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U N I V E R S I T Y O F C O P E N H A G E N
F A C U L T Y O F H E A L T H A N D M E D I C A L S C I E N C E S
PhD Thesis
By Pernille Frederiksen
Deciding to work in spite of back pain
-what makes a difference?
Supervisors: Tom Bendix & Aage Indahl
Submitted on the December 5th 2017
This thesis has been submitted to the Graduate School of Health and Medical Sciences, University of Copenhagen December 5th 2017. Graduate School of Health and Medical Sciences Institute: Department of Public Health Department: Copenhagen Centre for Back Research (COPE BACK), Centre for Rheumatology and Spine Diseases, Rigshospitalet Glostrup Author: Pernille Frederiksen Title and subtitle: Deciding to work in spite of back pain – what makes a difference? Submitted on: December 5th 2017 Supervisors: Professor Emeritus, MD Tom Bendix, Copenhagen Centre for Back Research (COPE BACK), Centre for Rheumatology and Spine Diseases, Rigshospitalet Glostrup, København Professor, PhD Aage Indahl, Department of Research and Development, Clinic Physical Medicine and Rehabilitation, Vestfold Hospital Trust, Stavern, Norway
”To be well is not to avoid backache;
it is to have the
wherewithal to cope with it
effectively and repeatedly.”
Nortin M. Hadler
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List of contents
Preface ........................................................................................................................................... 4
Acknowledgements ...................................................................................................................... 7
Original Papers ............................................................................................................................. 9
Study I: ....................................................................................................................................... 9
Study II: ...................................................................................................................................... 9
Study III: ..................................................................................................................................... 9
Abbreviations & definition of key notions ................................................................................. 10
1. Short English summary .......................................................................................................... 11
2. Kort dansk resumé.................................................................................................................. 13
3. Introduction ............................................................................................................................. 15
3.1. Pain-related work disability ............................................................................................. 15
3.2. Patho-anatomy ................................................................................................................. 16
3.3. Physical loads .................................................................................................................. 16
3.4. Classical Treatments and frequently used interventions .............................................. 17
3.4.1. Medicine and injection therapy ................................................................................. 17
3.4.2. Surgery ....................................................................................................................... 18
3.4.3. Exercise ...................................................................................................................... 18
3.4.4. Continuing normal activity ........................................................................................ 18
3.4.5. Ergonomic interventions ........................................................................................... 19
3.4.6. Education ................................................................................................................... 19
3.5. Multidisciplinary versus simple interventions for work disability ................................ 20
3.6. Population-based studies testing information-based interventions ............................. 22
3.7. The social and contextual factors and work disability .................................................. 22
3.8. Individual or ’whole-systems’ approach ......................................................................... 23
4. Aim ........................................................................................................................................... 24
4.1. Overall aim ........................................................................................................................ 24
4.2. The specific aims .............................................................................................................. 24
5. The studies in this thesis ....................................................................................................... 25
5.1. Study I ............................................................................................................................... 25
5.1.1. Publication.................................................................................................................. 25
5.1.2. Aim .............................................................................................................................. 25
5.1.3. Design ......................................................................................................................... 25
5.1.4. Sample and recruitment ............................................................................................ 25
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5.1.5. Inclusion and Exclusion criteria ............................................................................... 26
5.1.6. The intervention ......................................................................................................... 26
5.1.7. Data collection and outcomes ................................................................................... 27
5.1.8. Data analyses ............................................................................................................. 29
5.1.9. Results ........................................................................................................................ 30
5.2. Study II .............................................................................................................................. 36
5.2.1. Publication.................................................................................................................. 36
5.2.2. Aim .............................................................................................................................. 36
5.2.3. Design ......................................................................................................................... 36
5.2.4. Sample ........................................................................................................................ 36
5.2.5. Data collection ........................................................................................................... 37
5.2.5. Results ........................................................................................................................ 38
5.3. Study III ............................................................................................................................. 42
5.3.1. Publication.................................................................................................................. 42
5.3.2. Aim .............................................................................................................................. 42
5.3.3. Design ......................................................................................................................... 42
5.3.4. Defining the ‘Black Flags’ .......................................................................................... 42
5.3.5. Selection of Black Flags for the present study ........................................................ 42
5.3.6. Literature search ........................................................................................................ 43
5.3.7. Selection of relevant records and subtraction of evidence .................................... 44
5.3.8. Results ........................................................................................................................ 46
6. Discussion ............................................................................................................................... 50
6.1. The findings in Study I ..................................................................................................... 50
6.1.1. Strengths and limitations .......................................................................................... 54
6.1.2. Comparing the results of the thesis-studies ............................................................ 55
6.2. The findings in Study II .................................................................................................... 57
6.2.1. Limitations of the study ............................................................................................. 61
6.2.2. Comparing with the results from Study III ................................................................ 61
6.3. The findings in Study III ................................................................................................... 61
6.3.1. Limitations of the study ............................................................................................. 64
6.4. General discussion based on the results of the present thesis .................................... 64
6.4.1. Multiple/multidisciplinary versus simple interventions ........................................... 65
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6.4.2. Individual versus ‘whole-systems’ approach ........................................................... 66
7. Conclusion .............................................................................................................................. 68
8. Future perspectives ................................................................................................................ 69
9. References .............................................................................................................................. 71
Appendix 1-5 Published studies I-III
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Preface
This work presented in this PhD thesis was conducted from 2011-2016 at the Centre for
Rheumatology and Spine Diseases, Rigshopitalet Glostrup, and at Metropolitan University
College. Rigshospitalet Glostrup, The Danish Working Environment Research Fund
(Arbejdsmiljøforskningsfonden), and The Danish Rheumatism Association
(Gigtforeningen) funded the projects.
Important collaborators in the making of the studies, apart from my two supervisors,
were Kim Burton (Huddersfield University), Lars L. Andersen (National Research Centre
for the Working Environment), Serena Bartys (Huddersfield University), and the
management and employees in the five participating municipalities in two of three studies
(København, Roskilde, Høje-Taastrup, Gentofte, Lyngby-Taarbæk).
To help the reader understand how the thesis was created the following aim to explain
the process of its planning. As opposed to many PhDs, the present PhD does not consist
of highly related studies in terms of their objectives, target group, or methodology. This
was due to the fact that two of the studies were ‘born’ along the way as I identified gaps in
the existing empirical literature based on conversations with experienced researchers. The
three studies in this thesis are connected conceptually in the sense that they relate to
factors of the dominant bio-psychosocial approach. Moreover, they share overall focus: to
investigate factors influencing work participation in people suffering from back pain.
The first study I initiated was an experimental study with the purpose of adding evidence
to the ‘functional-disturbance’-model. The model was suggested by Aage Indahl from
University of Bergen (Norway) in 1999 in his PhD thesis and provides a theoretical
biological explanation to LBP, which, in the absence of identifiable pathology in most
cases of LBP, serves as an alternative to ‘no explanation’. Evidence from studies, which
had included information on the model along with other intervention elements, had
generally produced marked reductions in days of sickness absence among people with
LBP. I got to know Aage Indahl and his work through Tom Bendix, and my PhD was
initiated with the purpose of conducting a study using his model. Aage had shared the
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preliminary results from an ongoing study with Tom and me with the purpose of planning a
new study in cooperation. The results of the ongoing study indicated that group-based
information including information on the model might hold potential as an effective
intervention to reduce work disability; a highly simple one, which seemed easily
implementable as well. Thus, this constituted the first study in my PhD, which became an
experimental study (randomized controlled trial (RCT)) investigating the effect of guideline-
based information and information on the ‘functional-disturbance’-model on LBP-related
beliefs and behaviour.
The idea for the second and third study in the thesis came from a need to add further
information to the overall picture that I saw when doing the first study. Specifically, the
second study was formed during talks with Aage Indahl and during a visit at the research
unit Uni Helse in Bergen, which conducts studies in cooperation with Aage. Initially, the
objective of the study was to explore what was helpful in the information provided in my
experimental study – from the participants’ perspective. However, because the objective of
the study was conditional on the memory of the in terms of being able to recollect the
content of the information in detail up to a year after receiving it; it seemed risky to depend
on that objective alone. Thus, I decided to expand the objective. Literature searches
showed that evidence on factors important for work participation (when defined ad working
despite LBP) was underrepresented. Pursuing that seemed relevant and interesting to me.
Furthermore, I was curious to find out what – from a worker perspective – was influencing
the decision to stay home from work due to back pain with the multifactorial nature of back
pain and related behaviour in mind. Thus, my second study became a qualitative interview
study, which explored 1) the worker perspective on the factors influential on the ability to
work despite back pain and 2) the worker perspective on the decision to call in sick due to
back pain, and 3) the participant perspective on the experience of the talks in the prior
RCT.
During the planning of the RCT study, I had become acquainted with Kim Burton from
Huddersfield University (UK) through Tom. Kim took part in discussions concerning the
choice of outcomes because he was one of the creators behind The Back Beliefs
Questionnaire, which I was going to use. Furthermore, he took part in the discussions of
the overall design of the study being experienced in the field of low back pain and simple
information-based interventions. He has also contributed to the making of the ‘The
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Psychosocial Flags Framework’ used to identify psychosocial obstacles for work
participation following a pain episode. While talking to him, I learned that whereas the
suggested psychological and work-related factors (termed ‘Yellow Flags’ and ‘Blue Flags’,
respectively) believed to influence work participation had been thoroughly reviewed, the
contextual factors (termed ‘Black Flags’) had not. Thus, I decided to make the first attempt
to review some of the most explored suggested Black Flags – in cooperation with Kim. The
third study constituted a review of three suggested Black Flags: compensatory systems,
healthcare systems, and family systems.
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Acknowledgements
I am most grateful to the department at Rigshospitalet Glostrup, where I have worked
during most of the time while working on my studies: Centre for Rheumatology and Spine
Diseases. Thank you for giving me the opportunity to conduct the studies by providing me
with finances and office facilities. Also thank you to Metropolitan University College and my
current workplace: Health Centre Nørrebro (The Back Centre) for offering me the time and
support to finish my PhD studies.
The work was made possible due to a number of persons. First, I wish to express my
sincere thanks my supervisors. My principal supervisor Tom Bendix, who enthusiastically
encouraged me to start this project and with whom, I have shared many hours during the
past 7 years discussing, thinking, talking, and laughing. Tom, thank you so much for your
gentle and caring nature, your great trust in me, your humour, patience, and willingness to
share your great knowledge on back pain and on the profession of research in general. I
also owe sincere thanks to my co-supervisor Aage Indahl. Aage, you are the mastermind
behind the core ideas of the ‘functional disturbance- model’ and you have altered my entire
basic understanding of back pain management and of the role of the healthcare
professional. Your enthusiasm and your ideas, which break away from traditional thinking
is extremely inspiring!
Another important person, to whom I owe great thanks, is Kim Burton. Kim, apart from
offering useful advice for my experimental study, you also took on the job to help me with
my review because, “it could be great fun” you said. That sentence says a lot about you in
fact and you genuinely impress me with your experience, openness, great sense of
humour, professional passion, and your humble approach to research as well as to the
people you work with. I am amazed that you, with your kind of experience, amount of
knowledge, and workload would take the time to help me with my studies. I am very
grateful that you showed me your trust and that you considered your participation in my
studies worthwhile to you. Thank you so so much for all your help and for the many fun
correspondences along the way.
Furthermore, I would like to thank Mette Marie Vad Karsten, who took on the job of
assisting me with the qualitative study. Thank you so much for many hours of talking, hard
work, and discussion as well as for opening the world of Anthropology to me. You have
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been enthusiastic, dedicated, competent, and great fun to work with. I know you will bring
good things to the field of Anthropology in the future. Good luck on your PhD!
I also feel urge to thank Serena Bartys, who took on the task of leading the creation of
the paper based on my third study at a time when it was not possible for me to do so.
Serena, you added your valuable experience from the field to the work and managed to do
so while showing great respect for and loyalty to my original work. Thank you – your work
on our paper is highly appreciated! I hope we can continue working together in the future.
Thanks to Nina Beier for assisting me with the data keying in the experimental study, to
Sebastian Werngreen Nielsen for your help with the English wording and grammar in my
papers, and to Rasmus Hertzum-Larsen for assisting with the statistics in the experimental
study. I would also like to thank the participating municipalities and employees in the
experimental and qualitative studies for trusting me with their time and making the effort to
contribute to back pain research.
Finally, I would like to convey my deepest gratitude to my Christian - for your loving
support in this process as in everything else.
Pernille Frederiksen, Copenhagen, December 2017
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Original Papers
Study I:
Frederiksen P, Indahl A, Andersen LL, Burton K, Hertzum-Larsen R, Bendix T. Can group-
based reassuring information alter low back pain behavior? A cluster-randomized
controlled trial. Published in: PLoS ONE. 2017; 12(3):e0172003.
Study II:
Frederiksen P, Karsten MMV, Indahl A, Bendix T. What Challenges Manual Workers’
Ability to Cope with Back Pain at Work, and What Influences Their Decision to Call in
Sick? Published in: J Occup Rehabil. 2015 Dec;25(4):707-16.
Study III:
Bartys S, Frederiksen P, Bendix T, Burton K. System influences on work disability due to
low back pain: An international evidence synthesis. Published in: Health Policy. 2017
Aug;121(8):903-12.
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Abbreviations & definition of key notions
Abbreviations:
LBP – low back pain
RCT – randomized controlled trial
C-RCT – cluster-randomized controlled trial
SMS – short text message
The key notions and their definitions – in the present thesis:
Work disability: reduced work ability involving days of absence from work
Absenteeism: days of sickness absence
Work participation: coming to work during or following a pain episode
Staying at work or presenteeism: working despite pain
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1. Short English summary
Low back pain (LBP) is usually benign and self-liming. Nonetheless, it is one of the most
disabling conditions in the Western societies involving enormous human and societal costs
e.g. due to high sickness absence rates. Without a complete understanding of the patho-
anatomy behind LBP, the bio-medical paradigm has failed to help people with LBP. With
the introduction of the bio-psychosocial paradigm, clinicians and researchers have become
increasingly aware of the influence from the psychological and social factors on the course
of LBP. However, with LBP being multifactorial and the pain experience highly subjective
and personal, there are still several gaps in the existing knowledge in terms of finding
ways to help people continue their lives despite LBP. The present thesis help fill some of
these gaps by add to knowledge on whether, and to some extent how, selected elements
of the biopsychosocial model influence LBP-related behaviour, with specific emphasis on
occupational outcomes.
