treatment. Methods Using an existing algorithm, participants were identified as being high-risk (HR) or low-risk (LR) for developing CLBPD. HR participants were then randomly assigned to one of three groups: early intervention (EI); early intervention with work transition (EI/WT); or standard care (SC). Participants provided information regarding pain, disability, work status, and psychosocial functioning at baseline, periodically during treatment, and again 1 year following completion of treatment. Results At 1-year follow-up, no significant differences were found between the EI and EI/WT groups in terms of occupational status, self-reports of pain and disability, coping ability or psychosocial functioning. However, significant differences in all these outcomes were found comparing these groups to standard care. Conclusion The addition of a work transition component to an early intervention program for the treatment of ALBP did not significantly contribute to improved work outcomes. However, results further support the effectiveness of early intervention for high-risk ALBP patients.

Each month, several journals contain reports on new ways of looking at low back pain-related risk and prognostic factors, new clinical interventions and suggestions for improved care. This is because back pain continues to be a vexing condition to manage. It often defies evaluation, diagnosis and treatment, and is associated with considerable individual suffering and negative societal impact. Although reviewing new and promising strategies is always interesting and gratifying for the reader, it is sobering to reconsider similar efforts over the past decades. Most new ideas for low back pain care have not proven to be effective when subjected to repeated rigorous and independent evaluation. New developments in epidemiologic and clinical understanding, and innovative approaches to non-medical management now appear to provide the best opportunities for improving outcomes. In this article, we review new perspectives and research studies that show promise, and suggest alternatives to current clinical and research paradigms.

Prospective randomized and observational cohorts.To compare outcomes of patients with and without workers' compensation who had surgical and nonoperative treatment for a lumbar intervertebral disc herniation (IDH).Few studies have examined the association between worker's compensation and outcomes of surgical and nonoperative treatment.Patients with at least 6 weeks of sciatica and a lumbar IDH were enrolled in either a randomized trial or observational cohort at 13 US spine centers. Patients were categorized as workers' compensation or nonworkers' compensation based on baseline disability compensation and work status. Treatment was usual nonoperative care or surgical discectomy. Outcomes included pain, functional impairment, satisfaction and work/disability status at 6 weeks, 3, 6, 12, and 24 months.Combining randomized and observational cohorts, 113 patients with workers' compensation and 811 patients without were followed for 2 years. There were significant improvements in pain, function, and satisfaction with both surgical and nonoperative treatment in both groups. In the nonworkers' compensation group, there was a clinically and statistically significant advantage for surgery at 3 months that remained significant at 2 years. However, in the workers' compensation group, the benefit of surgery diminished with time; at 2 years no significant advantage was seen for surgery in any outcome (treatment difference for SF-36 bodily pain [-5.9; 95% CI: -16.7-4.9] and physical function [5.0; 95% CI: -4.9-15]). Surgical treatment was not associated with better work or disability outcomes in either group.Patients with a lumbar IDH improved substantially with both surgical and nonoperative treatment. However, there was no added benefit associated with surgical treatment for patients with workers' compensation at 2 years while those in the nonworkers' compensation group had significantly greater improvement with surgical treatment.

Background Low back pain (LBP) is a common and in some cases disabling condition. Until recently, workers presenting with non-specific LBP have generally been regarded as a homogeneous population. If this population is not homogeneous, different interventions might be appropriate for different subgroups. We hypothesized that (1) Clusters of individuals could be identified based on risk factors, (2) These clusters would predict duration and recurrences 6 months post-injury. Methods The study focuses on the 442 LBP claimants in the Readiness for Return-to-Work Cohort Study. Claimants (n = 259) who had already returned to work, approximately 1 month post-injury were categorized as the low risk group. A latent class analysis was performed on 183 workers absent from work, categorized as the high risk group. Groups were classified based on: pain, disability, fear avoidance beliefs, physical demands, people-oriented culture and disability management practice at the workplace, and depressive symptoms. Results Three classes were identified; (1) workers with ‘workplace issues’, (2) workers with a ‘no workplace issues, but back pain’, and (3) workers having ‘multiple issues’ (the most negative values on every scale, notably depressive symptoms). Classes 2 and 3 had a similar rate of return to work, both worse than the rate of class 1. Return-to-work status and recurrences at 6 months were similar in all 3 groups. Conclusion This study largely confirms that several subgroups could be identified based on previously defined risk factors as suggested by an earlier theoretical model by Shaw et al. (J Occup Rehab 16(4):591–605, 2006). Different groups of workers might be identified and might benefit from different interventions.

