On the Use of Quantitative Sensory Testing to Estimate Central Sensitization in Humans. Comment on Schuttert et al. The Definition, Assessment, and Prevalence of (Human Assumed) Central Sensitisation in Patients with Chronic Low Back Pain: A Systematic Review. J. Clin. Med. 2021, 10, 5931.

With great interest, I have read the systematic review in your journal [...].

Expectations for Return to Work Predict Return to Work in Workers with Low Back Pain: An Individual Participant Data (IPD) Meta-Analysis.

Purpose Low back pain is associated with disability and lost productivity due to inability of workers to return to work. Personal recovery expectation beliefs may be associated with return to work outcomes in those with low back pain at high risk for chronic disability. We aimed to (1) assess whether workers' expectations for return to work, following a low back pain episode, are associated with subsequent return to work; and (2) explore the relationships between return to work expectations and other prognostic factors in their association with work outcomes.Methods We conducted an Individual Participant Data (IPD) meta-analysis using data from five prospective cohort studies identified by a Cochrane prognostic factor review. A one-stage IPD meta-analysis approach was applied. Multi-level mixed effects models were used to determine the unadjusted and adjusted associations between expectations and return to work (logistic regression) and time to return to work (parametric survival models with Weibull distribution).Results The final dataset included 2302 participants. Positive expectations for return to work were associated with return to work at follow-up in both unadjusted (Odds Ratio (OR) 2.95; 95% Confidence Interval (CI) 2.21, 3.95) (n = 2071) and comprehensively adjusted (OR 2.01; 95% CI 1.46, 2.77) (n = 1109) models. Similar findings were identified for shorter length of time to return to work in both unadjusted (HR 2.40; 95% CI 2.09, 2.75) (n = 1156) and minimally adjusted (HR 2.43; 95% CI 2.12, 2.79) (n = 1154) models.Conclusions Results suggest workers with low expectations for return to work are at increased risk for long-term work disability.

The comparative effects of brief or multidisciplinary intervention on return to work at 1 year in employees on sick leave due to low back pain: A randomized controlled trial.

OBJECTIVE: To compare return to work (RTW) rates among patients with low back pain (LBP) and different job relations randomized to brief or multidisciplinary intervention. DESIGN: A randomized controlled trial with 1-year follow-up. SETTING: Silkeborg Regional Hospital, Denmark. SUBJECTS: Four hundred seventy-six participants were divided into two groups concerning job relations: strong (influence on job and no fear of losing it) or weak (no influence on job and/or fear of losing it), and afterwards randomized to brief or multidisciplinary intervention. INTERVENTIONS: Brief intervention included examination and advice by a rheumatologist and a physiotherapist. Multidisciplinary intervention included brief intervention plus coaching by a case manager making a plan for RTW with the patient. MAIN MEASURES: Primary outcome was 1-year RTW rate. Secondary outcomes included pain intensity (LBP rating scale), disability (Roland Morris disability scale), and psychological measures (Common Mental Disorder Questionnaire, Major Depression Inventory, and EQ-5D-3L). RESULTS: Mean (SD) age was 43.1 (9.8) years. Among 272 participants with strong job relations, RTW was achieved for 104/137 (76%) receiving brief intervention compared to 89/135 (66%) receiving multidisciplinary intervention, hazard ratio 0.73 (CI: 0.55-0.96). Corresponding results for 204 participants with weak job relations were 69/102 (68%) in both interventions, hazard ratio 1.07 (CI: 0.77-1.49). For patients with strong job relations, depressive symptoms and quality of life were more improved after brief intervention. CONCLUSION: Brief intervention resulted in higher RTW rates than multidisciplinary intervention for employees with strong job relations. There were no differences in RTW rates between interventions for employees with weak job relations.

Diffuse central sensitization in low back patients: A secondary analysis of cross-sectional data including tender point examination and magnetic resonance imaging of the lumbar spine.

