Work health determinants in employees without sickness absence.

BACKGROUND: Working ability is known to be related to good physical condition, clear work tasks, positive feedback and other occupational, organizational and psychosocial factors. In Sweden, high levels of sickness absence are due to stress-related disorders and musculoskeletal pain. AIMS: To identify work health characteristics in a working population with a large variety of professional skills and occupational tasks. METHODS: Employers' data on occupation, sickness absence, age and gender in a working population of 11 occupational groups and questionnaire responses regarding work-organization, environment, work stress, pain, health, and socio-demographic factors were collected. Employees with no history of sick-leave were compared with those with a history of sick-leave (1-182 days, mean 25 days). RESULTS: Of 2641 employees, 1961 participated. Those with no history of sick-leave reported less work-related pain, work-related stress, sleep disturbances, worry about their health, 'sick-presenteeism', monotonous work, bent and twisted working positions and exposure to disturbing noise than those with a history of sick-leave (P < 0.001). They also reported better health, support from superiors, having influence on their working hours and evening and week-end working, longer working hours per week (P < 0.001) and more regular physical training (P < 0.01). Socio-demographic factors were less important than gender, and differences in responses between occupational groups were also found. CONCLUSIONS: Workers without a history of sick-leave experienced less stress, sleep disturbances, worry about their own health and less neck, shoulder and back pain and more support from their superiors and influence on their working hours.

Hyperbaric oxygen in the treatment of postoperative infections in paediatric patients with neuromuscular spine deformity.

The aim of this study is to evaluate possible benefits of hyperbaric oxygen (HBO) therapy in the treatment of deep postoperative infections in six high risk paediatric patients with neuromuscular spine deformity. The study involved review of medical records including radiology, office visits, and telephone contacts for six patients, referred for postoperative HBO therapy in 2003-2005. Infection control and healing without removal of implants or major revision surgery with a minimum of 2-year follow-up after index surgery were considered to represent success. All infections were resolved. Median time for wound healing, normalisation of blood tests and antibiotic weaning were 3 months. Radiological bony fusion, intact implants without any signs of radiolucent zones were seen in all cases at a mean follow-up of 54 months (37-72). Side effects of HBO treatment were minor. HBO is a safe and potentially useful adjuvance in the treatment of early deep postoperative infections in complex situations with spinal implants in high risk paediatric patients.

Clinical evaluation of seating in persons with complete thoracic spinal cord injury.

STUDY DESIGN: Consecutive male patients studied with photographic measurement of a combination of clinical methods. OBJECTIVES: To describe seating in individuals with complete thoracic spinal cord injury (SCI) by using a combination of clinical methods. SETTING: Spinalis SCI unit, Stockholm, Sweden. METHODS: Wheelchair specifications were documented. Measurements of posture from photographs in 30 male subjects with complete thoracic SCI, sitting in a relaxed and an upright position on a standardized surface and in a wheelchair were calculated. A comparison was made between positions and seating surfaces. An examiner's classification of lower trunk position in wheelchair was compared to subjects' evaluations. SCI subjects reported sitting support, satisfaction, and wishes for improvement. RESULTS: Most SCI subjects used similar wheelchair specifications. None of the backrests were custom designed. Relatively small differences were found between the relaxed and upright position in the wheelchair regarding measurements of posture and according to the examiner's classification of the lower trunk position. Only 13/30 SCI subjects were sitting with the lower trunk centered relative to the backrest in the upright position. The examiner's classification and the subjects' evaluation of asymmetric sitting were not always in agreement. Only 12/30 SCI subjects were satisfied with their way of sitting. CONCLUSION: Current wheelchair specifications and adjustments seem to inhibit a postural correction towards upright sitting and fail to provide sufficient lateral support. Findings indicate an inability for SCI subjects to vary their sitting position in a wheelchair to a large extent. Both an examiner's classification and subjects' evaluation of asymmetric sitting are necessary to obtain a sufficient knowledge base for subsequent adjustment. By using methods regarding different aspects of seating, a more comprehensive view of seating was achieved. The combination of clinical methods seems to be useful in order to describe seating in individuals with complete thoracic SCI.