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.

Return-to-work (RTW) coordination programs are successful in reducing long-term work disability, but research reports have not adequately described the role and competencies of the RTW coordinator. This study was conducted to clarify the impact of RTW coordinators, and competencies (knowledge, skills, and attitudes) required to achieve optimal RTW outcomes in injured workers.Studies involving RTW coordination for injured workers were identified through literature review. Semi-structured interviews were conducted with 12 principal investigators to obtain detailed information about the RTW coordinator role and competencies not included in published articles. Interview results were synthesized into principal conceptual groups by affinity mapping.All investigators strongly endorsed the role of RTW coordinator as key to the program's success. Affinity mapping identified 10 groups of essential competencies: (1) individual traits/qualities, (2) relevant knowledge base, (3) RTW focus and attitude, (4) organizational/administrative skills, (5) assessment skills, (6) communication skills, (7) interpersonal relationship skills, (8) conflict resolution skills, (9) problem-solving skills, and (10) RTW facilitation skills. Specific consensus competencies were identified within each affinity group. Most investigators endorsed similar competencies, although there was some variation by setting or scope of RTW intervention.RTW coordinators are essential contributors in RTW facilitation programs. This study identified specific competencies required to achieve success. More emphasis on mentorship and observation will be required to develop and evaluate necessary skills in this area.

Objective: To assess the validity of the Back Disability Risk Questionnaire (BDRQ) to predict developing chronic back disability. Methods: Five hundred nineteen working adults (67% male) seeking outpatient care for acute, work-related back pain (14 days) completed the BDRQ. After the initial medical evaluation, clinicians provided prognostic impressions in a 10-item questionnaire. Pain, functional limitation, and work status were assessed at 3-month follow-up. Results: In multivariate analyses, the presence of persistent pain, functional limitation, or impaired work status (31.4%) was predicted by six BDRQ questions: injury type, work absence preceding medical evaluation, job tenure, prior back surgery, worries about re-injury, expectation for early return-to-work, and stress. Classification accuracy at 3 months was 76.3%. Initial clinician impressions showed no multivariate associations with outcomes. Conclusions: The BDRQ may provide prognostic information not observed in a routine medical evaluation for acute BP. (J Occup Environ Med. 2009;51:185–194)

Rationale and objectives Low back pain (LBP) is a common condition with frequent health care visits and work disability. Quality improvement efforts in primary care focused on guidelines adherence, provider selection and education, and feedback on appropriateness of care. Such efforts can only succeed if a health care provider is in charge of care over a substantial period. This study was conducted to provide insights about actual patterns of provider involvement in LBP care and implications for quality evaluation. Methods Established primary care patients with occupational LBP and health care covered by a workers’ compensation insurer were selected. Primary care physician (PCP) involvement was examined relative to overall health care utilization. Four methods of classifying PCP involvement were used to assess the association between PCP involvement and health care and work disability outcomes over a 2-year follow-up period. Results Primary care physician was rarely the sole provider during episodes of occupational LBP. PCP was the initial non-emergency room provider in 55% of cases, and was the most prevalent provider during at least one episode of care in 45% of cases. Different methods of classification led to different conclusions about the association between PCP involvement and work disability or number of health care visits. Multiple providers were involved throughout the clinical course of the small number of cases that accounted for most of the health care visits and work disability; in these cases, the role of PCP in care was difficult to determine. Conclusions Administrative data alone are adequate for provider comparisons only in relatively simple cases. Provider comparisons based on initial treating provider likely overstate the importance of early care, particularly in more complex cases. For LBP, quality improvement models based on PCP-directed interventions or reinforcing guideline adherence may not impact outcomes. A patient-centred model may be necessary to achieve outcome improvements.

The present study was designed to evaluate the relative degree and type of emotional distress in high-risk acute low back pain (ALBP) subjects (defined as less than 3 months since initial injury) vs. high-risk chronic low back pain (CLBP) subjects (defined as greater than 3 months since initial injury). It is an extension of earlier findings that demonstrated the significant role that such emotional distress may play in the development of CLBP disability if not appropriately treated in the acute phase. This work stems from a conceptual three-stage model, which characterizes the progression from acute to chronic pain. Several psychosocial measures were administered that included information allowing for the classification of subjects as high-risk based upon an earlier developed screening algorithm. The ANCOVA procedure in SPSS was used to compare groups, controlling for gender, ethnicity, and age. Results revealed that CLBP subjects had higher rates of certain measures of emotional distress and depression relative to ALBP subjects. These findings further support the importance of effectively managing emotional distress factors early, when treating musculoskeletal disorders such as low back pain.