Consistency between back pain intensity and degenerative changes on magnetic resonance imaging (MRI) of the lumbar spine is poor. This study aimed to show whether tender point (TP) examination, used as a test for diffuse central sensitization, may add valuable information to clinical assessment of patients with low back pain (LBP).This was a cross-sectional study including 141 patients with LBP on sick leave. Baseline measures comprised back pain, leg pain intensity, and LBP examination including TP examination. Degenerative MRI findings were assessed in a standardized manner and blinded for clinical data. The number of TPs was analyzed in relation to sex, widespread pain, radiculopathy, pain duration, and degenerative changes on MRI.The number of TPs was positively associated with the female sex, widespread pain, and pain duration. It was negatively associated with degenerative manifestations and radiculopathy, the latter displaying a low level similar to that of the general population. A positive association between back pain intensity and TPs was present in patients with and without radiculopathy and in patients with substantial degenerative changes. Men with >7-8 TPs and women with >10-11 TPs had more back pain and similar or fewer degenerative changes than patients with few TPs (<3 and <6 TPs, respectively), thereby identifying 34% to 44% of patients with nonspecific LBP and 5% to 8% of patients with radiculopathy, respectively, with disproportionate back pain in relation to degenerative changes.Supplemental TP examination improved clinical and MRI evaluation of patients with LBP. By using gender-specific cut points, patients with disproportionate back pain were identified, presumably indicating diffuse central sensitization.

Prediction of 2-year work participation in sickness absentees with neck or shoulder pain: the contribution of demographic, patient-reported, clinical and imaging information.

BACKGROUND: In cases of neck and shoulder pain, the responsibility for assessing work prognosis is held by clinicians with access to different domains of information. One of these domains is magnetic resonance imaging (MRI), and although MRI is increasingly used, it is unknown which domains of information contribute the most to the prediction of work prognosis. This retrospective cohort study explored the contribution of demographic, patient-reported, clinical, and MRI information to the prediction of work participation in sickness absentees with neck or shoulder pain. METHODS: From a secondary care setting, 168 sickness absentees with neck or shoulder pain were included. Based on registry data, a successful work outcome was defined as ≥50% work participation score (WPS) from Weeks 1 to 104 after enrolment. Prognostic variables were categorized into four domains (demographic, patient-reported, clinical, and MRI) resembling the order of information obtained in a clinical setting. Crude logistic regression analyses were used to identify prognostic variables for each domain (p < 0.2). This was followed by multivariable analyses including the identified variables in a domain-wise order. For each added domain, the probability of successful WPS was dichotomized leaving two possible classifications: ≥ 50% chance of successful WPS or not. In cross-tabulations of chance and the actual WPS outcome, positive and negative predictive values (PPV and NPV), sensitivity, specificity and area under the curve (AUC) were calculated. RESULTS: The combination of demographic and patient-reported variables yielded an NPV of 0.72 and a PPV of 0.67, while specificity was 0.82, sensitivity 0.54 and AUC 0.77. None of these values improved notably by adding clinical and MRI variables as predictors of successful WPS. CONCLUSIONS: These results suggest that - among sickness absentees with neck or shoulder pain - clinical and MRI variables provide no additional information for the prediction of work participation compared with only demographic and patient-reported information.

Employment status five years after a randomised controlled trial comparing multidisciplinary and brief intervention in employees on sick leave due to low back pain.

AIMS: To evaluate differences in employment status, during a five-year follow-up period in patients on sick leave due to low back pain who had participated in a trial comparing a brief and a multidisciplinary intervention. METHODS: From 2004 to 2008, 535 patients were referred to the Spine Centre at the Regional Hospital in Silkeborg if they had been on sick leave for 3-16 weeks due to low back pain. All patients underwent a clinical examination by a rehabilitation physician and a physiotherapist, and were randomised to either the brief intervention or the multidisciplinary intervention. The outcome was employment status from randomisation to five years of follow-up and was measured by the mean number of weeks in four different groups of employment status (sequence analysis) and a fraction of the number of weeks working (work participation score) that were accumulated over the years. RESULTS: A total of 231 patients were randomised to the brief intervention and 233 patients to the multidisciplinary intervention. No statistically significant differences in the mean weeks spent within the different employment statuses were found between the two intervention groups. After five years of follow-up, participants in the multidisciplinary intervention had a 19% higher risk of not having a work participation score above 75% compared to participants in the brief intervention. CONCLUSIONS: After five years of follow-up no differences in employment status were found between participants in the brief and the multidisciplinary intervention.