Three studies with varying methodology but conceptually similar and with work
participation as main outcome were conducted. The first study was a cluster-randomized
controlled trial (C-RCT), which investigated the isolated effect of a particular kind of
reassuring information on LBP-behaviour outcomes and on back beliefs. Two group-based
talks (one hour each) constituted the intervention. The participants were publically
employed workers mainly with manual work, with and without LBP experience at baseline.
Follow-up was one year. The results indicated that the intervention significantly positively
influenced a range of behaviour-outcomes and back beliefs in the workers, who
experienced LBP in the follow-up year.
The second study explored the worker perspective on what challenges workers’ ability
to stay working during back pain episodes and what influenced their decision to call in sick
due to back pain through focus group interviews. The participants were workers from the
study-population from the prior C-RCT study. An additional aim of the study was to explore
the experience of the talks in the C-RCT. However, due to the prospects of lacking data,
the aim was abandoned at an early stage in the study. The results showed that a generally
poor physical working environment (lack of appropriate equipment and lack of working
space) and lack of trust/support from the supervisors (lack of adjustment latitude)
challenged work during pain episodes. The workers stated that they were more inclined to
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call in sick when they experienced high pain intensity, in times with job strain (high work
pace) in cases where they did not feel responsible to any close co-workers, and when a
spouse believed and expressed that it was not sensible to go to work. Contrarily, they
were more inclined to go to work despite pain at times with job strain when close co-
worker relationships involving mutual responsibility, when they experienced the sickness
absence practices as threatening/unpleasant, and if they were bored when staying home.
The results add to a sparse amount of evidence on what is important for staying at work
when suffering from musculoskeletal pain conditions and provide a worker perspective on
the factors suggested to influence work participation.
The third study added to the evidence of the Psychosocial Flags Framework, which list
potential or known obstacles for work participation on three levels: individual (termed
‘Yellow Flags’), workplace (termed ‘Blue Flags’), and context (termed ‘Black Flags’). The
study reviewed three suggested Black Flags selected for the study: compensatory
systems, healthcare professionals, and significant others. A best-evidence synthesis-
method was considered most appropriate due to the well-known limited amount of
scientific evidence on the field. The evidence synthesis indicated that all three have the
potential to act as Black Flags and gave suggestions on how. The review constitutes the
first review of some of the suggested Black Flags.
The overall results of the thesis underlined the relevance of including all three domains
of the bio-psychosocial model in the approach to back pain. Furthermore, the results add
to important ongoing discussions on how to address the enormous problem with LBP-
related work disability.
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2. Kort dansk resumé
Lænderygsmerter er typisk godartede og selv-begrænsende af natur. Ikke desto mindre er
det én af de tilstande, der involverer mest funktionstab I de vestlige lande, hvilket
indebærer store menneskelige og samfundsmæssige omkostninger bl.a. på grund af højt
sygefravær. En ufuldstændig forståelse af den pato-anatomiske baggrund for
lænderygsmerter har betydet, at det biomedicinske paradigme ikke har kunnet dæmme op
for problemet. Med introduktionen af det bio-psykosociale paradigme er klinikere og
forskere blevet tiltagende opmærksomme på indflydelsen fra de psykologiske og social
aspekter på forløbet af lænderygsmerter, men idet lænderygsmerter er multifaktorielle, og
smerteoplevelsen i høj grad subjektiv og individuelle, så er der stadig mange huller i vores
viden i forhold til at hjælpe folk til at leve deres liv på trods af smerterne. Den aktuelle
afhandling bidrager med viden om og i nogen grad, hvordan udvalgte faktorer fra den bio-
psykosociale model influerer på lænderygsmerte-relateret adfærd med særlig fokus på
arbejdsrelaterede udfald.
Tre studier med forskellig metodologi men med ens koncept og med arbejdsdeltagelse
som fælles primære parameter blev gennemført. Det første studie var et gruppe-
randomiseret kontrolleret forsøg, der undersøgte den isolerede effekt af en særlig slags
tryghedsskabende information på lænderygsmerte-relaterede adfærds-parametre samt på
holdninger til ryggen. To gruppe-baserede foredrag af en times varighed hver udgjorde
interventionen. Deltagerne var offentligt ansatte primært med manuelt arbejde med og
uden forudgående erfaring med lænderygsmerter. Opfølgningsperioden var på et år.
Resultaterne indikerede, at interventionen gav en statistisk signifikant ændring af en række
adfærdsparametrene samt på rygrelaterede holdninger blandt arbejdere, der oplevede
lænderygsmerter i løbet af opfølgningsåret.
Det andet studie udforskede manuelle arbejderes perspektiv på, hvad der vanskeliggør
det at arbejde med rygsmerter, samt hvad der influerer på beslutningen om at sygemelde
sig på grund af rygsmerter gennem fokusgruppe interviews. Arbejderne var deltagere i det
forudgående forsøgsstudie. Et supplerende formål var at undersøge, hvordan deltagerne
havde oplevet foredragene i forsøgs-studiet, men med udsigten til manglende data blev
formålet droppet tidligt i studiet. Resultaterne viste, at et dårligt fysisk arbejdsmiljø
(manglende udstyr og dårlige pladsforhold) samt manglende støtte/tillid fra ledelsen
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(manglende handlefrihed) vanskeliggjorde arbejdet i perioder med rygsmerter. I forhold til
beslutningen om at sygemelde sig, så var arbejderen mere tilbøjelig til dette ved høj
smerte-intensitet, i tider med travlhed når man ikke havde tætte kollegiale relationer, samt
når ægtefællen syntes/ gav udtryk for, at det ikke var en god idé at gå på arbejde.
Omvendt var arbejderne mere tilbøjelige til at gå på arbejde i travle perioder, når de
oplevede at have tætte relationer til kolleger, når de oplevede praksis omkring
sygemelding som ubehagelig og intimiderende, samt når de oplevede at kede sig ved at
blive hjemme. Resultaterne føjer til den ellers sparsomme evidens omhandlende det at
forblive i arbejde trods muskel-skelet-smerter og tilføjer et arbejder-perspektiv på de
faktorer, der er foreslåede at influere på arbejdsdeltagelse.
Det tredje studie tilføjede evidens til det psykosociale Flags Frameworks, der oplister
kendte og foreslåede forhindringer for arbejdsdeltagelse på 3 niveauer: individuelt (kaldet
”Gule Flag”), arbejdsplads (kaldet ”Blå Flag”), samt kontekst (kaldet ”Sorte Flag”). Studiet
udgjorde et oversigtsstudie over tre faktorer, der er foreslået som Sorte Flag:
kompensations-systemer, sundhedsprofessionelle og nære relationer (her defineret som
ægtefælle/familie). En ”best-evidence” syntese metode ansås for at være den mest
passende, da det er velkendt, at der findes meget sparsom litteratur på emnet. Syntesen
indikerede, at alle tre faktorer har potentiale til at udgøre Sorte Flag og evidens-kilderne
rummede tillige forslag til, hvordan faktorerne agerer som sådanne flag. Oversigts-studiet
udgør det første af sin art på Sorte Flag.
Overordnet set understreger resultaterne af nærværende afhandling relevansen af at
inkludere alle 3 domæner af den bio-psykosociale model i tilgangen til rygsmerter.
Ydermere, bidrager resultaterne til den vigtige igangværende diskussion omkring, hvordan
man bedst adresserer det enorme ryg-relaterede sygefravær.
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3. Introduction
Back pain is a highly common condition with pain from the lower back (LBP) being the
most frequently reported. In 2010, LBP was assessed as the most disabling (years lived
with disability) condition out of 291 sickness entities [1]. The lower back is also the region
of the spine, which has been mostly explored in the scientific literature, and the following
introduction will focus on LBP.
According to the European guidelines from 2004, LBP can be defined as pain and
discomfort, localised below the costal margin and above the inferior gluteal folds and it can
involve leg pain as well [2]. The point- prevalence of LBP ranges from 12% to 37% [3-5],
whereas the lifetime prevalence ranges from 40% to 85% [3, 5, 6] depending on if it
measured globally or in a high-income country. In about 85% of people suffering from LBP,
it cannot be attributed to any certain pathology or neurological encroachment [2]. This type
of LBP is generally referred to as ‘simple’ or ‘non-specific’ LBP as opposed to ‘specific’
LBP, which has the most identifiable pathology. The most often used duration-based
classification of LBP is: acute (<4 weeks), subacute (5-12 weeks), and chronic (>12
weeks). At a LBP episode, most people (app. 90%) recover within six weeks from pain
onset and most recover ‘naturally’ - without interventions [2]. It does not seem that
treatment influence recovery vastly [8, 9], but very recent results have indicated that
genetics may play a part in recovery [10]. More than half will experience LBP relapses,
though [11-13], and 2-7% develop chronic LBP [2].
3.1. Pain-related work disability
With its’ benign, often self-limiting nature, and relatively fast recovery-time in most cases,
simple LBP does not naturally involve a long-term course with related work disability (pain-
related work absence). Yet, a marked increase in LBP-related work disability was
witnessed during the 1970’s and 1980’s, which could not be explained biologically [14].
The increase stabilized at a high level in the 1990’s. The development was seemingly a
phenomenon of the modernized western societies - an observation, which led to a theory
deeming the LBP-related work disability being a culturally induced problem – a
‘communicational disease’. Specifically, it was theorized that by applying an approach to
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simple LBP based on bio-mechanical principles and an injury paradigm had fostered
unhelpful beliefs in the general population, which had ultimately led to unhelpful pain-
related behaviour [14]. The theory was further reinforced by observations of similar
developments in the work disability rates, as seen in countries going through a
modernization process, e.g. East Germany after the fall of the wall [15]. Thus, despite the
advances within medicine and technology in the Western countries, improved diagnostics
and treatments for a range of diseases and conditions, it seemed that modern medicine
had failed at helping the majority of people with LBP. [14]
After the turn of the millennium, LBP has continued to be a major cause of work
disability [16, 17]. Studies have shown that it is a relatively small proportion of people with
LBP that progresses to long-term work disability, yet the numbers are large within the
community (because of the high prevalence rates) [2, 18, 19]. Pain-related work disability
involves a substantial economic burden for the society due to direct healthcare expenses,
but even more to the indirect costs such as productivity loss, disability benefits, and
healthcare [20, 21]. Furthermore, long-term work disability and chronic pain can have
deleterious effects on the individual's physical, mental and social wellbeing [16, 22, 23].
3.2. Patho-anatomy
Although no specific pathology has been demonstrated despite the enormous research
efforts, certain correlations between level of disc degeneration and LBP [24], and between
Modic changes and LBP [25-27] have been documented. However, both of these
conditions and others such as disc herniation, spondylolisthesis are sometimes rather
clearly associated with a pain condition, but generally, the overlap of MRI and pain is far
from always sufficient to name them ‘specific.’
3.3. Physical loads
Physical loading on the spine has also been suspected to be a cause of LBP, because the
two are associated [28, 29]. A causal relationship has not been confirmed, though. It is
discussed whether to believe the results of the range of systematic reviews based on the
strict Bratford-Hill criteria for causality speaking against a causal relationship [30-33] or
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whether to use scientific common sense deduction speaking for it. Doing the first, one
ought to consider the critique of the systematic reviews in terms of using “extremely
rigorous causality criteria” and failing to take all risk factors into account [28]. Doing the
latter, one must consider the following: 1) for decades it has been a common dogma
among people in general that loading on the spine not only involve risk of LBP but also risk
of injury, which e.g. was found in the population-based study by Buchbinder and
colleagues [34] and 2) the experience of pain is subject to an individual’s emotions,
attention, experience, and expectations etc. [35, 36]. Thus, it cannot be ruled out that
‘nocebo’ (when beliefs and expectations influence the pain experience) provides an
alternative explanation to the association between the two and the believed causal
relationship. Furthermore, despite the association between physical loads and LBP
reports, it has been shown that physical loaded work is virtually not associated with disc
degeneration. Of the known causes of disc degeneration genetics is by far the dominant
one [37]. In addition, it is worth taking into account too that some measure of physical
loading is actually beneficial, both for muscle strength and disc health [38].
3.4. Classical Treatments and frequently used interventions
Naturally, lack of identifiable specific pathology in most cases of LBP entails problems with
initiating effective treatment, which also displays in the results of various reviews of the
many existing clinical treatments; at best, some of these treatments have small effects on
subgroups of LBP patients in terms of reducing pain and improving physical function [39-
45]. Work disability is rarely an outcome in studies investigating treatment-effects.
3.4.1. Medicine and injection therapy
Recent studies have also questioned the benefits of means to relief the pain such as
prescription [46-49] and non-prescription [50-53] pain medication, especially when
compared to the potential harms they can cause when used long-term and/or in high
doses [46, 54-57]. Besides the well-known side effects from overuse, opioids are
suspected to lead to addiction and changes in the grey matter of the brain [56].
18
Furthermore, one in five taking paracetamol regularly seemingly have decreased liver
function [54], whereas NSAID are suspected to increase the risk of heart disease [57].
Injection therapy is another medical treatment form frequently used for LBP. According
to the existing evidence, the evidence supporting its use for patients with subacute or
chronic LBP is limited and at best, some patients can experience short-term effects [42,
58-60].
3.4.2. Surgery
The highly used (in some parts of the world) and more invasive treatment spinal fusion
surgery, often used for the ‘degenerative disc disease’, seems only marginally superior to
‘relevant’ non-surgical treatment [61, 62], and seemingly no more efficacious than
structured cognitive behavioural therapy [63, 64].
3.4.3. Exercise
Whereas exercise interventions (e.g. resistance training) have proven effective at
preventing LBP episodes [65-67], exercise therapy seem less effective at treating LBP. It
is helpful for some people with chronic LBP in terms of reducing pain and improving
function outcomes, but not for those with acute or subacute LBP [68]. In terms of work-
related outcomes, these are less frequently targeted in exercise interventions. However,
two independent randomized controlled trials have both shown that exercise programs at
the workplace positively influenced the work ability in non-similar worker-populations with
musculoskeletal pain conditions [69, 70]. Furthermore, limited evidence suggests that
graded activity (and graded exposure) might be somewhat helpful for people with
subacute/persistent LBP by reducing pain and related (work) disability [68, 71, 72].
3.4.4. Continuing normal activity
Already in 2001, an extensive evidence review, which aimed at providing occupational
guidelines for the management of LBP at work concluded that continuing normal daily
19
activities involves faster recovery in terms of pain relief, fewer recurrences, and reduced
work loss [73]. Today, the recent clinical guidelines in Denmark as well as the European
ones advocate the maintenance of usual activity when experiencing LBP [74, 75].