Primary care physicians care for work-injured women and men, yet there is little information on sex differences in outcomes and factors contributing to post-injury outcomes to guide their evaluation and recommendations.Two self-administered questionnaires were sent to a large sample of women and men with work injuries reported to the New Hampshire (USA) Department of Labour between November 2000 and March 2002. Factors associated with the work injury and outcomes were assessed.A total of 3001 persons (1448 women and 1553 men) completed the first questionnaire and 67% completed the second questionnaire. Work-injured women were significantly younger, more educated, more likely to be single, had more pre-injury comorbidities, and worked in less physically demanding occupations as compared to work-injured men. Women's injuries were more often a result of routine job tasks and of gradual onset. Women had worse long-term outcomes including job stability and post-injury income. In multivariate analyses, being female was independently associated with a negative employer response and greater future work concerns.Women and men differ in terms of work injury circumstances and factors contributing to post-injury outcomes. Primary care providers should consider sex when evaluating and treating work-injured adults.

Objective Return-to-work (RTW) coordination has been suggested as an effective strategy for preventing workplace disability, but the scope of these services is not well described. The objective of this study was to describe the activities of RTW coordinators in published trials to provide a basis for establishing necessary competencies. Methods A keyword search of MEDLINE and CINAHL databases was conducted to identify intervention studies with a RTW coordinator providing direct, on-site workplace liaison to reduce work absences associated with physical health ailments. This search yielded 2,383 titles that were inspected by two examiners. Using a stepwise process that allowed for assessment of inter-observer agreement, 90 full articles were selected and reviewed, and 40 articles (22 studies) met criteria for inclusion. Results All but two studies (of traumatic brain injury) focused on musculoskeletal conditions or work injuries. Twenty-nine RTW coordinator activities were identified, but there was variation in the training background, workplace activities, and contextual setting of RTW coordinators. Based on reported RTW coordinator activities, six preliminary competency domains were identified: (1) ergonomic and workplace assessment; (2) clinical interviewing; (3) social problem solving; (4) workplace mediation; (5) knowledge of business and legal aspects; and (6) knowledge of medical conditions. Discussion Principal activities of RTW coordination involve workplace assessment, planning for transitional duty, and facilitating communication and agreement among stakeholders. Successful RTW coordination may depend more on competencies in ergonomic job accommodation, communication, and conflict resolution than on medical training.

Workers' musculoskeletal disorders are often pain-based and elude specific diagnoses; yet diagnosis or classification is the cornerstone to researching and managing these disorders. Clinicians are skilled in pattern recognition and use it in their daily practice. The purpose of this study was to use the clinical reasoning of experienced clinicians to recognize patterns of signs and symptoms and thus create a classification system.Two hundred and forty-two workers consented to a standardized physical assessment and to completing a questionnaire. Each physical assessment finding was dichotomized (normal versus abnormal), and the results were graphically displayed on body diagrams. At two different workshops, groups of experienced researchers or clinicians were led through an exercise of pattern recognition (clustering and naming of clusters) to arrive at a classification system. Interobserver reliability was assessed (8 observers, 40 workers), and the classification system was revised to improve reliability.The initial classification system had good face validity but low interobserver reliability (kappa0.3). Revisions were made that resulted in a proposed triaxial classification system. The signs and symptoms axes quantified the areas in the involved upper limbs. The proposed third axis described the likelihood of a specific clinical diagnosis being made and the degree of certainty. The interobserver reliability improved to approximately 0.70.This triaxial classification system for musculoskeletal disorders is based on clinically observable findings. Further testing and application in other populations is required. This classification system could be useful for both clinicians and epidemiologists.

To identify subgroups of patients with work-related back pain based on disability risk factors.Patients with work-related back pain (N = 528) completed a 16-item questionnaire of potential disability risk factors before their initial medical evaluation. Outcomes of pain, functional limitation, and work disability were assessed 1 and 3 months later.A K-Means cluster analysis of 5 disability risk factors (pain, depressed mood, fear avoidant beliefs, work inflexibility, and poor expectations for recovery) resulted in 4 sub-groups: low risk (n = 182); emotional distress (n = 103); severe pain/fear avoidant (n = 102); and concerns about job accommodation (n = 141). Pain and disability outcomes at follow-up were superior in the low-risk group and poorest in the severe pain/fear avoidant group.Patients with acute back pain can be discriminated into subgroups depending on whether disability is related to pain beliefs, emotional distress, or workplace concerns.