Upper body movement during walking in children with lumbo-sacral myelomeningocele.

Eight children with lumbo-sacral myelomeningocele (MMC) underwent three-dimensional movement analysis to determine whether or not differing levels of lower extremity strength affected the extent of shoulder, trunk and pelvis movement during independent walking when wearing orthoses. Fourteen control children were also investigated. The patterns of upper body movements in all MMC children were well defined and consistent, showing small standard deviations from the mean. In the frontal and transverse planes, segment displacements of the MMC children assigned into Group II (hip extensor and abductor muscle strength grade 0-2) were almost twice that of the MMC children in Group I (hip extensor and abductor muscle strength grade 3-4). All segment displacements in the frontal, transverse and sagittal planes for Group I and Group II children were significantly greater than those for the controls. In the frontal plane these differences were approximately 4-10 times greater, with the Group II children having the largest peak-to-peak displacements. These results indicate that the motion amplitudes of the upper body segments are related to the degree of muscle weakness of the lower limbs. No significant differences were found when comparing segment motions during walking with either the Ferrari type knee-ankle-foot or ankle-foot orthoses.

Heart rate and walking velocity during independent walking in children with low and midlumbar myelomeningocele.

PURPOSE: The purpose of this study was to examine the heart rate and walking velocity of children with low and midlumbar myelomeningocele (MMC) using two types of orthoses. METHODS: Eight children with low and midlumbar myelomeningocele (mean age = 10.7 years) participated in the study. A clinical examination of muscle strength in the lower limbs was performed, and level of functional ambulation was defined. Weight and height were documented, and body mass index was calculated. Heart rate was recorded by a transmitter detecting heart beats, and walking time was registered as the children walked as far as possible along a straight corridor of 102 meters at a self-selected velocity. Two orthosis types were tested, each three times. RESULTS: All children showed higher heart rate than peers who were nondisabled. No steady-state heart rate level that could be used as a basis for calculating physiological cost index was achieved in any subject. In this study group, no difference was seen in heart rate trends with respect to the two tested orthoses. The children who were household ambulators, all with weaker hip abductors and hip extensors, walked with lower velocity than those who were community ambulators (all with stronger hip muscles). The children in the former group also walked significantly shorter distances, however, with similar heart rate. CONCLUSIONS: Pausing when the heart rate reaches a strenuous activity level is interpreted as a solution to maintain functional walking by keeping the heart rate and thus the energy expenditure at a comfortable level.

Factors influencing ambulation in myelomeningocele: a cross-sectional study.

A consecutive series of 53 children with myelomeningocele (mean age 7.6, range 3.2 to 11.4 years) was assessed in order to see if the children with motor paresis of the lower limbs achieved the expected level of ambulation, and if not, to identify possible causative factors. Methods used were clinical examination of orthopaedic and neurological status, information from medical reports, and documentation of orthoses use. Functional skills were documented and energy expenditure was examined. Thirty-one of 53 children had reached the expected ambulation considered possible according to their motor paresis, whereas 22 of the 53 performed worse than expected. Balance disturbances, occurrence of spasticity in knee and hip joints, and number of shunt revisions made differed significantly between the groups that achieved and did not achieve expected ambulation. Functional skills of mobility differed significantly between two muscle-function levels in children who had walking ability. Energy expenditure was higher in the non-achieving group than in the group who achieved expected ambulation in each of the muscle-function levels. Results show that children with similar muscle paresis exhibit different ambulatory function. This indicates the importance of a close analysis of other factors which may cause ambulation to deteriorate in order to predict future ambulation in children with myelomeningocele.

Does bracing affect self-image? A prospective study on 54 patients with adolescent idiopathic scoliosis.