3.4.5. Ergonomic interventions
Load-ergonomic interventions such as manual materials handling and application of
assistive devices have been commonly used since the beginning of the increase in LBP-
related work disability, however, reviews have concluded that they are not helpful at
relieving pain or reducing disability [73, 76, 77]. Furthermore, a large randomized
controlled trial have indicated that instruction in lifting technique, aiming to reduce loads,
rather tend to increase the risk of later LBP episodes [78]. However, with the uncertainties
about an actual causal relationship between physical loads, and the fact that workplace
regulations, at least in Denmark, involve obligatory safety precautions in terms of the
employer providing the workers with frequent ergonomic training and appropriate
equipment, it seems relevant to consider weighing up the potential harms against the
potential benefits when continuing to intervene using ergonomic workplace-interventions.
A practice guideline based on the best available scientific evidence to support
occupational safety was introduced by Kuijer et al. (2014) to help find that balance [79].
3.4.6. Education
Education was first included in LBP rehabilitation interventions in the “Swedish Back
Schools” introduced in 1969. The information in the back school was based on the
biomechanical principles in line with the, at that time, predominant ‘injury paradigm’. [80]
Later, with the introduction of the bio-psychosocial paradigm and the awareness of the
negative influence of peoples’ unhelpful beliefs on pain-related behaviour, the content of
the education changed to address emotions such as fear of movement/re-injury and
behaviour such as activity restrictions. A highly frequent education-based intervention
element has been cognitive behavioural therapy. The isolated effect of (individual)
education on pain and disability outcomes was investigated in 2008; intensive patient
education (>2.5 hours) was effective at reducing work disability in people with (sub)acute
20
LBP, whereas the effect in people with chronic LBP was unclear [81]. The evidence on the
effects of group-based education interventions is yet sparse; however, results from a
2015-review indicate that group-based education is as effective as physiotherapy or usual
medical treatment [82].
3.5. Multidisciplinary versus simple interventions for work disability
The multidisciplinary intervention programs emerged in response to the acknowledgement
of the multifactorial nature of back pain and related disability. An early example was the
before-mentioned Swedish Back School. It contained information on the anatomy of the
back, biomechanics, optimal posture, ergonomics and back exercises as elements [80].
Since the beginning of the back schools, the content and length of the back schools have
changed and vary widely today. However, recent systematic reviews have questioned the
effects of back schools for both chronic and acute/subacute LBP due to low quality
evidence from the great variation in content [83, 84].
During the late 1980’s, the Functional Restoration Programs were introduced as a new
kind of multidisciplinary intervention. These programs combined physical and ergonomic
training and psychological intervention with patient education for optimal coping. They
were clinical interventions aimed at chronic LBP patients focusing on clinical outcomes
(pain and function). However, although one of the first studies on the Functional
Restoration Program showed tremendous effects [85], later RCTs could not reproduce this
huge effectiveness [86]. Alongside, the back schools and functional restoration programs,
a growing number of multidisciplinary interventions were presented aiming at preventing
work disability during the 1990’s (e.g. the Sheerbroke Model by Loisel et al. (1997)) [97].
They generally took place at the workplace and typically combined elements addressing
the biomechanical factors believed to influence LBP (e.g. ergonomics or work task
adjustments) with elements addressing the psychosocial factors (e.g. education). Recent
reviews have confirmed the effect of such multidisciplinary interventions in a workplace
setting - both for chronic [88] and subacute LBP [89].
Interestingly, a range of studies testing simpler, typically education-based interventions
have also shown effect on work disability or (in one case) physical function. These studies
were carried out either in the clinic [90-92] or at the workplace [93, 94] and the education
21
was either provided in face-to-face conversations [90, 92], with use of a booklet/leaflet [91,
93], or in group-based talks [94]. The provided information targeted psychosocial factors
such as fear and insecurity about LBP based on the existing scientific knowledge and
contained advice on the benefits of resuming normal/light activity. The information-based
interventions all had the purpose at helping people cope with their pain. Two of the studies
stood out on one point, though: they also provided the participants with a theoretical
explanation to LBP based on the ‘functional-disturbance’-model proposed by Indahl in
1999 [95]. According to this model, LBP could be explained to be the result of a reflex
spasm in the para-spinal muscles caused by a degenerative process inducing
inflammation in innervated parts of a disc. Pain and anticipation of pain as well as lack of
activity and natural movement maintains the muscle spasm, which, with time, can entail
stiffness and pain. Furthermore, muscle tension – for whatever reason – could reinforce
the pain. Two studies, one testing a hospital-based brief intervention (a clinical
examination followed by information by a rehabilitation physician and advice from a
physiotherapist) and the other testing a combined intervention at the workplace
(reassuring information, peer support and access to clinical examination/more information)
both produced significant reductions in LBP-related sickness absence [90, 94]. The
hospital-based brief intervention also demonstrated significant effects at 5 years in a
subsequent follow-up study [96].
With multidisciplinary and simple interventions both showing effect on work disability,
and with the simpler interventions being less costly and easier to implement, it is natural to
consider which one of the two is best. However, the great variations in the content of the
multidisciplinary interventions and the often sparse descriptions of the content of the
simple information-based interventions make it difficult to sum up the effect of the two
different types of interventions and to compare them why few of such comparison studies
exist. Those that have been made have generally shown that the two are equally effective
[97, 98]. A study exploring the cost-effectiveness of a simple hospital-based intervention
(clinical examination followed by information by a rehabilitation physician and advice from
a physiotherapist) compared to a multidisciplinary intervention (the hospital-based
intervention in combination with an individual rehabilitation plan involving a case manager
and a multidisciplinary team) showed that the brief intervention was generally more cost-
effective [99].
22
3.6. Population-based studies testing information-based
interventions
Whereas interventions with the purpose of reducing pain-related work disability (sickness
absence) mainly include populations with ongoing pain issues, population-based
intervention studies (also) target prevention of negative consequences of first time or
recurrent pain episodes are sparsely represented in the empirical literature. The existing
ones have focused on improving pain-related beliefs [93, 100-102] and/or work outcomes
(mainly sickness absence) [93, 100-103]. Whereas all studies targeting pain-related beliefs
reported improved beliefs [100-102], only one of the four existing studies targeting
sickness absence have reported effect on that outcome [93]. Despite the sparse effects on
sickness absence so far, it is believed that influencing the knowledge and attitudes in large
proportions of a community, provides social support for (persistent) behaviour change.
Furthermore, due to the extent of back pain as a ‘widespread disease’, even small or
modest impacts in those at low or medium risk (of back pain-related work disability, red.)
are likely to deliver large improvements on a population-based scale [104]. However, with
the rather few existing population-based studies it is not possible to determine if such
studies have the expected potential yet.
3.7. The social and contextual factors and work disability
Social and contextual factors such as the family, the workplace, and the healthcare and
social systems have been suggested to influence work disability [105]. Nonetheless, social
factors are not well represented in current core-sets of outcome measure used by
clinicians and studies adding to bio-psychosocial evidence base on the influence from the
‘social’ component are scarce.
The Psychosocial Flags Framework constitutes an increasingly popular framework as
well as a generally applicable tool (for the clinician, the employer, the social worker etc.) to
identify obstacles for return-to-work in the individual. It clearly demonstrates that
musculoskeletal conditions such as LBP are multifactorial by suggesting that obstacles for
work participation exist on three levels: the individual level, the workplace level, and the
‘systems’ level (e.g. health or compensatory system) and categorize these levels into
‘flags’ categories. Its’ suggested flags are factors suggested to act as potential obstacles
23
for work participation and constitute: ‘Yellow Flags’ (personal emotions and beliefs such as
fear of re-injury), ‘Blue Flags’ (an individual’s perception/experience of the workplace such
as social support), and ‘Black Flags’ (factors in an individual’s immediate surroundings
such as the compensation system or the healthcare professional). [Kendall] Where the
evidence supporting the Yellow and the Blue Flags have been thoroughly reviewed [106,
107], the evidence on the Black Flags has not. Reviewing the Black Flags and thereby
confirming or rejecting their individual influence on work disability might strengthen the
general perception of their relevance and their incorporation into future work disability-
interventions.
3.8. Individual or ’whole-systems’ approach
Even if the introduction of the bio-psychosocial model has entailed much needed changes
in the clinical and scientific approach to LBP and related work disability, and the
presentation of the Psychosocial Flags Framework has made way for the identification of
the potentially important psychosocial factors, many interventions and actions still seem to
target the individual - at the individual level. E.g. interventions at the workplace is most
frequently constituted by elements such as job accommodation, working techniques,
whereas the clinical interventions often contain elements such as physical training or
patient education. It is less frequently seen that the interventions or actions have to do with
the organization of the work, workplace regulations, or the social environment. Both
studies and The International Labour Organization have emphasized the need to add the
‘social’ component in a ‘whole-systems’ approach meaning that we probably need to do
both [108-110].
24
4. Aim
4.1. Overall aim
The overall aim of the studies reported in this thesis was to add to knowledge on whether,
and to some extent how, selected elements of the biopsychosocial model influence LBP-
related behaviour, with specific emphasis on occupational outcomes.
4.2. The specific aims
The specific aims belonging to each of the three studies were:
1. To test if a workplace intervention based on a particular kind of reassuring information is
effective at altering LBP-related behaviour in particular but also LBP-related beliefs - in a
population of workers with or without previous LBP experience. The information was in line
with the general guidelines for management of LBP and combined with messages of the
’functional-disturbance’-model (Study I)
2. To explore the perspective of the participants from Study I in terms of their experiences
of the talks and to explore manual workers’ perceptions of factors influencing the ability to
work while experiencing back pain and what influences their decision to call in sick due to
back pain (Study II)
3. To determine if selected factors believed to act as obstacles for work participation,
which are related to a person’s context (so-called ‘Black Flags’) do really seem to work as
obstacles for work participation according to the existing empirical literature (Study III)
25
5. The studies in this thesis
5.1. Study I
5.1.1. Publication
Frederiksen P, Indahl A, Andersen LL, Burton K, Hertzum-Larsen R, Bendix T. Can group-
based reassuring information alter low back pain behaviour? A cluster-randomized
controlled trial. PLoS ONE. 2017; 12(3):e0172003.
5.1.2. Aim
To test the isolated effect of reassuring information based on guideline-based information
combined with information on the ‘functional-disturbance’-model on LBP-behaviour
outcomes and back beliefs.
5.1.3. Design
Cluster-randomized controlled trial
5.1.4. Sample and recruitment
Based on results from initial power calculations, 505 participants from five different
municipality centres from Zealand (Denmark) were included in the study (recruitment
meetings) and then randomized (cluster level) into ‘Intervention group’ and ‘control group’
using a highly simple envelope-method (Figure A). All municipalities were represented with
at least one centre in both groups in order to reduce the risk of bias (cluster effects).
Administrative workers were also invited to participate in addition to the target population
(manual workers) mainly due to time limitations of the study.
26
Figure A: The randomization process in the five municipalities
5.1.5. Inclusion and Exclusion criteria
Inclusion criteria were employment at one of the 11 included centres (clusters), adequate
proficiency to read and write in Danish, and agreement to participate. Exclusion criteria
were surgery- or trauma-induced LBP, illness seriously affecting the person (e.g. current
cancer) at baseline, and illness/pain conditions severely affecting the individual (e.g. acute
RA, Lupus), and pregnancy during the first nine months of the study.
5.1.6. The intervention
The intervention was carried out immediately after randomization of each municipality and
consisted of two talks of 1-hour each. The talks were held with a two weeks-interval. By
the end of the second talk, the participants were provided with two booklets; one which
27
highlighted the most important messages of the two talks and another illustrating a range
of general stretching exercises, normally used by the physiotherapists at Rigshospitalet
Glostrup for back pain patients (Appendix 1 & 2). Furthermore, the intervention group was
offered the possibility to get in touch with a physiotherapist during the follow-up year if they
had questions concerning LBP.
The content of the talks was information on the existing evidence on LBP regarding:
aetiology and prognosis, anatomy and function of the spine, treatment options and their
general effects if any, the rationale for load ergonomics and its poor effectiveness, myths
and facts about disc herniation, pain mechanisms, effects of physical training, and pain
self-management (coping) strategies. Furthermore, the talks also contained information on
the ‘functional-disturbance’-model, which explains LBP to be the result of a temporary
muscular disturbance in the para-spinal muscles. It was stressed that the explanation was
theoretical and thus, not a validated explanation to LBP. It was considered important that
the speaker used a non-directive approach in the talks meaning that she gave information
without giving advice or instructions – but simply passed on knowledge in order to enable
the listeners to draw their own conclusions on if or how to use the ‘new’ knowledge.
The control group received no intervention during the study but was offered to attend
post-study talks resembling those from the intervention.
5.1.7. Data collection and outcomes
One month following the second talk, the first follow-up data collection took place using
short message service (SMS). After the reply of the question: “During the past month, how
many days have you had pain in your lower back (+/÷ sciatica)?” – the participants who
had replied ≥1 received seven more questions (Table A) concerning their pain experience
and pain-related behaviour. Similar data collection took place each month for 12 months. A
separate data collection measuring back beliefs took place 5.5 months into the follow-up
year. Telephone interviews, running through the same questions, were attempted in cases
where the participants had not responded to the regular (SMS) data collections.
28
Tab
le A
: P
ara
me
tre
, sca
le,
origin
, w
ord
ing a
nd
va
lida
tio
n s
tatu
s o
f th
e p
rim
ary
an
d s
eco
ndary
ou
tco
me
s
Par
ame
ter
Me
asu
re
Ori
gin
W
ord
ing*
Si
nge
-ite
m
valid
ate
d
Val
idat
ed
sc
ale
1.L
BP
day
s≥0
N
ot
fro
m p
reex
isti
ng
scal
e
"Du
rin
g th
e p
ast
mo
nth
…"
or
"Sin
ce o
ur
last
dat
a co
llect
ion
, ho
w m
any
day
s h
ave
you
had
wit
h L
BP
(+/
÷sci
atic
a)?"
N
o
No
2.C
ut-
do
wn
day
s≥0
C
ore
Ou
tso
me
s M
easu
re
Ind
ex (
CO
MI)
item
4
"Du
rin
g th
e p
ast
mo
nth
…"
or
"Sin
ce o
ur
last
dat
a-c
olle
ctio
n, a
bo
ut
ho
w m
any
day
s d
id y
ou
cu
t d
ow
n o
n t
he
thin
gs y
ou
no
rmal
ly d
o f
or
mo
re t
han
hal
f a
day
bec
ause
of
LBP
(+/
sci
atic
a)?"