To examine the association between occupational physical demands and risk of same-level falls resulting in fracture in female workers' compensation claimants.From workers' compensation claims for same-level falls, 7286 female workers from three age groups (18-49, 50-59 and 60-79 years) were randomly selected. Levels of occupational physical activity, standing and sitting were assigned using occupational codes. Fracture occurrence was determined using the International Classification of Diseases codes. Risks of same-level falls resulting in fracture were compared by quartiles of physical activity, standing and sitting.In the 18-49-year age group, physical activity, standing and sitting at work were not significantly associated with risk of same-level falls resulting in fracture (p value trend: 0.07, 0.18 and 0.10, respectively). In the 50-59 and 60-79-year age groups, increasing duration of standing and decreasing duration of sitting were associated with decreasing risk of same-level falls resulting in fracture (p value trend: standing0.001, 0.01; sitting0.001, 0.02). In the 50-59-year age group, the relative risks of same-level falls resulting in fracture were 0.53, 0.41 and 0.82 for the second, third and highest quartiles of physical activity, respectively, as compared with workers in the lowest quartile (95% confidence interval 0.35 to 0.80, 0.23 to 0.72, 0.56 to 1.21, respectively). In the 60-79-year age group, there was a similar, but not significant, U-shaped association between occupational physical activity and risk of same-level falls resulting in fracture.Moderate occupational physical demands may be associated with a decreased risk of same-level fall resulting in fracture in female workers' compensation claimantsor=50 years of age.

Background Returning to work following a job-related injury or illness can be a complex process, influenced by a range of interrelated personal, psychosocial, and organizational components. System dynamics modelling (SDM) takes a sociotechnical systems perspective to view return-to-work (RTW) as a system made up of multiple feedback relationships between influential components. Design and Methods To build the RTW SDM, a mixed-method approach will be used. The first stage, that has already been completed, involved creating a baseline model using key informant interviews. Second, in two manufacturing companies, stakeholder-based models will be developed through interviews and focus groups with senior management, frontline workers, and frontline supervisors. Participants will be asked about the RTW process in general and more targeted questions regarding influential components. Participants will also be led through a reference mode exercise where they will be asked to estimate the direction, shape and magnitude of relationships between influential components. Data will be entered into the software program Vensim that provides a platform for visualizing system-structure and simulating the effects of adapting components. Finally, preliminary model validity testing will be conducted to provide insights on model generalizability and sensitivity. Expected Impact of the study for Public Health The proposed methodology will create a SDM of the RTW process using feedback relationships of influential components. It will also provide an important simulation tool to understand system behaviour that underlies complex RTW cases, and examine anticipated and unanticipated consequences of disability management policies. Significance for public health While the incidence of occupational injuries and illnesses has declined over the past two decades, the proportion resulting in sickness absence has actually increased. Implementing strategies to address sickness absences and promote return-to-work (RTW) can significantly benefit physical and mental health, and work outcomes like worker engagement, job satisfaction and job strain. As a key social determinant of health, participation in paid work can also ensure that work-disabled individuals generate income necessary for access to housing, education, food, and social services that also benefit health. Improving RTW outcomes can also have significant societal benefits such as a reduction in workers compensation costs, increased economic activity and less burden on social assistance programs. Despite its benefits, returning to work after injury or illness is not a straightforward process and can be complicated by the individual, psychosocial, organizational and regulatory components that influence a disabled person’s ability to resume work activities.

PurposeThe purpose of this paper is to assess the feasibility and comparability of daily self‐report and objective measures of work performance in complex office tasks, and factors affecting the correlation between these measures.Design/methodology/approachMedical bill auditors provided daily information for 12 weeks through interactive voice response (IVR) on their speed, concentration and accuracy at work, compared to their best job performance.FindingsThe paper found that 124 of 142 recruited subjects (87 percent) completed > 50 percent of daily IVR reports. Concentration, speed and accuracy were highly inter‐correlated (R=0.75), and right‐skewed (mean speed=7.7, SD=1.5). Mean adjusted daily productivity rate (MAP) was 34 bills/hour (range 4.7 to 111, SD12.6, 61 percent within‐person variation). Subject‐specific speed – MAP correlation varied from R=−0.20 to +0.75 (mean, 0.28). Health status, years on job, age, IVR completion rate, site, month of study, or total hours worked were not associated with these variations.Originality/valueThis paper provides an unprecedented level of detail in the comparison of self‐reported and objective daily measures of work performance, demonstrates the feasibility of data collection and analysis, and identified significant inconsistencies among workers in the correlation between the two types of measures. Results demonstrated that daily self‐reports cannot be used as a direct surrogate for objective performance measures.