To evaluate the effect of brace treatment on self-image in patients with adolescent idiopathic scoliosis, 54 consecutive patients admitted for brace treatment were interviewed before bracing. A prevalidated questionnaire including the following five aspects of self-image was used: (1) body-image, (2) self-perception of skills and talents, (3) emotional well-being, (4) relations with family, and (5) relations with others. As a control group, the answers of 3465 normal school children were used. Forty-six patients participated in a follow-up interview 1.7 (range 0.8-3.0) years later. In addition, during the first interview, the scoliosis patients answered selected questions about their social circumstances and attitudes towards their forthcoming brace treatment. Grossly, the patient group lived in stable family conditions with a high percentage (40%) of fathers and/or mothers with an academic education or with a high employee status. The patients' relations with families were generally good. Nearly all believed that the brace would affect their posture, but only a few thought that wearing the brace would influence their growth. Two-thirds believed that it would be difficult to wear the brace, and often reflected on the use of it. There were no statistically significant differences between the scoliosis patients and the age-matched controls at the pre-bracing nor at the follow-up interviews. Neither were there any statistically significant differences between the answers of the scoliosis patients in the pre-bracing and follow-up interviews. This was valid for the total score as well as for each subscale item score. It is concluded that wearing the brace does not affect the self-image of adolescents with idiopathic scoliosis negatively.

Brace treatment in neuromuscular spine deformity.

We reviewed 90 consecutive patients with various neuromuscular diseases and a progressive spine deformity treated with a prefabricated Boston-type underarm corrective brace. Of these, 38 patients had spastic tetraplegia; seven, syndrome-related muscular hypertonia; 24, muscular hypotonia; and 21, myelomeningocele. The mean age at the treatment start was 9.2 years (range, 1.4-17.7 years). Twenty-four were ambulating and 66 wheelchair-bound. Hypotonia was the dominant type of muscle involvement in 49, spasticity in 28, and athetosis in 13 patients. The mean pretreatment Cobb angle was 47 degrees, with a range from 23 to 95 degrees. The mean brace-induced Cobb-angle correction was 60%, thus well comparable to that in idiopathic scoliosis. However, this did not predict favorable treatment results. At the follow-up, on average 3.1 years (range, 1-5.5 years) after weaning from the brace, the brace treatment was successful in 23 patients. Successful was defined as <10 degrees curve progression during the observation time and a good brace compliance. Forty-one patients discontinued the brace treatment, and 19 progressed despite adequate brace wear. Five patients are still in treatment, and two have died. Successful treatment was seen in ambulating patients with muscle hypotonia and short thoracolumbar/lumbar curves measuring <40 degrees as well as in nonambulating patients with spastic short lumbar curves. These types of neuromuscular scoliosis may be the only ones to respond to brace treatment. In other cases, the brace treatment cannot be expected to have a lasting corrective effect although it can be used as sitting support.

Ambulation in patients with myelomeningocele: a 12-year follow-up.

Factors determining change in ambulatory status were studied over a 12-year observation time in 60 ambulating patients with myelomeningocele. There were 26 female and 34 male subjects with a median age of 22 years (range, 12-54). We used the method of Lindseth to define the neurologic level of the lesion and classified walking ability according to the criteria of Hoffer. The prevalence of spasticity and spine and lower-limb deformities was assessed. Orthopedic and neurosurgical interventions and other medical events were registered, as well as occurrence of pressure sores, musculoskeletal pain, and use of orthoses. There were 19 patients with downward transitions in ambulatory level during the follow-up time. Factors explaining deterioration in these 19 patients included deterioration of the neurologic level of lesion, spasticity, knee and hip flexion contractures, low-back pain, lack of motivation, as well as those of major medical events like stroke, recurrent septicemia, lower limb edema, and invasive surgical interventions.

Comparison of different systems to classify the neurological level of lesion in patients with myelomeningocele.

In 73 patients with myelomeningocele (mean 17.2 years, range 5 to 40 years) the classification of level of lesion was studied according to six commonly used classification systems and to the ambulation groups of Hoffer. The distribution of the patients into classes of thoracic-level lesions was the same for four classification systems in 10 patients and for two classification systems into categories of level L3 in 14 patients. For the other patients discrepancies occurred between systems for lesions of level L3 and downward. None of the patients was consistently categorized in the functional ambulation groups of Hoffer using all classification systems. The results show that it is not possible to compare neurological lesion levels classified according to the different systems described in this study and consequently that the distribution into the functional ambulation groups of Hoffer varies. To enhance communication and facilitate comparing the results of treatment we suggest using some basic criteria for patient documentation.