Return to Work in Employees on Sick Leave due to Neck or Shoulder Pain: A Randomized Clinical Trial Comparing Multidisciplinary and Brief Intervention with One-Year Register-Based Follow-Up.

Purpose The aim of this study was to evaluate the effect of a multidisciplinary intervention (MDI) compared to a brief intervention (BI) with respect to return to work (RTW), pain and disability in workers on sick leave because of neck or shoulder pain. Methods 168 study participants with sickness absence for 4-16 weeks due to neck or shoulder pain were enrolled in a hospital-based clinical study and randomized to either MDI or BI. The primary outcome was RTW obtained by a national registry on public transfer payments. Secondary outcomes were self-reported pain and disability levels. One-year follow-up RTW rates were estimated by Cox proportional hazard regression adjusted for gender, age, sick leave prior to inclusion, part-time sick leave and clinical diagnosis. Secondary outcomes were analysed using logistic and linear regression analysis for pain and disability, respectively. Results In the MDI group, 50 participants (59%) experienced four or more continuous weeks of RTW while 48 (58%) returned to work in the BI group during the 1 year of follow-up. Results showed a statistically non significant tendency towards a lower rate of RTW in the MDI group than in the BI group (adjusted HR = 0.84, 95% CI 0.54, 1.31). There were no statistically significant differences in secondary outcomes between the MDI and BI groups. Conclusion The brief and the multidisciplinary interventions performed equally with respect to both primary and secondary outcomes. The added focus on RTW in the multidisciplinary group did not improve RTW rates in this group.

Comparing multidisciplinary and brief intervention in employees with different job relations on sick leave due to low back pain: protocol of a randomised controlled trial.

BACKGROUND: Low back pain (LBP) is a common problem that affects the lives of many individuals and is a frequent cause of sickness absence. To help this group of individuals resume work, several interventions have been studied. However, not all individuals may profit from the same intervention and the effect of a given intervention on return to work (RTW) may depend on their work situation. The aim of this study is to evaluate whether employees on sick leave due to LBP and with poor job relations will benefit more from a multidisciplinary intervention, while patients with strong job relations will benefit more from a brief intervention. METHODS: The study is designed as a randomised controlled trial with up to five years of follow-up comparing brief intervention with brief intervention plus multidisciplinary intervention. Employees, aged 18-60 years, are included in the study from March 2011 to August 2016 if they have been on sick leave for 4-12 weeks due to LBP with or without radiculopathy. They are divided into two groups, a group with poor job relations and a group with strong job relations based on their answers in the baseline questionnaire. Each group is randomised 1:1 to receive the brief intervention or brief intervention plus multidisciplinary intervention. The brief intervention comprises a clinical examination and advice offered by a rheumatologist and a physiotherapist, whereas the supplementary multidisciplinary intervention comprises the assignment of a case manager who draws up a rehabilitation plan in collaboration with the participant and the multidisciplinary team. The primary outcome is duration of sickness absence measured by register data. Secondary outcomes include sustainable RTW and questionnaire-based measures of functional capacity. Outcomes will be assessed at one, two and five years of follow-up. DISCUSSION: This trial will evaluate the effect of brief and multidisciplinary intervention on RTW and functional capacity among employees on sick leave due to LBP with poor or strong job relations. This will indicate whether work-related characteristics should be considered when providing treatment of LBP patients in the health care sector. TRIAL REGISTRATION: Current Controlled Trials ISRCTN14136384 . Registered 4 August 2015.

Back pain was less explained than leg pain: a cross-sectional study using magnetic resonance imaging in low back pain patients with and without radiculopathy.