No
Ye
s
3.D
ays
off
wo
rk≥0
C
ore
Ou
tso
me
s M
easu
re
Ind
ex (
CO
MI)
item
5
"Du
rin
g th
e p
ast
mo
nth
…"
or
"Sin
ce o
ur
last
dat
a-c
olle
ctio
n,
ho
w m
any
(hal
f o
r fu
ll) d
ays
did
LB
P (
+/ s
ciat
ica)
ke
ep y
ou
fro
m g
oin
g to
wo
rk?"
N
o
Yes
4.W
ork
ab
ility
0-1
0 s
cale
Wo
rk A
bili
ty In
dex
(W
AI)
"O
n a
sca
le f
rom
0 t
o 1
0, h
ow
is y
ou
r cu
rren
t w
ork
ab
ility
co
mp
ared
wit
h y
ou
r lif
e-
tim
e b
est
? (0
= n
o w
ork
ab
ility
—1
0 =
op
tim
um
life
-tim
e w
ork
ab
ility
)?"
Yes
Yes
5.H
eal
th c
are
visi
ts≥0
N
ot
fro
m p
reex
isti
ng
scal
e
"Du
rin
g th
e p
ast
mo
nth
…"
or
"Sin
ce o
ur
last
dat
a co
llect
ion
, ho
w m
any
visi
ts t
o
hea
lth
car
e p
rofe
ssio
nal
s h
ave
you
mad
e d
ue
to L
BP
(+/
÷sci
atic
a)?"
N
o
No
6.
Bo
the
rso
men
ess
1-5
sca
leC
ore
Ou
tso
me
s M
easu
re
Ind
ex (
CO
MI)
item
1
"On
a s
cale
fro
m 1
to
5, h
ow
mu
ch h
as y
ou
r LB
P (
+/÷
scia
tica
) b
oth
ered
yo
u in
th
e p
ast
we
ek?"
N
o
Yes
7.R
est
rict
ed
acti
vity
1-5
sca
leC
ore
Ou
tso
me
s M
easu
re
Ind
ex (
CO
MI)
item
2
"On
a s
cale
fro
m 1
to
5, h
ow
mu
ch h
as y
ou
r LB
P (
+/÷
scia
tica
) re
stri
cted
yo
ur
acti
vity
in
th
e p
ast
wee
k?"
No
Ye
s
8.F
req
ue
ncy
of
pai
n m
ed
icat
ion
inta
ke
No
t at
an
y ti
me/
Less
fr
equ
entl
y th
an e
very
w
eek
/On
a w
eek
ly
bas
is/D
aily
The
Osl
o H
ealt
h S
tud
y (H
UB
RO
) "D
uri
ng
the
pas
t m
on
th, h
ow
oft
en h
ave
you
use
d p
ain
me
dic
atio
n (
for
LBP
or
any
oth
er r
easo
n)?
" Ye
s Ye
s
9.L
eve
l of
sad
ne
ss/
de
pre
ssio
n
No
t at
all/
A li
ttle
/To
so
me
deg
ree/
To a
hig
h
deg
ree
Sub
ject
ive
Hea
lth
C
om
pla
ints
(SH
C)
Inve
nto
ry
"Du
rin
g th
e p
ast
mo
nth
…"/
"Sin
ce o
ur
last
dat
a co
llect
ion
, to
wh
at e
xten
d h
ave
you
b
een
aff
ecte
d b
y sa
dn
ess/
dep
ress
ion
?"
Yes
Yes
10
.1 B
ack
Be
liefs
0-6
sca
leB
ack
Bel
iefs
Q
ues
tio
nn
aire
(B
BQ
) it
em 1
0
“On
a s
cale
fro
m 0
(co
mp
lete
ly d
isag
ree)
to
6 (
com
ple
tely
agr
ee),
ho
w m
uch
do
yo
u
agre
e w
ith
th
e fo
llow
ing:
bac
k p
ain
mea
ns
lon
g p
erio
ds
off
wo
rk”
No
Ye
s
10
.2 B
ack
Be
liefs
0
-6 s
cale
Bac
k B
elie
fs
Qu
esti
on
nai
re (
BB
Q)
item
12
“On
a s
cale
fro
m 0
(co
mp
lete
ly d
isag
ree)
to
6 (
com
ple
tely
agr
ee),
ho
w m
uch
do
yo
u
agre
e w
ith
th
e fo
llow
ing:
on
ce y
ou
’ve
had
bac
k tr
ou
ble
it w
ill a
lway
s b
e w
eake
ned
”
No
Ye
s
10
.3 B
ack
Be
liefs
0
-6 s
cale
Bac
k B
elie
fs
Qu
esti
on
nai
re (
BB
Q)
item
13
“On
a s
cale
fro
m 0
(co
mp
lete
ly d
isag
ree)
to
6 (
com
ple
tely
agr
ee),
ho
w m
uch
do
yo
u
agre
e w
ith
th
e fo
llow
ing:
wh
en
yo
u h
ave
bac
k tr
ou
ble
yo
u s
ho
uld
res
t”
No
Ye
s
10
.4 B
ack
Be
liefs
0
-6 s
cale
Bac
k B
elie
fs
Qu
esti
on
nai
re (
BB
Q)
item
14
“On
a s
cale
fro
m 0
(co
mp
lete
ly d
isag
ree)
to
6 (
com
ple
tely
agr
ee),
ho
w m
uch
do
yo
u
agre
e w
ith
th
e fo
llow
ing:
bac
k tr
ou
ble
wo
rsen
s la
ter
on
in li
fe”
N
o
Yes
29
Main outcomes were (Table A) LBP-related days of cutting down on activity and work
participation days (measured as days of LBP-related sickness absence) with LBP.
Secondary outcomes were overall work ability, number of LBP-related treatment visits,
LBP-related bothersomeness, LBP-related restrictions in activity, frequency of pain
medication intake during LBP, and level of sadness/depression during LBP. The outcomes
‘pain medication intake’ and ‘level of sadness/depression’ were included for two reasons:
to be able to adjust for their influence in the subsequent analyses because they, according
to the existing literature, might influence pain reports, but also to treat them as ‘true’
outcomes – influenced by the intervention.
5.1.8. Data analyses
The analyses were carried out by a blinded assessor. Analyses on baseline data used
both parametric and non-parametric analyses. On follow-up data (the seven pain-
experience and pain-behaviour parameters), the analyses constituted cumulative logistic
regression (Proc Genmod of SAS version 9.4) based on one-year-means for each of the
participants (minimum one and maximum 12 responses from the monthly assessments to
compare the two groups. Group (intervention/control) was entered in the model as a fixed
factor, whereas cluster was entered using the repeated option (repeated subject = cluster
variable) in Proc Genmod. Linear mixed models (Proc Mixed, SAS version 9.4) was used
to analyse the back beliefs outcome. Again, Group (intervention/control) was entered in
the model as a fixed factor. Cluster was entered as a random factor. The analyses were
first adjusted for the baseline value of the outcome measure, and in a second analysis also
for gender, age, smoking, and type of work. Intention-to-treat (ITT), per-protocol (PP), and
drop-out analyses were carried out.
It wasn’t possible to make an analysis on the non-participants in order to determine
whether or not our worker-population was representative for the worker-population in their
municipality. This was because the municipality regulations did not allow us to get access
to information on the people, who did not consent to participate. However, for the purpose
of this thesis, our worker-sample was compared to a highly similar worker-sample
(building- and construction workers) - in terms of the type of work - from a large Danish
survey on the working environment. Specifically they were compared on their responses to
30
two variables: ‘self-reported physical job demands’ measured and ‘workability’, both
measured on 0-10 scales same as in our study.
5.1.9. Results
Of the 505 recruited participants a total of ten participants were excluded based on the
exclusion criteria (Figure B). Thus, 495 participants were randomized. The intervention
group contributed with 256 and 217 participants for the ITT and PP analyses, respectively,
whereas the control group contributed with 239 and 228, respectively. Dropout-rates
between baseline and follow-up were less than 5%.
Figure B: Flow of the participants in the study
31
Tab
le B
: B
ase
line
ch
ara
cte
ristics o
n d
em
ogra
ph
ic f
acto
rs, w
ork
-rela
ted
fa
cto
rs, fa
cto
rs c
once
rnin
g o
ve
rall
he
alth, lo
w b
ack p
ain
-da
ys,
low
ba
ck p
ain
be
ha
vio
ur,
an
d b
ack b
elie
fs (
n =
495
).
Sig
.
N o
f questionnaire r
esponders
elig
ible
for
analy
sis
De
mo
gra
fic f
acto
rsn
%M
ean
SD
Me
dia
nIQ
Rn
%M
ean
SD
Me
dia
nIQ
RP
β£
Perc
enta
ge m
ale
194
76.1
-
- -
-201
84.5
- -
- -
0.0
24
*
Age
255
-49.1
0
10.5
251.0
044.0
0-5
7.0
0236
-48.1
010.7
650.0
042.0
0-5
5.7
50.2
79
Perc
enta
ge s
mokers
67
26.2
- -
- -
94
39.5
- -
- -
0.0
02
*
Perc
enta
ge o
f unskill
ed w
ork
ers
87
34.3
- -
- -
93
39.4
- -
- -
0.2
61
Perc
enta
ge w
ith h
alf-
or
full
day m
anual w
ork
172
67.2
- -
- -
218
92.0
- -
- -
<0.0
01
*
Wo
rk-r
ela
ted
fa
cto
rs
Self-
report
ed p
hysic
al jo
b d
em
ands 0
(lo
w)
- 10 (
hig
h)
252
-4.5
93.0
25.0
02.0
0-7
.00
231
-5.8
42.4
16.0
05.0
0-8
.00
<0.0
01
*
Ove
rall
job s
atisfa
ction 0
(lo
w)
- 10 (
hig
h)
252
-7.6
91.6
58.0
07.0
0-9
.00
232
-7.5
61.8
48.0
07.0
0-9
.00
0.5
46
Leasure
tim
e a
ctivi
ty:
'mostly s
edenta
ry' o
r 'li
ght
activi
ty'
175
69.2
- -
- -
163
70.3
- -
- -
0.8
43
Ove
rall
he
alt
h a
nd
ba
ck p
ain
fa
cto
rs
Perc
enta
ge r
ating h
ealth a
s p
oor/
very
poor
32
12.6
- -
- -
26
11.1
- -
- -
0.6
75
Self-
report
ed d
ays o
f sic
kness a
bsence (
all
causes)
during t
he p
ast
12
month
s224
-7.2
810.8
45.0
02.0
0-1
0.0
0205
-7.3
910.6
55.0
01.0
0-1
0.0
00.8
88
Perc
enta
ge a
ffecte
d b
y illn
ess/s
pecifi
c (
back/o
ther)
pain
conditio
ns
69
27.7
- -
- -
58
25.3
- -
- -
0.6
05
Back b
elie
fs s
um
: 4-2
0 (
20=
faulty b
elie
fs)
250
-11.5
13.4
311.8
99.2
0-1
3.9
0235
-12.5
03.4
412.5
010.5
0-1
4.6
00.0
02
€*
Perc
enta
ge w
ith fre
quent/
consta
nt
LB
P82
41.4
- -
- -
69
37.5
- -
- -
0.4
64
Self-
rate
d c
hance o
f re
cove
ry fro
m L
BP
within
6 w
eeks 0
(good)
- 10 (
poor)
130
-2.1
82.7
01.0
00.0
0-3
.00
125
-2.4
92.6
62.0
00.0
0-4
.00
0.2
38
Pain
days last
month
246
-5.6
49.0
44.3
40.0
0-4
.34
218
-5.5
78.2
74.3
40.0
0-4
.34
0.2
67
Pa
in b
eh
avio
ur
am
on
g t
ho
se r
ep
ort
ing
LB
P a
t b
ase
lin
e
Cutd
ow
n d
ays last
month
234
-1.1
64.5
70.0
00.0
0-0
.00
214
-1.1
43.4
90.0
00.0
0-0
.00
0.5
35
Sic
k d
ays last
month
238
-0.1
90.8
90.0
00.0
0-0
.00
216
-0.2
20.9
20.0
00.0
0-0
.00
0.6
57
Work
abili
ty 0
(none)
- 10 (
lifetim
e b
est)
243
-9.0
61.5
210.0
08.0
0-1
0.0
0219
-8.5
21.8
39.0
08.0
0-1
0.0
0<
0.0
01
*
HC
P v
isits last
month
240
-0.3
01.0
40.0
00.0
0-0
.00
212
-0.4
31.1
60.0
00.0
0-0
.00
0.0
51
Both
ers
om
eness last
week 1
(not
at
all)
- 5
(to
a m
axim
um
leve
l)244
-1.2
71.4
31.0
00.0
0-2
.00
218
-1.5
61.5
12.0
00.0
0-3
.00
0.0
35
*
Restr
icte
d a
ctivi
ty last
week 1
(not
at
all)
- 5
(to
a m
axim
um
leve
l)244
-1.0
41.2
51.0
00.0
0-2
.00
220
-1.3
21.3
31.0
00.0
0-2
.00
0.0
19
*
Perc
enta
ge w
ith a
ny p
ain
medic
ine inta
ke
124
51.0
- -
- -
124
59.0
- -
- -
0.0
90
Perc
enta
ge w
ith s
om
e d
egre
e o
f re
port
ed s
adness/d
epre
ssio
n123
50.6
- -
- -
123
58.6
- -
- -
0.1
08
β P
roport
ions w
ere
teste
d u
sin
g C
hi-square
tests
. £ M
edia
ns w
ere
teste
d u
sin
g M
ann-W
hitn
ey U
test. €
Means (
back
belie
fs o
utc
om
e o
nly
) w
ere
teste
d u
sin
g u
npaired t-t
est. *
P <
0.0
5
Inte
rve
nti
on
gro
up
Co
ntr
ol g
rou
p
n=
256
n=
239
32
The response rates were generally high in the follow-up data collections: minimum 84% at
group level and 70% at cluster level. The cluster randomization did not manage to
distribute all variables equally at an individual level. There existed some significant
baseline differences between the two groups in terms of sex, smoking, type of work
(administrative versus half/full day manual work), physical job demands, work ability, pain-
related bothersomeness and activity restrictions, and back beliefs (Table B, Appendix 3:
Baseline questionnaire).