Boston brace in the treatment of idiopathic scoliosis.

In a retrospective follow-up study of 64 patients with adolescent idiopathic scoliosis, the initial correction of Boston brace with straight lumbar profile strongly predicted good treatment results at follow-up (mean, 4.8 years). If the initial correction was > 50%, the curve was permanently reduced with an average of 7.2 degrees. The average initial correction was 62%. This initial brace effect was preserved in another comparable group of 60 patients treated with a Boston brace with 15 degrees lumbar lordosis. It is concluded that the Boston brace is effective in the conservative treatment of idiopathic scoliosis, and the corrective ability seemingly does not deteriorate with a change in the brace design from 0 to 15 degrees lordosis.

Physical and psychological workload in men with and without low back pain.

Current and retrospective physical and psychological workload was studied in 148 mean, 45-55 years old. The men represented three groups with respect to low back health status: Healthy low back (Group 1, n = 36), intermittent low back pain (LBP) (Group 2, n = 91) and chronic LBP (Group 3, n = 21). The methods used were a self administered questionnaire, a rating scale of perceived exertion, and blind expert assessment built on a classification of job titles. Group 1, the back-healthy subjects, had been less exposed to heavy physical work than subjects with intermittent LBP (Group 2) and chronic LBP subjects (Group 3) through their whole working-career and in their present work (p < or = 0.05, p < or = 0.01). Group 2 tended to be significantly less exposed in their present work than Group 3 (p < or = 0.06). Non-neutral working postures were reported more often in Groups 2 and 3 than in Group 1 (p < or = 0.05, p < or = 0.001). Both groups 2 and 3 perceived present and earlier work to be more strenuous than Group 1, with respect to the low back (p < or = 0.000). Subjects in the healthy low-back group had lower values in the qualitative demand index ("too difficult working tasks" and "too great responsibility") than subjects in Groups 2 and 3 (p < or = 0.01). This study indicates that more attention should be given to the individual's perception of physical workload.

Body composition, endurance, strength, cross-sectional area, and density of MM erector spinae in men with and without low back pain.

Thirty-six 45-55-year-old men with healthy low backs were studied with respect to body composition, isokinetic and isometric trunk strength, trunk muscle endurance, and cross-sectional area and radiological density of mm erector spinae. Results were compared to those of men in the same age group with intermittent low back pain (LBP) (n = 91) and with chronic LBP (n = 21). The back healthy group was significantly stronger and had longer trunk muscle endurance times than men with chronic LBP. Men with intermittent LBP had strength and endurance values in between the back healthy and chronic groups. There were no significant differences between any of the groups with respect to body composition and cross-sectional area of mm erector spinae. Radiological density for mm erector spinae was significantly decreased in the chronic LBP group compared to the back healthy and intermittent LBP groups. The deconditioning syndrome and its relationship to intermittent and chronic LBP is discussed.

Anterior fusion insufficient for scoliosis in myelomeningocele. 8 children 2-6 years after the Zielke operation.

8 children with a mean age of 13 years with paralytic scoliosis due to myelomeningocele (MMC) were operated on according to Zielke with anterior fusion and instrumentation. There were no infections. All fusions healed. The postoperative mean follow-up was 4 years. The average correction of the primary curve was 62 degrees. In 5 cases proximal curve progression required reoperation; posterior fusion with Harrington rods was also done. Our last 2 patients, primarily operated on with both an anterior and posterior fusion, had no postoperative progression. Anterior fusion according to Zielke as the only procedure cannot be recommended in the treatment of severe paralytic scoliosis due to MMC. We advise a combined anterior and posterior approach in these cases.

Spondylolysis and spondylolisthesis.