BACKGROUND: Cross-sectional studies have shown associations between lumbar degenerative manifestations on magnetic resonance imaging (MRI) and low back pain (LBP). Disc herniations and other degenerative manifestations, however, frequently occur in asymptomatic individuals. The purpose of this cross-sectional study was to analyze for associations between pain intensity and degenerative manifestations and other pain variables in patients for whom prognostic factors have been published previously. METHODS: Included were 141 consecutive patients with and without radiculopathy, all sick-listed 1-4 months due to low back pain and subsequently examined by MRI of the lumbar spine. Using different methods of grouping the degenerative manifestations, linear regression analyses were performed with the intensity of back + leg pain, back pain and leg pain as dependent variables covering actual pain and pain the preceding 2 weeks. The clinical classification into +/- radiculopathy was established before and independently of the standardised description of MRI findings. RESULTS: Radiculopathy was present in 43 % of the patients. Pain was best explained using rank-ordered degenerative manifestations on MRI. Back pain and leg pain were differently associated, and back pain was less explained than leg pain in the multivariate analyses (15 % vs. 31 % of the variation). Back pain intensity was higher in patients with type 1 Modic changes and in some patients with nerve root touch, but was not associated with disc herniations. Leg pain intensity was well explained by disc herniations causing MRI nerve root compromise and radiculopathy. In patients with radiculopathy, nerve root touch caused as much leg pain as nerve root displacement or compression. High intensity zones and osteophytes were not associated with back pain, but only associated with leg pain in patients with radiculopathy. Tender points explained some of the back pain, and widespread pain explained leg pain in some of the patients without radiculopathy. CONCLUSIONS: Back pain was associated with type 1 Modic changes, nerve root touch and tender points, whereas leg pain was associated with osteophytes, HIZ, disc herniation, all sorts of MRI nerve root compromise, radiculopathy and widespread pain.

Multiple somatic symptoms in employees participating in a randomized controlled trial associated with sickness absence because of nonspecific low back pain.

BACKGROUND CONTEXT: The prevalence of multiple somatic symptoms is high in primary and hospital outpatient populations. Multiple somatic symptoms may be present in patients sick-listed because of low back pain (LBP) and may be associated with increased risk of not returning to work (RTW). PURPOSE: To explore whether multiple somatic symptoms in a subset of patients with nonspecific LBP was associated with RTW, sickness absence (SA), or other social benefits. STUDY DESIGN: The study was a cohort study based on a randomized clinical trial with a prospective 2-year follow-up period. Patients were referred from general practices to the Spine Center, Regional Hospital Silkeborg, Denmark. PATIENT SAMPLE: Patients were 285 sick-listed employees (4-12 weeks), with nonspecific LBP as their prime reason for SA. Exclusion criteria were unemployment, radiculopathy, LBP surgery within the past year, previous lumbar fusion, suspected cauda equina syndrome, progressive paresis or other serious back disease, pregnancy, known substance abuse, or primary psychiatric diagnosis. OUTCOME MEASURES: Self-reported health was assessed by the LBP rating scale and questions about pain and health in general. Disabilities were measured by the Roland Morris Questionnaire, the Short Form-36, and the Fear-Avoidance Beliefs Questionnaire. Work-related questions comprised expectations about RTW and risk of losing job because of SA. The Common Mental Disorder Questionnaire (subscale SCL-SOM) was used to assess multiple somatic symptoms (12 items). We categorized multiple somatic symptoms into four groups based on the SCL-SOM sum score: <6, 6 to 12, 13 to 18 and >18. Status of SA (>2 weeks) and RTW were gathered from a national database (DREAM). METHODS: The patients (N=285) were randomized into either multidisciplinary or brief intervention at the Spine Center (2004-2008). Both interventions comprised clinical examination and advice by a physiotherapist and a rheumatologist. Data were collected from questionnaires at baseline (inclusion) and 1 year after inclusion. Data on SA benefits were gathered from the DREAM database that contains data on all social transfer payments (such as sick leave benefits and other disability benefits) registered on a weekly basis. RESULTS: All health factors, female gender, and poor work ability were significantly associated with a higher level of multiple somatic symptoms. The percentage of persons with SA increased significantly with the symptom score after 1 year, and the duration of SA remained significantly longer after 2 years of follow-up between the multiple somatic symptoms groups. The percentages with RTW after 1 and 2 years were negatively associated with a higher level of multiple somatic symptoms at baseline. We found no difference between the intervention groups. CONCLUSIONS: A higher level of multiple somatic symptoms was significantly associated with poor health and work ability at baseline and with longer duration of SA and unsuccessful RTW through a 2-year follow-up period.