Study design Retrospective cohort study. Objectives Practical evaluation of a rapid prognostic screening method to predict length of disability after acute occupational low back pain (OLBP). Summary of background data Few studies have evaluated the prognostic value of administrative data and selected clinical variables in typical practice settings. Methods Nurse case manager (NCM) input for 16 variables and 7 administrative data variables were collected for 494 OLBP cases with at least 30 days of disability. Length of disability (LOD) was ascertained by individual indemnity payment analysis. Cases were censored after accumulating 365 days of temporary total disability or if they received a lump sum settlement. Prognostic variables were evaluated by Cox proportional hazards modeling. Results In a multivariate model, prolonged LOD was associated with older age, shorter job tenure, female gender, presence of language barriers, comorbidity, prior work absence, delayed referral, attorney involvement nonsupportive of return to work (RTW), and low RTW motivation. Although only 12% of overall variance in LOD was explained by the model, high-risk and low-risk terciles were readily distinguished. Conclusions In a typical setting, data collection and risk prediction by nurses or case managers are feasible and provide specific information that can be used to identify who should receive intervention, as well as some guidance on factors that should be addressed.

Study design Retrospective analysis of workers' compensation (WC) claims data for nonspecific low back injuries (LBI) in a single jurisdiction. Objective To examine whether recurrences, defined as post-initial episodes of work disability or medical care, substantially contribute to total medical and indemnity costs, and total duration of work disability. Summary of background data Previous studies have not measured the proportion of care seeking and work disability that are associated with recurrences in claims for work-related LBI. Methods All persons with new lost-time claims for nonspecific LBI reported in New Hampshire to a large WC provider from 1996 to 1999 were selected (N = 1867). Three years of follow-up data, starting at the beginning of the first episode, were collected. Previously validated definitions of recurrence were used identify new episodes of care and new episodes of lost work time (work disability). Total duration of work disability, total medical costs, and total indemnity costs were investigated. For individuals with recurrences, these variables were separated into first-episode and recurrent period duration and costs. Results The rate of recurrent work disability was 17.2%, and the rate of recurrent care seeking was 33.9%. Individuals with recurrence had significantly higher total length of work disability, and higher medical and indemnity costs. For those with recurrent work disability, 69% of total lost time from work, 71% of associated indemnity costs, and 84% of total medical costs occurred during the recurrent period. For those with recurrence of care, the respective values were 48%, 47%, and 42%. Conclusions Recurrences contributed disproportionately to the total burden of work-related nonspecific LBI, through both additional care seeking and work disability. Results imply that those who have recurrences may be an especially important target for secondary prevention efforts.

Introduction: There is a body of literature that indicates that physical exercise interventions, with a primary focus on improvement of functioning instead of pain relief, might be effective to stimulate return to work and improve function in workers who are absent from work due to low back pain (LBP). Successful application and implementation of these interventions however, depends on multiple factors that need to be addressed carefully in clinical practice as well as research. Methods: Descriptive literature review, to identify an overview of current knowledge with respect to the safety, content- and context-related aspects of physical exercise interventions, issues relating to timing, the influence of treatment confidence and patient expectations, and the process of changing provider and employer behavior. Results: Physical exercises are not associated with an increased risk for recurrences. The effects of interventions may vary depending on content-related factors (i.e., type of exercises, dosage, frequency, skills of the healthcare providers, etc.) and contextual factors (i.e., treatment setting, compensation system, etc.). Treatment confidence and patients' expectations also significantly influence outcomes of physical exercise interventions. Timing is also important; interventions targeting return to work, applied during the acute phase of work absenteeism, compete with a high rate of spontaneous recovery and may therefore be inefficient. Conclusions: Despite numerous studies, more quantitative and qualitative investigations are needed to further clarify the requirements for a successful application and implementation of physical exercise interventions for disabled workers with low back pain. © 2005 Springer Science + Business Media, Inc.