The follow-up data showed no between-group differences in the reports of LBP-days or
days of cutting down on activity (Table C). However, it did show that the intervention group
participants were significantly more prone to report: more days of work participation
(OR=1.83 95% CI: 1.08-3.12), higher work ability (OR=1.40 95% CI: 1.01-1.94), fewer
health care visits (OR=1.72 95% CI: 1.01-2.94), lower levels of bothersomeness (OR=1.50
95% CI: 1.06-2.11), and lower levels of sadness/depression (OR=1.80 95% CI: 1.10-2.96).
Furthermore, the analysis showed a significant reduction (10.22 on a 100-scale) in the
negative back beliefs compared to the control group (Table D).
When assessing the mean days of LBP-related cutting down on activity and of LBP
work absence at a monthly basis, the intervention group reported consistently more days
of cutting down over the 12 data collections, whereas this was the case in 11 of 12 data
collections on days of work absence (Figure C).
The intervention group participant’s option of contacting a physiotherapist during follow-
up was only chosen by two individuals.
33
Table C: Odds ratios for LBP-behaviour outcomes in the intervention group compared with the controls
34
Table D: Multiple regression analysis of back beliefs sum score¥ in the intervention group and control group, respectively at 5.5 months follow-up. Higher score means more negative back beliefs
Figure C: Days of cutting down on usual activity (C1) and days of sickness absence (C2) at each of the 13 data collections in the two groups
C1:
35
Figure C continued - C2:
Table E: Means of physical work demands (0-10 scale) and work ability (0-10 scale) in the present study population compared with the population from Arbejdsmiljø og Helbred 2014
When comparing our specific worker-sample with an overweight of manual workers with
the sample of public workers from a large Danish national survey (“Arbejdsmiljø og
Helbred”) from 2014 [111], the mean reports on physical work demands and work ability,
seem highly comparable (Table E). The slightly higher mean on the parameter physical
work demands in our population can be explained by the fact that the sample from the
national survey did not have the same high proportion of manual workers that our
population did.
36
5.2. Study II
5.2.1. Publication
Frederiksen P, Karsten MMV, Indahl A, Bendix T. What Challenges Manual Workers’
Ability to Cope with Back Pain at Work, and What Influences Their Decision to Call in
Sick? J Occup Rehabil. 2015 Dec;25(4):707-16.
5.2.2. Aim
The specific aim of study II was to explore the worker perspective on factors perceived to
be challenging and helpful, respectively, in terms of working during back pain episodes
and on factors influencing their decision to call in sick due to back pain. A secondary aim
was to explore the participants’ experience of the talks given in Study I. However, that aim
was dropped at an early stage in the data collection because we could not retrieve
sufficient data.
5.2.3. Design
Focus-group interviews
5.2.4. Sample
The participants were recruited from the population in Study I using stratified purposeful
sampling to ensure a representation of participants across age, gender and municipality.
Furthermore, three criteria for participation were formed to ensure that included workers
were relevant to fulfil the purpose of the study: 1) being intervention-group participant and
having attended both talks in Study I, 2) having reported LBP at least once during the 1-
year follow-up, 3) having half- or full day manual work. Workers eligible for participation
were selected using alphabetically indexed name lists from each municipality by starting
from the top. A specific sample size was not set prior to inclusion but we aimed at
conducting three focus-group interviews with 6-8 participants each. The participants were
included consecutively until we reached the desired number of participants and groups. Of
37
the 24 workers asked, 20 consented to participation. The four ‘decliners’ gave reasons like
“lack of time” or “lack of interest”. The participants were invited by phone.
The focus of the study, which naturally was influenced by the authors’ pre-
understanding of the challenges with back pain in relation to work participation, was aimed
at the workplace (and to some extend also context) issues influencing the ability to stay
working during pain episodes.
5.2.5. Data collection
Three focus-group interviews were conducted during February and March 2014. Three of
five municipalities which had participated in Study I were represented in the data. The
interviews took place in meeting-room facilities at two of the municipality centres. Any
transportation costs for the participants were covered by the study. Participants were
reminded about the interview the day before by SMS.
The group-discussions were audio-taped. Summarizing field notes were taken right
upon completion of the interview. The interviews were transcribed verbatim. An Interview
guide constituted the frame of the interview ensuring the initiation and relevance (cf. the
study objectives) and the chosen topics were inspired by the existing empirical literature as
well as the knowledge of the authors. The interview guide addressed overall topics related
to the general work environment (Appendix 4).
The primary investigative topics during the interviews were:
a) Challenges with working during back pain episodes
b) Factors within the physical working environment, which facilitates or impede the
ability to stay working while in pain
c) The experience of the social environment when working with back pain and in
general
d) Factors influencing the decision to stay home from work due to back pain and
general perception about pain-related sickness absence
e) Desired future scenarios
38
The secondary investigative topic was experience of the talks, but this was only included in
the first of the three interviews and since abandoned. During the first interview, it became
obvious that the participants could not recall anything specific from the talks other than:
“they were good”. For those participants, the talks were a year back in time. This would
almost be the same for the participants in focus-group two, why it was decided to abandon
the investigative topic and instead expand the explorations of the primary investigative
topics. Abandoning the topic also allowed the first author to act as observer and notary.
The focus-group interviews were facilitated by the second author, who had not been
involved in the Study I. The sessions varied some in character by shifting between being
an interview (lead by the interview guide and involving all the participants) and discussions
(between two or more participants, which were not necessarily directly answering the
research questions). The discussions were allowed in order to pursue an inductive
approach, however, the facilitator made sure to stick to the interview guide.
The data were transcribed verbatim shortly after collecting them. Thematic Analysis was
used as an analytical tool to interpret the statements made by the participants. An
inductive explorative approach was kept during the process in order to stay ‘true’ to the
data. To ensure that themes were well founded in the data, these were identified and
defined across all three transcripts at once. Software was not involved in the analytic
processes.
5.2.6. Results
The 20 participants had a mean age of 53.5 years (SD 7.0) and 1/4 was a women. Three
had half-day manual and half-day administrative work, whereas the rest had full-day
manual work. The three groups differed slightly in terms of age and self-reported physical
work demands, however, overall, the three groups were very similar in terms of
background characteristics.
Regarding the challenges when working with back pain, three overall themes emerged
from the analysis: 1) Self-management strategies, 2) Social Climate, and 3) General
working conditions. The themes constitute the overall topics which the participants’
39
statements was centred on in the interview-part concerning the challenges with working
during back pain episodes.
Figure D list the two main challenges mentioned by the participants and a range of
factors, which they had experienced or believed to positively influence their ability to cope
with back pain and the challenges.
Figure D: challenges and positive influencers on the ability to cope with back pain while working
Poor physical work conditions constituted a main challenge covering: inappropriate
equipment/working space, job strain, habits, or cooperation with external partners (e.g.
workers from other municipal departments). The workers mentioned two self-
managements strategies, which was used as a response to this: Individual adjustments
(defined as individually formed alternative work routines e.g. related to the work pace, the
order of tasks, or the way the task was carried out), individual initiatives (defined as e.g.
applying specific work wear, using pain medication, and seeking treatment). A
contradictory perception was mentioned concerning the individual adjustments: although
they were perceived to be effective, whereas traditional ergonomic techniques were
experienced as inconvenient and even idle time, the individual adjustments still ranged
‘lower’ in the workers’ perception of what was best for them. A believed positive influence
on the poor physical working environment was, according to the workers, if the supervisors
would provide them with appropriate equipment.
Lack of trust/support from the supervisors was defined as when they did not provide the
worker with adjustment latitude. As part of the talk about desired future scenarios, the
workers mentioned three potential actions, which the supervisor could take to increase the
40
experience of being trusted and supported: providing frequent ergonomic training,
appropriate equipment, and access to health care. These suggestions constituted ideas.
Little insight in the workers tasks and considerations about economy rather than the
workers’ health and well-being were mentioned as explanations to why the workers felt
distrusted and not supported.
Back pain in itself did not range as a challenge in the results, but the workers mentioned
that the unpredictable nature of back pain entailed feelings of despair, insecurity, and fear
of pain progression. Furthermore, when back pain led to decreased work ability, it made
the workers feel insufficient and weak.
In terms of the factors influencing the decision to call in sick due to back pain, naturally,
high pain intensity was mentioned as one of the key factor decreasing work participation
(Table F). High pain intensity increased the likeliness of deciding to stay home. Other
factors mentioned to decrease work participation were job strain (in cases where the
workers did not have close co-workers and thus, did not feel responsible to them) and a
spouse’s opinion that going to work was not sensible.
Table F: Factors decreasing or increasing work participation during back pain episodes
Factors mentioned to increase work participation were job strain (feeling responsible to co-
workers who would otherwise have to do the work of the absentee too), threatening
sickness absence policies (experiencing contact during absence as a supervisor’s means
to control the worker and counts on the total amount of days of absence, which made the
worker fear dismissal), and boredom with staying home.
41
The Psychosocial Flags Framework was applied to the results in order to increase the
transparency and by that also the applicability of the findings. The application simply
involved a comparison of the results with the three categories from the framework: the
Yellow Flags (personal emotions), the Blue Flags (perceptions of the workplace), and the
Black Flags (contextual factors related to the individual, the workplace or the societal
systems) as well as a labelling constituting the ‘arena’ in which they display (individual,
workplace, context). Because the purpose of the Psychosocial Flags Framework is to help
identify potential obstacles for work participation, only the challenges, their related
negative influencers, and the factors mentioned to decrease work participation were
included in the comparison.
Both main challenges belong to the Black Flags category, by being factors related to the
worker’s context; the workplace. Because the workplace constitutes the specific
department and the municipality, any actions to address the challenges is a supervisor or
top management task – perhaps even a political decision. The positive factors mentioned
to improve the abilities to cope with back pain and the workplace challenges (Figure D)
also mainly involve actions by the supervisor or management with exception of the
individual strategies/initiatives, which were actions taken by the worker him/herself.
42
5.3. Study III
5.3.1. Publication
Bartys S, Frederiksen P, Bendix T, Burton K. System influences on work disability due to
low back pain: An international evidence synthesis. Health Policy. 2017 Aug;121(8):903-
12.
5.3.2. Aim
To determine if selected factors related to a person’s context and believed to act as
obstacles to work participation (so-called ‘Black Flags’) do in fact seem to act as such
according to the existing empirical literature.
5.3.3. Design
A best-evidence synthesis
5.3.4. Defining the ‘Black Flags’
According to the most recent evidence on the Psychosocial Flags Framework, the Black
Flags constitute system or contextual factors including relevant people, systems, and
policies that can affect disability [WD bog] and concern the context in which the person
functions, and include relevant people, systems, and policies. The Black Flags may
operate at a societal level, or in the workplace. [105] Table G provides a list of the
suggested Black Flags according to the existing literature.
5.3.5. Selection of Black Flags for the present study
Due to time limitations, the focus of the study could not involve all the suggested Black
Flags. Thus, three were selected: compensatory systems, healthcare ‘systems’ (mainly
healthcare professionals), and family ‘systems’ (specifically ‘significant others’ – here
defined as spouse or close family).
43
Table G: List of suggested Black Flags. The flags selected for the present study are underlined.
5.3.6. Literature search
Searches for literature were conducted in eight scientific databases (PubMed, CINAHL,
EMBASE, PsychINFO, Scopus, Web of Science, Cochrane Library, ProQuest) and in two
grey databases (Google Scholar and OpenGrey) during December 2013. In addition,
evidence sources were added consecutively by four independent experienced researchers
within the field of work participation and through weekly database alerts until July 2014.
In the scientific databases and in the OpenGrey database, the search was conducted in
two ways: by using fixed key words (e.g. MeSH terms) made by the respective database
and by using free text combinations of similar words/terms – related to LBP, work
participation and the selected Black Flags e.g. “low back pain” or “back pain” and “work
disability” or “return-to-work” and “worker’s compensation” or “sick benefits”/and
“Healthcare professionals” or ”Family Physicians” or ”Health personnel” /and “Spouse” or
”Social support” or ”Significant others”. The Boolean operators “OR” and “AND” was used
to combine words or terms and a variety of combinations were attempted in each database
to increase chances of collecting all relevant material. Only language limits were applied
(English, Danish, Norwegian, and Swedish) to the searches. In the grey database Google
44
Scholar only free text combinations were used with similar word combinations as listed
above.
5.3.7. Selection of relevant records and subtraction of evidence
After the collection of records from the various databases, a selection process took place
involving two screenings performed by the second author PF and two rounds of voting
among three authors (PF, TB, KB) (Figure E). The initial screening was for overall
relevance. Based on that, the number of remaining records was down to 498. The first
voting round concerned removal of irrelevant records based on their title/author/journal
and brought the remaining number of record further down to 272. Then another screening
took place, removing irrelevant records based on their abstract. Thus, the remaining
records were 126. The final voting round between the authors based on the records’
abstracts removed yet another 89 record leaving 57 records for inclusion. Next, the
selected records were read by PF, who proposed the content for the evidence tables
(Appendix 5 is an example of an evidence table). This content formed the basis for the
subsequent evidence grading of each record which was performed by three of four
reviewers (PF, KB, and TB). For this an evidence grading system adapted from a previous
large scale review was applied. The last step with forming the evidence statement by
summarizing the retrieved evidence was performed in cooperation between two of the
authors: PF and KB - as iterative process with discussions until consensus was reached.
TB then read and commented on the suggestions and final decisions were made in
cooperation. The fourth author (SB) joined the author group at a later stage and she gave
her input to the finally selected records and evidence statements at that point.
Although our search terms were strictly related to LBP, some articles were included
which concerned other non-specific musculoskeletal conditions in relation to work
participation because these were deemed highly relevant to our objective.
45
Figure E: flow chart of the retrieved records and actions by the authors during the selections process
The evidence grading system (Table H) used for this review was adapted from the large-
scale review: “Is work good for your health?” by Waddell & Burton from 2006 [16]. The
46
grade of this system refers to both the amount and quality of the evidence, which can be
referred to as the ‘strength’ of the evidence.
Due to the disparate nature of available evidence, it was not fit for application of a
formal method of quality assessment to each article. Thus, for the purposes of this study,
‘quality’ was largely attributed to academic peer-reviewed published articles. The
suggested explanations to how(/why) the Flag (obstacle) might influence work participation
were based on both evidence from the studies and theories presented by the authors in
the various studies – thus, they do not only constitute valid explanations but may also be
hypotheses or theories proposed by the author group behind the record.