Type 1 Modic changes was a significant risk factor for 1-year outcome in sick-listed low back pain patients: a nested cohort study using magnetic resonance imaging of the lumbar spine.

BACKGROUND CONTEXT: It is not clear whether Modic changes (MC) is associated with low back pain (LBP) outcome. PURPOSE: To study associations between baseline degenerative manifestations and outcome in sick-listed LBP patients. STUDY DESIGN: Prospective nested cohort study based on a randomized controlled trial. PATIENT SAMPLE: Out of 325 sick-listed LBP patients, 141 were consecutively examined by magnetic resonance imaging (MRI) and included and 140 completed the study. OUTCOME MEASURES: Degenerative manifestations of the lumbar spine were quantified; associations were studied in relation to the three primary outcomes: change of back+leg pain, change of function as measured by Roland-Morris questionnaire, and 1-year unsuccessful return to work (U-RTW). METHODS: By using a previously validated MRI protocol, a specialist in radiology, who had no access to clinical data, described the images. Associations were studied by linear and logistic regression with adjustment for previously identified prognostic factors for 1-year pain and function and for U-RTW. RESULTS: Clinically, 43% of the patients had radiculopathy. Degenerative changes were prevalent with altered disc contours in 84%, high-intensity zones in 70%, and nerve root touch or impingement in 63% of the patients. MC was identified in 60% of the patients, 18% with Type 1 changes and 42% with Type 2 changes, Type 1 including both Type 1 and Type 1 in combination with Type 2. Patients with Type 1 changes reported more back pain and did not improve in pain or disability. They increased to include 30% of the patients with U-RTW at 1 year. Patients with Type 2 changes did not differ significantly from patients without MC but differed significantly from patients with Type 1 changes in all three outcomes. Other degenerative manifestations were not significantly associated with any of the three outcomes. CONCLUSIONS: The only degenerative manifestation negatively associated with outcome was Type 1 MC that affected 18% of the cohort at baseline and implied an increased risk for no improvement in pain and function and for U-RTW, even after adjustment for other prognostic factors.

Prediction model for unsuccessful return to work after hospital-based intervention in low back pain patients.

BACKGROUND: Many studies on low back pain (LBP) have identified prognostic factors, but prediction models for use in secondary health care are not available. The purpose of this cohort study, based on a randomised clinical study, was to identify risk factors for unsuccessful return to work (U-RTW) in sick-listed LBP patients with or without radiculopathy and to validate a prediction model for U-RTW. METHODS: 325 sick-listed LBP patients with or without radiculopathy were included in an intervention study and followed for one year. Afterwards, 117 other LBP patients were recruited similarly, included in a validation study and also followed for one year. All patients were subjected to identical procedures and interventions and received a brief intervention by the same rehabilitation doctor and physiotherapist. Half of them received case manager guidance within a multidisciplinary setting. At baseline, they completed a questionnaire and went through a clinical low-back examination. Sciatica was investigated by magnetic resonance imaging (MRI). U-RTW was registered in a national database both initially and at 1-year. RESULTS: Neither initial U-RTW (24.0%) nor one-year U-RTW (38.2%) were statistically significantly different in the two intervention groups nor in patients with and without radiculopathy. Multivariate logistic regression analysis identified two clinical and five psychosocial baseline predictors for one-year U-RTW (primary outcome). The clinical predictors included pain score (back+leg pain) and side-flexion. The five psychosocial predictors included 'bodily distress' 'low expectations of RTW', 'blaming the work for pain', 'no home ownership' and 'drinking alcohol less than once/month'. These predictors were not statistically significantly different in patients with and without radiculopathy, and they also predicted initial U-RTW (secondary outcome). Obesity and older age were only supplementary predictors in patients with radiculopathy. A prediction model was established and tested in the validation study group. The model predicted one-year U-RWT in patients with intermediate and high risk, but only partially in patients with low risk. The model predicted all three risk categories in initial U-RTW. CONCLUSIONS: A prediction model combining baseline clinical and psychosocial risk factors predicted patients with low, intermediate and high risk for unsuccessful return to work, both initially and at 1-year.