Descriptive study.To document the characteristics of rehospitalization following work-related tetraplegia, investigate risk factors for rehospitalization and identify opportunities for rehospitalization prevention.Workers' compensation administrative database with national coverage.The administrative database of a large workers' compensation provider was searched for work-related tetraplegia claims with dates of injury between 1 January 1989 and 31 December 1999. In all, 61 cases were identified where detailed rehospitalization information was available. Medical payment data were extracted, rehospitalization reasons were coded, and rates, costs and length of stay were calculated.In all, 62% of cases were rehospitalized at some time during the period for which data were available. The average number of days the study group spent rehospitalized per year was 9.2 and the average annual cost was 14,197 US dollars. The most common reasons for rehospitalization were dermatological (23%), orthopedic (18%) and urological (14%). It was found that as many as 74% of the total number of days persons spent rehospitalized, 64% of the monies spent on rehospitalization, and 47% of rehospitalizations could have been prevented.Consistent with earlier research, the ability to identify risk factors for rehospitalization was limited. However, the current study does highlight the extent to which rehospitalizations disrupt the lives of people with work-related tetraplegia and that a substantial proportion of rehospitalizations can be avoided.The research was supported, in part, by a grant from the National Institute on Disability and Rehabilitation Research National Model SCI Systems (Grant no. H133N00024).

Decreased on-the-job productivity represents a large yet poorly characterized indirect cost to employers. We studied the impact of employee health risk factors on self-reported worker productivity (presenteeism).Using a brief version of the Work Limitation Questionnaire incorporated into a Health Risk Appraisal, 28,375 employees of a national company responded to the survey. The association between health risks and work limitation and each of the four domains was examined. Percentage of lost productivity also was estimated.Ten of 12 health risk factors studied were significantly associated with self-reported work limitations. The strength of the associations varied between risks and the four domains of work limitation. Perception-related risk factors such as life dissatisfaction, job dissatisfaction, poor health, and stress showed the greatest association with presenteeism. As the number of self-reported health risk factors increased, so did the percentage of employees reporting work limitations. Each additional risk factor was associated with 2.4% excess productivity reduction. Medium and high-risk individuals were 6.2% and 12.2% less productive than low-risk individuals, respectively. The annual cost of lost productivity in this corporation was estimated at between 99Mdollars and 185Mdollars or between 1392dollars and 2592dollars per employee.Health risk factors represent additional causes of lost productivity.

Objectives: Studies on the impact of illness on work productivity are important to rationally allocate healthcare resources and to design programs to mitigate these effects. This investigation was conducted to develop and apply daily measures of illness episodes, and to collect subjective and objective data on work performance impacts. Medical bill reviewers completed daily responses to a questionnaire about headache manifestations, severity, and speed of work using interactive voice response (IVR). Of 134 eligible enrolled subjects, 117 (86%) provided at least 30 daily reports over 3 months. Their responses were matched to difficulty-adjusted objective measures: daily output, time on the system, and productivity. Respondents were clinically classified as migraineurs (n = 56), other headache disorders (n = 47), or having no headache disorder (n = 14). Each headache episode was classified as a migraine or nonmigraine headache based on reported manifestations. Results: The three groups were similar in a variety of demographic factors, and mean subject-specific measures of speed, output, and productivity. In a multivariate model using general estimating equations, only episode severity (not type of headache or person-specific diagnosis) was found to be associated with a significant decrement in speed or productivity. The self-reported decrement in speed (approximately 20%) was much greater than the actual measured effect on productivity (approximately 8%). Intensive daily diary collection by IVR on symptoms and work performance is feasible. However, analysis of detailed daily objective productivity data can be complex, with significant unmeasured sources of variance. Severity may be a more important determinant of headache effect on work performance than specific diagnosis. Future studies on illness episodes and work performance should measure informal accommodations that may enable employees to compensate for episodic illnesses.

This study examined the loss of productivity and health risk status associated with employees who provide care for an ill dependent. A total of 16,651 employees (23% response rate) of a major financial services company completed a confidential Health Risk Appraisal (HRA) that included an eight-item version of the Work Limitations Questionnaire and a self-report of time missed from work during the previous 2 weeks to care for an ill dependent. A total of 10.6% of the respondents reported an average of 7.7 hours absent from work during the previous 2-week period to provide care for an ill dependent. Caregiving also was associated with a significant increase in the number of health risks for the employee. As the demand for caregiving time increased, caregivers reported a significant increase in work limitations. Caregiving for an ill dependent is associated with increased absenteeism and significant work limitations while on the job. Programs and work organization that helps employees balance their caregiving responsibilities for ill dependents may have a positive effect on health and productivity.