Table H: the evidence grading system
5.3.8. Results
Of the initial 1.762 records retrieved in the literature searches (Figure F – displayed
earlier), a total of 65 were included in the evidence statements on the three potential Black
Flags for work participation: Compensatory systems (n=22), Healthcare systems
(healthcare professionals) (n=35), and Family systems (significant others) (n=7).
47
The results of the synthesis of the evidence (Table I) on the compensatory systems
showed that the evidence supporting the suggestion that receiving worker’s compensation
in itself is an obstacle to work participation is limited (evidence statement no. 1) Instead,
robust evidence suggested that it is in fact the construct and conduct of the systems,
which entail delays in work participation (evidence statement no. 2).
Table I: The evidence statements of the three Flags
These comprised of i.e. financial insecurity during return-to-work, compensatory
regulations unfit for non-specific conditions, and high wage compensation rates.
On the Healthcare systems topic, the results of the synthesis indicated that the
healthcare professionals have the potential to work as an obstacle to work participation
when their practice lacks work-focused guidance (evidence statement no. 3). According to
the records, examples of work-focused guidance were: talking to the worker and the
employer, posing questions and giving advice to the patient about work
48
accommodation/date for return-to-work and prevention of re-injury, and referral to other
relevant healthcare professionals. One of the 21 records contributing to the evidence
statement indicated that injury and workload characteristics worked as confounders on the
effect on work participation. Proposed explanations to why healthcare professionals would
refrain from providing work-focused guiding was: a belief that such guidance was not a
natural part of their professional remit, lack of financial incentives, lack of standard
procedures and role clarity, increasing job demands, distress about the complexity of LBP,
‘incorrect’ beliefs about work and LBP, distrust in the validity of the existing guidelines, and
struggling with acting as both a patient advocate and ‘gate-keeper’ of sickness
certification. Specific examples of work-focused guiding were suggested to be giving the
patient a return-to-work date and guidance on how to prevent recurrence or re-injury.
The evidence also showed that a lack of communication/cooperation between
healthcare professionals and other stakeholders negatively influenced work participation
(evidence statement 4). Lacking communication and/or cooperation was suggested to be
the result of factors such as poor communication skills, poorly communicated and/or
coordinated work participation activities among involved stakeholders, or unidirectional
communication. Furthermore, barriers to communication/cooperation were suggested to
consist of for example: lack of common goals, structural barriers, societal norms,
healthcare professionals’ desire to maintain the professional status quo, lack of trust,
conflicting demands among stakeholders, and healthcare professionals being
unaccustomed with involving others in their practice. One record emphasized the potential
of systematic cooperation between employer, occupational health service and social
insurance office to increase work participation on both a short- and long-term basis.
Another record questioned the effect of stakeholder collaboration because the association
between work participation and stakeholder contact (healthcare professional and
workplace) was weakened when adjusting for variables such as socio-demographic and
job characteristics, pain duration, and co-morbidity.
Finally, (adequate) evidence showed a lack of access to suitable and satisfactory
healthcare could act as an obstacle to work participation (evidence statement no. 5).
According to the interview-studies providing the evidence, suitable and satisfactory
healthcare referred to having easy and quick access to quality healthcare. Easy access
was governed by the type of healthcare (i.e. health insurance) and quick access by the
49
geographical location of it and/or related to demands of the compensatory systems in
terms of the ‘claimant’s status’. Satisfactory healthcare depended on the preferences and
expectations of the patient. Furthermore, the employer was mentioned as an important
player in terms of how a disability claim was handled and if the employment involved
health insurance.
The results regarding the significant others indicated that the behaviour of the significant
other (evidence statement no. 6) negatively influences work participation if the significant
other does not offer appropriate support (adequate evidence). Although ‘support’ was
highlighted in all three records as influential on work participation, it seems that support
was not definitively beneficial. The evidence was inconsistent in the sense that both the
presence and lack of support negatively affected work participation – seemingly depending
on the type of support and the persons involved. Thus, the issue is rather complex and
highly related to interpersonal aspects.
In terms of the beliefs (e.g. fear/negative beliefs/expectations) of the significant others
(evidence statement no. 7), limited evidence constituting an evidence-informed guidance
document supported that such ones could be obstacles to work participation. Furthermore,
three records based on small qualitative studies indicated that the illness perceptions of
absentees are similar to those of their significant others but none of the records
investigated the actual influence of significant others on work participation.
The results of the study led to a range of recommendations for the revising the bio-
psychosocial-informed policies and practices aimed at improving work participation
following a LBP-episode (Table J).
Table J: recommendations for policies and practices to improve work participation following a LBP-episode episode (quote from the published paper)
“•integrating compensatory and health systems to ensure individuals have access to what’s needed, when it’s
needed, in a way which is personalised to their circumstances and needs;
•embedding work as a health outcome to stimulate all health-care professionals to implement work-focused
healthcare, and to promote the need for high quality occupational health provision, which will likely require
changes in the educational curriculum;
•ensuring a consolidation and standardisation of data collection around work participation to facilitate future
workforce planning and capacity requirements: these data will also facilitate a better understanding of what
works for whom, when, and at what cost;
•promoting the positive health benefits of work at a societal level using a public health approach involving all ‘key
players’”
50
6. Discussion
In the following section, the results in each of the studies will be discussed first, followed
by a general discussion of the overall results of the thesis in relation to its overall aim.
6.1. The findings in Study I
The test of the effect of group-based reassuring information at the workplace on LBP-
related behaviour and beliefs showed that in the year following the intervention, the
intervention group reported significantly: more days of work participation, higher overall
work ability, fewer visits to healthcare professionals, lower levels of bothersomeness, and
lower levels of sadness/depression during LBP-episodes compared to the control group.
Furthermore, the intervention group reported more positive back beliefs compared to the
control group at 5.5 months into follow-up. There were no between-group differences in
the reports of days with LBP. It seems reasonable to attribute the group-differences seen
during the follow-up year to the intervention because the analysis included adjustments for
the observed differences in baseline characteristics as well as for the potential influence
from relevant co-variates. Furthermore, the results of the per-protocol analysis and the
intention-to-treat analysis were highly similar. Thus, in response to the specific aim of the
study, our findings did indicate that the information element is effective as an isolated
mean to improve behaviour and beliefs outcomes in a worker population.
The primary outcome LBP-related days of cutting down on activity did not show
between-group differences at follow-up. This may be explained by potential differences
participants’ response to the promotion of “light activity” as advantageous (message in the
talks) - in relation to their potentially different pre-existing activity-norms. In theory, an
alternative response to increased activity based on such a message could be a reduction
of the non-work activity to compensate for continuing work activities. If so, the results
would not necessarily show if a proportion of workers in fact did increase their activity in
response to the talks. The secondary outcome work ability also demonstrated between-
group differences, which, according to Hagen and colleagues, could be expected if one
assumes that work participation and work ability are related [112]. However, it is important
to note that Hagen and colleagues used a condition-specific work ability item as opposed
51
to our, which measured the overall work ability. Frequency of healthcare visits also
seemed influenced by the intervention. However, generally, information-based or
education-based interventions have not seemed effective at reducing use of healthcare
[113]. The level of pain/symptom severity measured as ‘Bothersomeness’ was significantly
reduced following the intervention in the intervention group. The conclusions by other
information-based intervention-studies with similar outcomes have been inconsistent,
though [91, 114, 115]. These studies delivered somewhat different messages in different
ways, so perhaps the effect on pain depends partly on the nature, the style and the
consistency of the messages; a feature that has been considered previously to be
important [104]. Reporting feelings of sadness/depression was also seemingly positively
influenced by the reassuring information. Strong evidence has suggested depression to be
a predictor of chronic pain and disability [116]; however, the nature of the relationship
between depression and pain is largely unknown [117]. Furthermore, the finding was not
supported by the findings from a similar study [114]. Thus, our finding is somewhat
unexpected since it is difficult to see why (positive) information about back pain, delivered
generically outside a healthcare setting, should influence sadness/depression. On the
other hand, we did not distinguish sadness (a state of mind) from depression (a clinical
condition) and getting a benign, non-threatening, and believable explanation to LBP and
reassurance that it seems ‘safe’ to resume normal activities, could perhaps entail positive
alterations in the general mood why our results could reflect alterations in the level of
sadness rather than in the level of depression.
Although it is possible, it seems unlikely that the pamphlets handed out to the
intervention group (one containing key messages from the talks and another containing
illustrations/ instructions on general stretching exercises) played any crucial part in the
effect of the intervention. The ‘reminder-pamphlet’ may have supported the effect of
information from the talks a little. The pamphlet with the general stretching exercises was
not discussed in detail with the participants and the exercises were not demonstrated, why
it is unlikely that they have applied them as part of a daily ‘regime’ to manage their pain.
Moreover, evidence has shown that up to 70% of LBP-patients who have been instructed
e.g. by a physiotherapist to do home exercises do not do them, even if they probably have
been made aware of are important for their recovery from LBP [118].
52
Because only two participants used the option of seeking physiotherapist-advice during
follow-up, this additional aspect in the intervention cannot have played any major part in
the results either.
Our results add to the evidence on information based on the ‘functional-disturbance’-
model and the findings on work participation and back beliefs highly resemble most of the
previous intervention-studies (three of four) involving information on the ‘functional-
disturbance’-model as an intervention-element [90, 92, 94], although these differ in terms
of study population (patient- versus worker-population), setting (clinic versus workplace)
and method of the delivery of the information (face-to-face versus group-based talks).
Our results also add to the existing but sparse evidence from population-based
intervention-studies testing the effects of simple information on pain-related absenteeism
and beliefs-outcomes. According to them, such brief information-based interventions have
been consistently effective at altering beliefs [93, 94, 100, 101]The results of a recent
Danish national campaign among public sector workers supported that [119]. The effects
on absenteeism of such studies have varied though [93, 94, 101, 103]. An important thing
to consider when looking at the overall effects of such information is, of course, the
specific content of the information, the method used to deliver the information and the
‘intensity’ of the information in terms of the duration and repetition of the information. The
existing population-based studies vary greatly on these aspects, why it is difficult to sum
up on the overall effect of them. However, with their consistent effect on pain-related
beliefs, the likely close link between beliefs and behaviour, and the generally simple and
implementable designs of such interventions in mind, they lend hope for the potential of a
suggested future public health-based approach to pain-related work disability [120].
Furthermore, the present study also adds to the discussion of multiple/multidisciplinary
versus simple interventions. Evidence has indicated that simple interventions can be
equally effective at improving various clinical as well as occupational outcomes as the
multiple/multidisciplinary interventions [97, 98]. In addition, a recent review evaluating the
effectiveness and cost-effectiveness of most community and workplace-based
interventions to manage musculoskeletal-related sickness absence and job loss suggested
a future focus on low-cost simple interventions [98]. A response to that was the study by
53
Rantonen et al. (2016), which showed that a highly simple information-based intervention
(the Back Book patient information booklet) was cost effective when compared to the
natural course in terms of reducing healthcare costs and sickness absence [121].
Determining the long-term effects of simple interventions is obviously important. Three
of the previous studies using information on the `functional-disturbance'-model showed
maintained significant effects at six months, one year and five years, respectively,
following the intervention [96, 122, 123]. Although our main outcome measure was 12-
month means, our monthly registrations (Figure C) indicate that the effect at six months
was also evident.
Another issue to consider is that of individual versus population intervention in terms of
aiming the interventions at the individual rather than targeting populations. The present
study confirms that simple educational interventions aiming at a worker-population can
have an influence on work participation for those workers who experience LBP. However,
the literature also support the use of interventions/actions providing individual workplace
support (such as transitional work arrangements) to facilitate work participation for workers
with LBP [73, 105]. According to recent qualitative studies, workers themselves have
suggested that having adjustment latitude/leeway at the workplace improves their
possibilities for coping with LBP at work [124, 125]. To draw an overall conclusion, it
seems that there may be good reasons to consider combining individual and population
educational approaches if behaviour-outcomes are targeted.
One relevant question that our results did not provide evidence for was which part(s) of
the information that was the more influential ones in terms of altering LBP-related
behaviour. Knowing that would help future studies focus their information. Speaking for the
information-part based on the ‘functional-disturbance’-model as being a weighty aspect is
the consistently positive results on work participation shown by the studies using it.
Furthermore, we know that patients seek to get an explanation of their pain conditions
even if they range as ‘non-specific’ and studies have shown that when patients find their
physician’s explanation inadequate, they are dissatisfied, want more diagnostic tests, do
not cooperate well with treatment, and have poorer clinical outcomes [126, 127]. Thus,
54
getting no explanation for their LBP does not favour recovery. In addition, it has been
shown that it is important for the patient that the explanation fit with their own
understanding of their problem in terms of trusting the person, who provides it [128].
Finally, evidence suggest that individual recovery expectations is one of such cognitive
factors working as a prognostic factor for poor outcome on return-to-work in people
suffering from non-specific LBP [129, 130]. Based on this, it seems likely that getting a
benign, non-threatening and believable (although theoretical) explanation to LBP could
entails changes in behaviour and beliefs. On the other hand, information using guideline-
based messages alone has been shown to be effective at altering both back beliefs and
work participation before [93]; however, not consistently [101, 112].
6.1.1. Strengths and limitations
Risk of bias was markedly reduced by the high response-rates and low drop-out rates. It
seems plausible that our data collection method (SMS service combined with telephone
interview), the manageable number of questions in follow-up data-collections, and the fact
that only one investigator (PF) conducted all steps of the study involving participants
contributed to this.
The choice of a cluster-randomization strengthened the study by reducing
‘contamination’ between intervention and control group. Furthermore, ensuring that all five
municipalities were represented in both groups reduced potential bias from
geographical/cultural differences between clusters. The fact that our data was collected on
a monthly basis reduced the risk of recall bias [131].
The limitations of the study constituted some design-related issues. First of all, some
participants may be have ‘learned’ that by reporting “0 LBP days” they would not have to
answer on any more questions during each monthly data collection. This may have
involved bias from the non-detectable proportion of people responding “0 LBP days”, when
they in fact had days with LBP. However, this factor would equally affect the intervention
and control groups, and thus not represent a systematic bias. Secondly, the randomization
resulted in unequal proportions of manual and sedentary workers across the two groups;
however we adjusted for these baseline differences (as well as for differences in gender,
age, smoking, and cluster) in the statistical analyses. A third potential limitation of the
55
study was the fact that the design did not allow us to have the participants blinded to group
allocation. Thus, placebo effects and reporting bias cannot be ruled out. The fact that we
had to rely on self-report may also have been a limitation to the study by potentially
introducing information bias. Finally, a potential source of bias could also be the highly
consistent use of the primary investigator during the recruitment and data collection
phases.