Cost-effectiveness and cost-benefit analyses of a multidisciplinary intervention compared with a brief intervention to facilitate return to work in sick-listed patients with low back pain.

STUDY DESIGN: Randomized clinical trial of 2 interventions in 351 employees sick listed due to low back pain (LBP) and a subsequent validation study (n = 120) to validate results from subgroup analyses in the original study. OBJECTIVE: To compose health economic analyses (cost-effectiveness- and cost-benefit analyses) of multidisciplinary versus brief intervention by calculating health care sector costs and sick leave benefits. SUMMARY OF BACKGROUND DATA: Both brief and multidisciplinary interventions have been reported to be superior relative to usual care when comparing intervention costs with saved costs for sick leave benefits. We reported similar return to work rates in a brief and a multidisciplinary intervention group, but different return to work rates in subgroups. METHODS: The brief intervention comprised clinical examination and reassuring advice. The multidisciplinary intervention was conducted by a case manager and a team of specialists. The costs of medicine, health care services, and sick leave benefits were calculated on the basis of registers. RESULTS: The mean intervention cost per patient was € 1377 higher in the multidisciplinary intervention (n = 176) than in the brief intervention group (n = 175), and sick leave was not averted. However, sick leave was averted in a subgroup receiving the multidisciplinary intervention and the mean incremental intervention cost for 1 saved sick leave week in this subgroup (n = 60) of patients, who thought they were at risk of losing their job or had little influence on their work situation was € 217. The latter finding was verified in the validation study (n = 28). CONCLUSION: The brief intervention resulted in fewer sick leave weeks and was less expensive than the multidisciplinary intervention. The multidisciplinary intervention only outperformed the brief intervention in terms of costs in a subgroup of sick-listed employees who thought they were at risk of losing their job or had little influence on their work situation. LEVEL OF EVIDENCE: 2.

Reproducibility of tender point examination in chronic low back pain patients as measured by intrarater and inter-rater reliability and agreement: a validation study.

OBJECTIVES: To evaluate the reliability and agreement of digital tender point (TP) examination in chronic low back pain (LBP) patients. DESIGN: Cross-sectional study. SETTINGS: Hospital-based validation study. PARTICIPANTS: Among sick-listed LBP patients referred from general practitioners for low back examination and return-to-work intervention, 43 and 39 patients, respectively (18 women, 46%) entered and completed the study. MAIN OUTCOME MEASURES: The reliability was estimated by the intraclass correlation coefficient (ICC), and agreement was calculated for up to ±3 TPs. Furthermore, the smallest detectable difference was calculated. RESULTS: TP examination was performed twice by two consultants in rheumatology and rehabilitation at 20 min intervals and repeated 1 week later. Intrarater reliability in the more and less experienced rater was ICC 0.84 (95% CI 0.69 to 0.98) and 0.72 (95% CI 0.49 to 0.95), respectively. The figures for inter-rater reliability were intermediate between these figures. In more than 70% of the cases, the raters agreed within ±3 TPs in both men and women and between test days. The smallest detectable difference between raters was 5, and for the more and less experienced rater it was 4 and 6 TPs, respectively. CONCLUSIONS: The reliability of digital TP examination ranged from acceptable to excellent, and agreement was good in both men and women. The smallest detectable differences varied from 4 to 6 TPs. Thus, TP examination in our hands was a reliable but not precise instrument. Digital TP examination may be useful in daily clinical practice, but regular use and training sessions are required to secure quality of testing.

Sustainability of return to work in sick-listed employees with low-back pain. Two-year follow-up in a randomized clinical trial comparing multidisciplinary and brief intervention.