Lysis is common and its causes are mainly constitutional. Most of slipping has already occurred when the patient comes for consultation. A further progress is often caused by disc pathology. Neurological deficits are rare. A high-degree olisthesis and L4 location are risk factors for future back pain. Asymptomatic lysis with or without olisthesis should not be treated. A posterolateral fusion in situ without instrumentation gives good results in adolescents and young adults, whereas old patients benefit from instrumentation. Reduction cannot be recommended as a routine method.

Anthropometry, spinal canal width, and flexibility of the spine and hamstring muscles in 45-55-year-old men with and without low back pain.

One hundred fifty 45-55-year-old men were divided into three groups: those with healthy backs, recurrent low back pain (LBP), and chronic LBP. These groups were studied with respect to anthropometry, spinal canal width, spinal sagittal configuration and flexibility, and the flexibility of the hamstrings musculature with straight leg raising (SLR). There were no differences between the groups with respect to anthropometry. The group with healthy backs had significantly greater lordosis and sagittal flexibility than the other groups. The width of the spinal canal was correlated to body height. The SLR test showed significantly higher values in the group with healthy backs and in the recurrent pain group than in the chronic pain group. The possible role of restoring normal range of motion to minimize the risk of LBP recurrence is discussed.

Vertebral resection and fusion for paralytic kyphosis. 9 patients followed up for 6 (2-14) years.

Nine patients with a thoracolumbar, progressing, paralytic kyphosis, pressure sores from gibbus, an inability to lie on the back, and deterioration of the sitting balance were operated on with resection of two to three vertebrae and a thoracolumbar fusion. One child died from intracranial bleeding caused by a halo screw. There were no implant loosenings or non-unions. Pressure sores healed, sitting improved, and lying on the back became possible. A mild scoliosis above the fusion level developed in 2 patients, but neither of them needed any treatment.

Long-term clinical and radiological follow-up of spondylolysis and spondylolisthesis.

A clinical and radiological follow-up study with at least 20 years of observation was made of 255 spondylolysis and spondylolisthesis patients for examination of the clinical course and its possible correlation to radiographic findings. The progression of slipping was small and not correlated to age at diagnosis and initial degree of spondylolisthesis. Disc height reduction at the spondylolytic level occurred at an earlier age and was more severe than in a normal control group. Symptoms were correlated to radiographic pathology. Risk factors for low-back symptoms were greater than 25% slipping, low lumbar index in L5 spondylolysis, spondylolysis at the L4 level, and early disc degeneration.

Bone and joint pathology in workers using hand-held vibrating tools. An overview.

A literature evaluation was made with regard to the radiological documentation of bone and joint pathology in the hands and arms of workers using vibrating tools. There is evidence that work with pneumatic percussive tools (such as chipping hammers and scalers) may cause premature elbow and wrist osteoarthrosis, although of very low prevalence. This work-related disorder is not specific to vibration exposure. Instead, it is likely to result from the strong dynamic and static joint loading (often in extreme positions of the joint) and the repetitive hand-arm movements (sometimes also repeated minor traumatization) typical for tool manipulation in any heavy labor. Exposure to low-frequency percussion may, however, play a particular etiologic role: damage to the joint cartilage by repeated shocks from the tool, additional articular load (and consequent strain) associated with a vibration-induced increase in the need for joint stabilization and higher gripping forces, the tonic vibration reflex (which increases muscle contraction), and a stronger grip induced when tactile sensibility is diminished by vibration. So far, no investigations have ventured into the great complexity of possible confounders and effect modifiers. -A constitutional susceptibility may be required to produce osteoarthrosis. -The allegation that hand-arm vibration exposure causes an excess prevalence of bone cysts, vacuoles, Kienböck's disease, or pseudarthrosis of the scaphoid has not been validly documented. -Exposure to vibration of higher frequencies (such as from rotating drills, grinders, and chain saws) does not seem to be associated with excess bone and joint pathology. -The observed large variation in the prevalence of skeletal disorders may be explained by biodynamic and ergonomic differences between various occupations.