Since 80% of the participants in our study population were manual workers with half or
full day physical work, the findings are highly generalizable to a manual worker population
and less generalizable to a general working population.
Based on the highly simple nature of the intervention, the limitations, and the results of
the study, the obvious next step would be to repeat the study on other populations (other
worker-populations from countries outside Scandinavia) - perhaps in a form that minimize
the risk of bias even more. An example could be to use register-based days of sickness
absence and increase the use of blinding in terms of the researchers conducting the study.
If the results are reproduced to an extent where it seems reasonable to conclude that the
intervention is in fact effective, relevant further investigations would be who benefits from it
and why/how, its effect size, and its cost-effectiveness. This would help determine to what
extent it is relevant to consider implementing it. With regard to the fact that LBP is such a
widespread problem and that it has been suggested that even small or moderate impacts
on those at low or medium risk of LBP-related work disability [104], one could suspect that
the intervention has potential in terms of being one appropriate action targeting LBP as a
public health issue in the nearby future.
6.1.2. Comparing the results of the thesis-studies
The results from Study II provide some potentially relevant information related to Study I.
First of all, the participants were not able to remember any key messages from the talks,
why the topic was abandoned in the following focus-group interviews. Being the statement
of very few we cannot know if it was a general issue in the entire Study I-population,
56
however, assuming that it was, perhaps the messages from the talks were simply forgotten
and replaced by ‘old’ beliefs. Ree et al. (2016) concluded that the highly comparable
intervention to ours by Odeen et al. 2013 produced significant between-group differences
at 3 and 6 months but not at 9 or 12 months, which could imply that maybe our effect is
limited to the first year [94, 122]. Such short-term effect could be explained by the fact that
the participants are constantly subject to the beliefs and behaviour of their surroundings,
which, most likely, are not generally positive/appropriate with regard to the results from
previous population-based studies [100, 102]. Some specific statements from Study II also
seem to support that the effect of the talks may be short-term. the participants described
how high pain intensity fostered feelings of despair, insecurity, and fear of pain
progression, 2) that they highlighted ergonomic training as ideal in terms of managing back
pain at work, 3) they highlighted access to health care as important. The reassuring
information was designed to provide insight that would reduce negative feelings, insecurity
and fear of pain progression. Furthermore, the talks specifically addressed the topics
ergonomic training and treatment in relation to LBP.
It is also a possibility that the participants were not able to repeat any of the key
messages because they did not recollect what they believed before attending the talks. If
so, the talks gave them a new insight and a permanently changed approach to back pain.
A follow-up study at e.g. three years would reveal if this was the case.
The findings from Study III that the beliefs and behaviour of healthcare professionals
and significant others (spouse) influence an individual’s decision to go to work during or
following a LBP episode seems relevant for both the interpretation and the potential further
use of the results from Study I. As mentioned above, being subject to the beliefs and
behaviour of the surroundings likely have some ‘contamination’ effect on an individual
might explain why the messages of the talks were forgotten. It is also a fact, which should
be taken into account when using highly simple and short-term interventions such as that
in Study I.
The overall findings from Study III supporting that contextual factors influence work
participation implies that a highly simple intervention such as that from Study I cannot
stand alone when battling the extensive negative consequences of LBP.
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6.2. The findings in Study II
Study II covered the worker perspective on what challenges their ability to work during a
back pain episode and highlighted potentially helpful actions to improve this ability. Here
the workers emphasized a poor physical work environment and lack of supervisor
trust/support as the main challenges. Actions experienced or believed to improve their
ability to work while in pain were improvement of the physical working environment
(frequent ergonomic training, appropriate equipment, access to health care) on the
supervisor/workplace part and use of individual adjustments/initiatives on their own part.
The results regarding the factors influencing work participation due to back pain showed
that, apart from high pain intensity, job strain and a spouse’s opinion decreased work
participation whereas job strain (in workplaces where workers were organized into small
teams), threatening sickness absence practices, and boredom with being home increased
work participation. The factors experienced to increase work participation were mainly
related to an individual’s context and thus any actions to reinforce them would be on the
workplace/municipality part. However, it is important to note that the present study was a
qualitative study, and rather than guiding political decision-making or constituting high-
quality evidence, the results of it merely act as preliminary indications of what could guide
future research projects.
As mentioned in the section describing the rationale for the present thesis, the amount
of pre-existing evidence on factors influencing work participation (when defined as working
despite pain) with back pain was sparse. Furthermore, most of the retrieved studies
tended to focus on the influence of individual factors rather than factors related to the
workplace or the context. Thus, we had to make more broad-based searches and draw
inspiration from and compare results with studies with a slightly different focus. The results
on the challenges with working during back pain episodes were compared to the results of
four highly comparable qualitative studies and two somewhat comparable quantitative
studies. The results on the factors influencing the decision to call in sick were mainly
compared with literature on obstacles and facilitators for return-to-work and one qualitative
study with a similar focus. Because presenteeism (defined as working while in pain),
absenteeism, and loss of work are linked in a dynamic process, which is not yet fully
understood [16], it seemed reasonable to include evidence on e.g. return-to-work - for the
comparison of our results.
58
Although ‘poor physical work conditions’ and ‘lack of supervisor trust/support’ have not
been specific reported findings in similar studies, it does seem that other studies have
implied something similar to those also constituted challenges according to their study
populations [124, 132]. In terms of the challenge ‘lack of supervisor trust/support’, Tveito et
al. (2010) described how their workers highlighted that being granted with sufficient leeway
not only helped the worker manage pain while working but also made the worker feel
valuable to the management, which is highly similar to the statements from the present
study. ‘Leeway’ was understood as being provided with appropriate equipment as well as
being allowed to make work task modifications (equal to ‘individual adjustments’ in the
present study). [124] Both were mentioned in our findings as part of the either poor
physical work conditions or lack of supervisor trust/support. Another study with a
somewhat similar focus to ours also highlighted factors such as control/flexibility in the
work and unmet need for making adjustments as challenges for remaining at work during
pain episodes [132]. Furthermore, a review by experienced researchers within the field of
work and musculoskeletal conditions also highlighted how a lack of work accommodations
might impede presenteeism and work participation [133]. Where the evidence from the
comparable studies did not mention the physical work conditions specifically, it is widely
accepted that working conditions impeding the possibility of applying assistive devices and
ergonomic working techniques (fc. bio-mechanical ergonomic principles) induce risk of e.g.
back pain. Thus, it seems reasonable to assume that poor physical work conditions (as
defined by us) do act as a challenge to workers in general in terms of managing (back)
pain while working.
Close co-worker relationships acted as a positively aspect in terms of coping with back
pain during pain episodes in the present study, which is in line with what the comparable
qualitative studies [124, 132, 134] and quantitative studies [135, 136] have found. In many
of these studies it is termed “support” or “social support” and is described as coming from
both the co-workers and the management – like in the present study. However, none of
the studies have presented that the organization of the workers might act as a key element
in creating these co-worker relationships. Tveito et al. (2010) did state that their workers
had mentioned team organization as advantageous – because it made it easier to take
over for each other when a pain episode resulted in days off work. Furthermore, one
informant had mentioned that he and some co-workers had formed an informal support
59
group, which gave each other advice and support during pain episodes [124]. Thus, it
seems that small teams or groups could have a positive influence on the ability to cope
with pain at work. In our study, close co-worker relationship was described to foster
verbalization of pain, which was mentioned as positive as well e.g. by entailing helpfulness
between ‘team-members’. Communicating the pain to co-workers was also mentioned as
important by Tveito et al. (2010) because it made it easier for workers to ask for help,
whereas communicating the pain to the management was perceived to valuable when the
workers felt understood and accommodated [124].
The ‘individual adjustments’ and ‘individual initiatives’ described by our workers
somewhat resemble the worker-strategies described by all three comparable studies.
Tveito and colleagues used an overall term: ‘worker strategies’, which constituted altering
work and leisure time activities and routines to get one’s work done, reducing pain
symptoms, using cognitive strategies, and communicating pain effectively [124]. According
to de Vries et al. (2012), workers who stay working during pain episodes have higher pain
self-efficacy [137], which in principle could be linked to making use of self-developed
strategies to relief or endure the pain. Our workers compared their individual adjustments
with traditional ergonomic training - a phenomenon, which was not described in any of the
comparable studies. The fact that they ranked them as inferior to traditional ergonomic
training even though they perceived them as more helpful and applicable, show that they
tend to disregard their own experience and trust ‘the experts’. Perhaps it also implies that
they keep them to themselves instead of sharing their experience with co-workers and
supervisors e.g. due to a generally distrustful social environment.
The factors which according to our workers made them more inclined to call in sick were
high pain intensity, job strain (when perceiving the social environment as non-supportive),
and a spouse’s opinion that going to work was not a good idea. In the literature on the
obstacles for return-to-work, factors, which somewhat resemble these, are mentioned.
High pain intensity could resemble the psychological obstacles: ‘catastrophizing’,
‘unhelpful beliefs and expectations about pain and work’ [105], or ‘fear of re-injury’
[Dionne], which were described to potentially act as obstacles for return-to-work, however
we got no specific explanation from our workers, why it is guessing. The factors job strain
combined with a non-supportive working environment and the beliefs/support from a
spouse have been highlighted as influential on pain-related work disability by both Kendall
60
et al. (2009) and Shaw et al. (2013) [105, 138]. In terms of the factors making our workers
more inclined to go to work during back pain episodes, a combination of job strain and
responsibility towards co-workers increased the likeliness of going to work, which
somewhat resembles the finding by two other qualitative studies. Both describe how their
workers expressed feeling of guilt towards their co-workers if they were absent [132, 139],
which could influence the decision on presenteeism [139]. The positive influence of
threatening sickness absence practices on work participation mentioned by our workers,
have also been supported somewhat by the findings from these studies. One described
how the policies and practices focusing on reducing absenteeism could ‘enforce’
presenteeism while disregarding the severity of the workers condition [132]. The other
described how concerns about the e.g. the managers’ perceptions could influence the
decision to take sickness absence [139]. Finally, our workers mentioned that boredom with
staying home could be decisive in terms of going to work despite back pain. Wynne-Jones
et al. (2011) described that a desire to work was mentioned as positively influencing
presenteeism [139]. Furthermore, de Vries et al. (2011) described how work acted as
therapy during pain episodes by e.g. creating structure and involving social contact, which
ultimately motivated work participation [140].
Overall, when comparing the results of the present study with similar studies as well as
the evidence on factors known to influence work participation outcomes, our findings did
not add new factors. However, it did highlight how some of the core factors become
influential e.g. by mentioning that the organization of workers might be a key to improve
the social environment at work, which ultimately have the potential to reduce the negative
impact of job strain on work participation. Furthermore, it confirmed that a range of
psychosocial factors otherwise known to influence return-to-work also influence the
decision to go to work despite being in pain.
In terms of the abandoned investigative topic concerning the experiences of the talks
given in Study I, one could hypothesize that if we had conducted the interviews at an
earlier stage, we would have been more successful. A Norwegian focus-group study with a
highly similar objective was successful at collecting data on the participants’ experience of
a similar information-based intervention [141]. They conducted their focus group interviews
4-6 months following the intervention whereas our focus-groups were interviewed after
study completion (12 months+). Conducting the interviews during the follow-up period in
61
Study I would have involved some different conditions in terms of inclusion and sampling.
Alternatively, we could have investigated the experience of the talks using questionnaires
with open-ended questions.
6.2.1. Limitations of the study
An obvious limitation of the study was the relative specific group of workers (public sector
manual workers above 35 years of age), who participated. Moreover, they had participated
in a previous study, in which they had received information about coping strategies for
LBP. This might have influenced both their way of coping back pain at work and their
attitudes towards pain-related work absence. Because we did not have a study population
who resembles that of workers in general, naturally, have decreased the transferability of
the results. However, the results are seemingly highly transferable to populations of
manual workers, and with them being generally difficult to recruit for scientific purposes,
our results may be valuable in that respect. Furthermore, our results did resemble those of
other studies, which have included a much more varied group of people in terms of sector,
type of work and background characteristics.
6.2.2. Comparing with the results from Study III
Study II showed that work participation was influenced by two factors suggested to be
Black Flags according to the Psychosocial Flags Framework: a spouse and the workplace
sickness absence policies and practices. Both were confirmed as Black Flags in Study III.
In general, the other mentioned factors: lack of adjustment latitude, job strain (defined as
high work pace), lack of appropriate equipment and working space, and cooperation with
external partners are all potential Black Flags, which could be added to future more
extensive reviews of Black Flags.
6.3. The findings in Study III
From our extracted evidence records, we found that there existed adequate or robust
evidence to support that all three selected factors (‘Black Flags’) have the potential to act
62
as obstacles for RTW. However it is important to note, that as opposed to a classic
systematic review, an evidence synthesis ‘accept’ evidence of lower quality (lower quality
studies and fewer of them) – due to a pre-identified lack of a sufficient number of existing
high-quality studies. Thus, the results should be interpreted with that in mind.
In the present study, limited and inconsistent evidence suggested that receiving
worker’s compensation (‘compensatory systems’) in itself act as an obstacle to work
participation. It has frequently been suggested that having access to such compensation,
in itself, negatively influence disability and work participation [142]. The main argument
has been that ‘rewarding’ people for their disability has led to fraud. One the other hand, a
multi-national study by Anema et al. (2009) indicated that less strict systems involving
easier access to compensation is in fact positively influencing disability and work
participation [143]. Contrarily, a recent critical narrative review argued that a general
source of ‘bias’ in such conclusions is that individuals with risk factors for protracted
disability and several (other) health problems are over-represented among workers who
file compensation claims [142]. Our results also indicated (robust evidence) that it could be
fertile to focus on the construct and conduct of the compensatory systems in order to
improve work participation in people receiving disability benefits or compensation instead -
rather than considering to remove or restrict this welfare service. Specifically, our results
gave indications that we could benefit from having compensatory system-regulations that
reduce financial insecurity during return-to-work/re-education/transition into a new job.
Instead of very high wage compensation rates during the absence and low/no rates during
return-to-work, it would perhaps be better to consider more equalized rates. Furthermore,
it seemed important to consider how the compensatory regulations influence peoples’
incentives to focus on work participation instead of having to justify their entitlement to
compensation or benefits. Finally, our evidence indicated that a part of the problem might
also be the ineffective case management. Altogether, it seems that the welfare societies
may benefit from introducing better worker transitions from being work absent to working
and by increasing people’s incentives and possibilities to focus on work participation.