BACKGROUND: Sick-listed employees with low back pain had similar return to work (RTW) rates at one-year follow-up in a randomized trial comparing two interventions, but the effects were modified by specific workplace related factors. The present study addressed the sustainability of the intervention effects by performing a two-year follow-up and by using different outcome measures. METHODS: A total of 351 employees sick-listed for 3-16 weeks due to LBP were recruited from their general practitioners and were randomly allocated to a hospital-based brief or multidisciplinary intervention. Outcome measures were based on sick leave registered in a national database of social and health-related benefits. RTW rates, RTW status, sick leave weeks and sick leave relapse were studied. RESULTS: During the two-year follow-up 80.0% and 77.3% had RTW for at least four weeks continuously, and the percentages with RTW at the 104th week were 61.1% and 58.0% in the brief and multidisciplinary intervention groups, respectively. At the 104th week 16.6% and 18.8% were on sick leave in the two groups, respectively, and about 12% were employed in modified jobs or participated in job training. The number of weeks on sick leave in the first year was significantly lower in the brief intervention group (median 14 weeks) than in the multidisciplinary intervention group (median 20 weeks), but during the second year the number of weeks on sick leave were not significantly different between intervention groups. Subgroups characterised by specific work related factors modified the effect of the intervention groups on RTW rates (p = 0.017). No difference in sick leave relapse was found between the intervention groups. CONCLUSION: The effects of the brief and multidisciplinary interventions at the two-year follow-up were in general similar to the effects at one-year follow-up. TRIAL REGISTRATION: Current Controlled Trials ISRCTN18609003.

One-year follow-up in employees sick-listed because of low back pain: randomized clinical trial comparing multidisciplinary and brief intervention.

STUDY DESIGN: Randomized clinical trial comparing two interventions in employees sick-listed 3 to 16 weeks because of low back pain (LBP). OBJECTIVE: To compare 1-year return to work (RTW), pain, disability and physical and mental health dimensions in subjects offered a hospital-based multidisciplinary intervention or a brief intervention. SUMMARY OF BACKGROUND DATA: Previous studies in sick-listed employees with LBP have indicated efficacy of both brief and more comprehensive multidisciplinary interventions. However, it remains unknown, which is the more effective, and which elements are instrumental in furthering RTW, and improving health. METHODS: The brief intervention comprised clinical examination and advice offered by a rehabilitation physician and a physiotherapist. In the multidisciplinary intervention, this intervention was supplemented with the expertise of a team and the assignment of a case manager who drew up a rehabilitation plan in collaboration with the patient and the multidisciplinary team. One-year RTW was estimated by data from a comprehensive national database of social transfer payments. Questionnaires were used to obtain baseline and 1-year data on Roland Morris disability score, LBP Rating Scale, SF36, and fear-avoidance. RESULTS: A total of 351 patients were included and randomized and 344 (98%) patients participated in all the consultations according to the study protocol. RTW was achieved by 125 (71.0%) participants in the multidisciplinary and 133 (76.0%) participants in the brief intervention group. The hazard ratio was 0.84 after adjustment for sex, age, smoking, compensation claims, disability score, and diagnosis (95% confidence interval [CI]: 0.65-1.08,P = 0.18). Multiple linear regression analysis displayed no differences in secondary outcomes, except for the mental health score (SF36), which was a little higher in the multidisciplinary intervention group than in the brief intervention group. CONCLUSION: Hospital-based multidisciplinary intervention may be no better than brief intervention to increase RTW and improve health in sick-listed employees with low back pain.

Pain response classification does not predict long-term outcome in patients with low back pain who are sick-listed.

STUDY DESIGN: Prospective cohort study nested in a randomized clinical trial. OBJECTIVE: To investigate the prognostic value of pain response classification at initial physiotherapy examination in patients with low back pain (LBP) who are sick-listed. BACKGROUND: Recurrent and chronic LBP accounts for a substantial proportion of all absence from work. In predicting outcome in patients with LBP, psychosocial factors are thought to play an important role, while findings from clinical examination seem to be of more limited value. Mechanical evaluation, using repeated end range spinal movements that result in specific pain responses, has been shown to be of some value. METHODS: The study included 351 patients sick-listed because of LBP with or without sciatica. Prior to clinical examination, the patients completed a comprehensive questionnaire including questions on pain, function, and psychosocial factors. The physiotherapy examination included a standardized mechanical evaluation. Patients were classified into 3 groups according to their pain response: centralization, peripheralization, or no response. Outcomes were obtained by national register data, medical records, and a postal questionnaire at 1 year. RESULTS: At 1-year follow-up, 65% of the patients had returned to work. All pain response groups showed significant and clinically important improvements in both pain and disability. No significant differences were found between pain response groups in any outcome measure. Results remained unchanged after adjustment for potential confounders. CONCLUSION: The prognostic value of pain response classification seems limited in patients sick-listed from work because of LBP.

One-year prognosis in sick-listed low back pain patients with and without radiculopathy. Prognostic factors influencing pain and disability.

BACKGROUND CONTEXT: Previous research has documented various psychosocial risk factors with influence on outcome in low back pain (LBP) patients, but the value of clinical predictors has been less well documented. PURPOSE: To identify clinical and psychosocial risk factors at baseline influencing disability and pain at 1 year in LBP patients sick-listed 3 to 16 weeks, and to look for differences between nonspecific LBP and radiculopathy. STUDY DESIGN: Cohort study with 1-year follow-up based on a randomized clinical trial. OUTCOME MEASURES: Disability and change of disability, pain and change in pain at 1 year. METHODS: In a randomized clinical study evaluating multidisciplinary versus brief intervention, 325 patients were followed for 1 year. At baseline, they completed a questionnaire and went through a clinical low back examination, including measure of forward flexion and side flexion as well as tender point examination, a method to estimate diffuse tenderness. Furthermore, degenerative changes on plain X-rays of the lumbar spine were quantified, and sciatica was investigated by magnetic resonance imaging. RESULTS: Radiculopathy was verified by magnetic resonance imaging in 111 (34%) patients. At 1 year, questions of disability in daily life activities and pain were answered by 60% and 67%, respectively. The intensity of back+leg pain and disability was closely correlated. Statistically significant predictors for both disability and back+leg pain at 1 year were intensity of back+leg pain, worrying and health anxiety, many tender points, and little or moderate exercise in leisure time. Two additional risk factors were identified in patients with radiculopathy: older age and "drinking alcohol less than once per month." Furthermore, disability at 1 year was associated with initial disability and compensation claim, and back+leg pain at 1 year was associated with fear avoidance about physical activity and the duration of pain. Change in disability was more closely associated with return to work than change in pain. Disc degeneration was not associated with disability or pain at 1 year. General health was not statistically significantly associated with outcome when adjusted for back+leg pain, disability, and worrying and health anxiety. CONCLUSIONS: Disability and pain at 1 year were associated with baseline disability and pain, diffuse tenderness, worrying and health anxiety, compensation claim, fear avoidance, and baseline exercise habits. Only in patients with verified nerve root affection, older age, and restrained alcohol seemed to play a role. The multivariate models were insufficient in predicting disability and pain, partly because disability and pain were also strongly associated with return to work.

Low back pain may be caused by disturbed pain regulation: a cross-sectional study in low back pain patients using tender point examination.

BACKGROUND: Widespread pain has negative influence on outcome in low back pain (LBP) patients. Tender point (TP) examination is a standardized examination method to estimate diffuse tenderness. AIMS: To assess diffuse tenderness by means of a standardized TP examination and to analyse for associations between the number of TPs and spinal structural changes as well as psycho-social factors. METHODS: Patients sick-listed 3-16 weeks due to LBP with or without sciatica completed a questionnaire and went through a clinical low back examination and TP examination. Of 326 patients 111 had verified nerve root affection and 215 had non-specific LBP with or without radiating pain. Disc height reductions were estimated on lateral X-rays. RESULTS: Multivariate logistic regression analysis showed that more than 8 TPs were strongly negatively associated with disc degeneration (Odds Ratio (OR) 0.58 (0.40-84), 95% Confidence Interval (CI): 0.39-0.84, p=0.004) and verified nerve root affection (OR 0.15 (0.04-0.54), p=0.004) and were positively associated with number of years since first episode of LBP (OR 1.05, CI: 1.01-1.09, p=0.009). Furthermore, more than 8 TPs were positively associated with widespread pain, female sex and bodily distress. With all patients included, bodily distress and the number of tender points were positively associated with the intensity of LBP, but disc degeneration was only positively associated with LBP in patients with less than 6 TPs. CONCLUSIONS: The pain in patients with diffuse tenderness was rarely related to disc degeneration or nerve root affection, rather it may be caused by disturbed pain regulation.