Regarding the influence from healthcare professionals (‘healthcare systems’), our
evidence pointed towards a need for an improved clinical practice in terms of engaging in
return-to-work as a part of the clinical encounter and communication and cooperation with
other return-to-work stakeholders, in order to improve work participation (robust evidence).
63
To make such changes, it is probably necessary to address actions at the practice of
issuing sick certifications in terms of standard procedures and at the healthcare
professionals in terms of their understanding the clinician’s important role in return-to-work
and willingness to engage in the return-to-work process. This might involve the need for a
change in the culture among clinicians as suggested by Waddell & Burton (2005) [144]. It
will probably also require an improvement in the clinicians’ awareness and knowledge on
the scientific basis of the clinical guidelines, especially in the non-specific conditions such
as most cases of LBP. Another relevant piece of evidence from the present study was that
a lack of access to suitable healthcare could be an obstacle for work participation
(adequate evidence), which could be caused by geographical issues or issues related to
the eligibility according to one’s ‘claimant’s status’. A straightforward solution maybe to
have employers offer workers the necessary healthcare at the workplace. However, this
would require careful considerations about how to ensure that all workers have equal
access, without at the same time, either imposing unreasonable expenses on i.e. small
sized workplaces or the welfare system. Another advantage from having the employer
provide work-focused healthcare is that it might improve the employer-employee
relationship and improve the healthcare professionals/occupational therapist’s
communication and cooperation with both the employer and employee.
In terms of the influence from the significant others (family ‘systems’), adequate
evidence suggesting that their behaviour could act as an obstacle for work participation.
Very little evidence exists on this topic so far, which was also the conclusion by a recent
study attempting to systematically review it in relation to musculoskeletal pain conditions
[145]. Most existing studies investigating the influence from significant others have focused
on chronic pain conditions. A range of them have stated though, that often, significant
others shoulder the burden of care for individuals suffering from pain conditions such as
LBP, why significant others should be considered as an important key to work participation
[146-149]. The present study also gave indications that the beliefs of a significant other
may act as an obstacle for work participation (limited evidence). A potential explanation to
that could be that presented by three small qualitative studies, which stated that significant
others seemingly share the negative illness perceptions of their sick-absent family
members. The authors hypothesized that this might negatively influence the absentee.
64
However, none of the three studies investigated if these beliefs directly affected work
participation [150-152].
The results of the study confirm that the suggested contextual factors seem to
negatively influence work participation, although the quality of the evidence was lower
compared to the results of systematic reviews in general. The conclusion is the best ‘we
can do’ for now. The obvious next step would be adding to the evidence and thereby
enabling a future conduction of less inclusive types of reviews to make more weighty
conclusions. The results of the present study can so far act as a guide for political
decision-making and for scientific researchers in terms of pointing out where more
evidence is needed.
6.3.1. Limitations of the study
Obviously, the best evidence synthesis method involves less strict inclusion and more
judgement in terms of data extraction, the formation of the evidence statements, and the
evidence grading – when compared with a classic systematic review. One way in which it
was attempted to minimizing the risk of bias was to keep a systematic approach through
all parts of the process and make the steps and decisions taken as transparent as
possible. Applying the method and thereby accepting the potential of bias was necessary,
though, in light of the highly sparse evidence on the field. The compromise of using such
inclusive and broad approach evidence can be necessary, though, to provide pragmatic
answers with the purpose of guiding international policy and practice [153].
6.4. General discussion based on the results of the present thesis
The present thesis support the relevance of the bio-psychosocial paradigm – by showing
that, within the field of back pain, factors within all three domains were found to be
influential on work participation outcomes. Study I added evidence to the biological domain
by showing that guideline-based information added a simple, believable, and non-
threatening explanation to LBP positively influence LBP-related behaviour and beliefs.
Study II showed that biologic, psychologic and social factors influences staying at work
during pain and work participation. Finally, Study III added to the social domain by
65
confirming that the suggested contextual factors do have the potential to negatively
influence work participation following a LBP episode.
6.4.1. Multiple/multidisciplinary versus simple interventions
The studies in this thesis all naturally bring up the discussion of simple versus
multiple/multidisciplinary interventions when targeting LBP-related consequences. As
mentioned in the introduction section, studies have shown that the two seem equally
effective on work outcomes [97, 98]. Due to the reasonable assumption (based on limited
evidence so far) that simple interventions are more cost-effective [Jensen], much speaks
for their use. The results from Study I seem to support the simple interventions-approach,
because the highly simple intervention managed to produce significant reductions on the
work participation-outcome among others. The effect size was not interpreted though,
however according to Main and Burton (2012) even small or moderate impacts on those at
low or moderate risk of pain-related disability are likely to deliver large improvements on a
population-based scale [104]. One relevant question that has not been answered, though,
is who benefitted from the intervention and why/how. A Danish intervention-study, which
also used information based on the ‘functional disturbance’-model (and compared it with a
multidisciplinary intervention) did conduct such subgroup analyses and found that
reporting low job satisfaction, no influence on work planning, and feeling at risk of losing
their jobs due to their sick leave seemed to be features involving that an individual
benefitted more from a multidisciplinary approach [154]. Thus, there are indications that
some people might not benefit from the Study I-intervention. More of such specific
knowledge would help determining the rationale for the use of the intervention from Study I
in terms of serving best as a population-based intervention which could be part of a
greater public health action or serving better as an intervention used on specific
subgroups.
The results from Study II and III, on the other hand, seem supportive of a
multiple/multidisciplinary approach, where several factors known to influence LBP-related
work outcomes are targeted at once. Study II showed that factors related to the individual,
the working environment, and the practices/policies at the workplace influenced the ability
to work despite pain and the decision to call in sick. Study III confirmed that suggested
66
factors belonging to an individual’s context (compensatory systems, healthcare systems,
and family systems) have the potential to act as obstacles for work participation. The
designs of the studies did not allow for interpretations on the degree of influence from each
aspect. Based on the results from the two studies and the existing evidence on the many
influential factors, it is difficult to imagine that addressing at least some of these factors too
(together with an intervention such as the one from Study I) would not improve the
outcomes. However, to know which factors to target, more knowledge is needed on the
impact of the single factors and how/if they interact. Speaking against simply adding more
elements to e.g. the Study I-intervention is the phenomenon described by two recent
Norwegian studies, which indicated that adding more seemingly relevant elements to the
Study I-intervention does not necessarily add to the effect as well [155, 156]. In support of
that, Karjalainen et al. (2004) concluded that the more elements that were added to a mini-
intervention highly similar to the Study I-intervention, the less effective the intervention
became [157].
However, instead of going for either/or perhaps we should consider a both/and. Until a
sufficient amount of quality studies have determined how to stratify interventions according
to the differential needs of the large proportions suffering from acute/subacute and chronic
LBP, one might consider taking a stepped approach where the simple population-based
interventions are used as a start. This will help a proportion of the people to stay working
or resume work and probably start an important alteration in the beliefs and attitudes
general population (including healthcare professionals), which seems necessary in the
long term. Then one could consider adding more complex actions or interventions aimed
at the people that did not benefit sufficiently from the population-based approach. By
taking on such a stepped approach it may be possible to intervene broad-based but at
lower cost than if a multiple approach was used on everyone with LBP and to maintain a
‘how little is best’-approach, which seems important.
6.4.2. Individual versus ‘whole-systems’ approach
In line with the idea of a stepped approach perhaps it is also most effective to combine the
use of an individual approach with a ‘whole-systems’ approach. Some actions will target
the individual and some will target the workplace and e.g. compensatory or the healthcare
67
systems too. However, when looking at a stepped approach as a whole it will fit the ‘whole-
systems’ approach.
68
7. Conclusion
The studies in this thesis all added to the evidence on factors of the biological,
psychological, and social domains of the bio-psychosocial paradigm, which influence LBP-
related behaviour. A cluster-randomized controlled study showed that providing workers
with guideline-based information including a benign, non-threatening, and believable
biological explanation for most cases of LBP, produced significant alterations in LBP-
related behaviour (e.g. work participation and overall workability) and in back beliefs. The
intervention constituted a novel non-medical intervention targeted at peoples’
understanding of the ‘bio’-component. A focus-group interview study showed that when
manual workers experience their physical work environment as poor and do not feel
trusted/supported by their supervisor, their perceived ability to work during back pain
episodes was impeded. Furthermore, the study showed that, in addition to pain intensity,
workplace and personal factors also influenced a worker’s decision to call in sick due to
back pain. Finally, a best-evidence synthesis confirmed that selected contextual factors
(‘Black Flags’ - compensatory systems, healthcare professionals, and significant others)
have the potential to acts as obstacles for work participation.
The studies in the present thesis have added important evidence to ill-understood areas
and helped to fill gaps in the existing knowledge. In addition, their results added to the
highly relevant ongoing discussions about ‘how and when to intervene and on who?’ in
terms of finding effective ways to reduce the negative consequences of back pain for the
individual, the workplace, and the society.
69
8. Future perspectives
With the current situation, where we do not fully understand the patho-anatomic
background for most cases of back pain, the best that scientific researchers can do is to
try to uncover how to intervene/act and on who. The best that clinicians can do is to
approach LBP using a ‘whole-person’ approach and inform the patients thoroughly about
what we know and do not know about back pain and how the patient can handle the pain -
in line with the clinical guidelines. Studies have shown that large proportions of healthcare
professionals do not adhere to the clinical guidelines in their management of patients with
musculoskeletal conditions [158-161]. This is a tendency which seems highly related to
their negative beliefs and attitudes about back pain e.g. fostered by a bio-medical
approach to back pain [162]. The previous studies, which have evaluated the beliefs and
attitudes in the general population, also indicate a need for a better basis of knowledge
among the people [100, 163]. Intervention studies have been consistently effective at
altering negative beliefs [93, 100-102], and some of them have also been successful at
altering work outcomes [93, 100]. Thus, it seems relevant to consider introducing e.g.
media-/public health campaigns more widely and consistently. Based on the evidence from
the present thesis and the existing knowledge from previous scientific research, such
campaigns could constitute the first of a range of actions in a ‘stepped approach’ designed
to address back pain at any stage. The proposed public health campaign will, with time,
alter the beliefs and attitudes among the general population, including healthcare
professionals, and will probably help a proportion of people to handle future back pain
episodes. Next, various actions within the various public sectors and the labour market
sector could follow. Such a stepped approach may be seen as a way of operationalizing
the idea of ‘how little is best’ in order to address the differing need of the individuals
experiencing back pain. Improvements within the labour market of e.g. the workers’
possibilities to modify their work during pain-episodes and the support from their
supervisors could be some of the following steps. Another could be actions to improve the
knowledge and practice of future and current doctors (general practitioners and hospital
doctors) in terms of providing work-focused guiding and thorough reassuring information to
the patients as part of the clinical encounter. Both steps can be seen as improvement of
the public health approach to back pain. In order to improve the people in need for
secondary preventions, a seemingly relevant step could be to take actions to reduce the
70
incentives that might exist within the compensatory systems which tend to keep people
from returning to work such as financial insecurity during the transition from sick absent to
back at work. Within the healthcare system engaging the patients and their significant
others in the patient’s own care seem relevant and tailoring the treatment to address
individual risk-factors for chronicity and (work) disability. Finally, much speaks for
continuing to improve the interdisciplinary communication and cooperation between e.g.
general practitioner, hospital, job centres, and employer for this group of patients.
Such a stepwise approach would be in line with the ‘all players onside and acting’-
message promoted by several scientific researchers over the past decades [108, 109, 164]
and furthermore, it constitute both a ‘whole systems’ and ‘whole-persons’-approach, which
based on the current knowledge is highly relevant for conditions such as back pain.
71
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Workload due to Lifting for Preventing Work-Related Low Back Pain. Ann Occup
Environ Med. 2014 Jun 24;26:16.
79
80. Forssell MZ. The back school. Spine (Phila Pa 1976). 1981 Jan-Feb;6(1):104-6.
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91.
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99. Jensen C, Nielsen CV, Jensen OK, Petersen KD. Cost-effectiveness and cost-
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Appendix 1:
Pamphlet with the key messages from the talks
(Study I)
Tilli
d t
il ry
ggen
– o
g ar
bej
det
Ph
.d. p
roje
kt o
m læ
nd
ery
gsm
erte
r
20
12
-20
14
v. V
ide
nce
nte
r fo
r R
ygsy
gdo
mm
e
Tilli
d t
il ry
ggen
– o
g ar
bej
det
Fin
ansi
eret
af
Glo
stru
p H
osp
ital
&
Gig
tfo
ren
inge
n
Har
du
sp
ørg
smål
til
aktu
elle
ryg
smer
ter
er d
u
velk
om
men
til
at k
on
takt
e P
ern
ille
på
tlf.
38
63
42
52
Ryg
fakt
a:
Lan
gt d
e fl
este
tilf
æld
e af
læn
der
ygsm
erte
r h
ar in
gen
alv
orl
ig
bag
ved
ligge
nd
e år
sag
som
får
lan
gvar
ige
følg
er. O
g d
e fo
rtag
er
sig
oft
est
ind
enfo
r d
age/
uge
r –
af s
ig s
elv.
Aku
t læ
nd
eryg
smer
te e
r n
orm
alvi
st i
bed
rin
g in
den
for
få d
age
elle
r u
ger
– i h
vert
fal
d n
ok
til a
t m
an k
an f
ort
sætt
e si
ne
no
rmal
e ak
tivi
tete
r.
No
gle
gan
ge v
arer
læn
der
ygsm
erte
rne
ved
ove
r en
læn
gere
p
erio
de,
me
n d
et b
etyd
er s
tad
ig ik
ke, a
t d
et e
r u
dtr
yk f
or
no
get
alvo
rlig
t. N
orm
alvi
st a
ftag
er s
mer
tern
e ti
l sid
st –
men
det
er
nat
url
igvi
s fr
ust
rere
nd
e, a
t m
an ik
ke v
ed, h
vor
lan
g ti
d d
er g
år.
Om
krin
g h
alvd
ele
n a
f d
em, d
er f
år læ
nd
eryg
smer
ter,
får
nye
sm
erte
-ep
iso
der
ind
enfo
r et
par
år.
Det
bet
yde
r st
adig
ikke
at
det
er
alvo
rlig
t. M
elle
m s
mer
te-e
pis
od
ern
e le
ver
de
fles
te e
t h
elt
no
rmal
t liv
med
få
elle
r in
gen
sm
erte
r.
Din
hån
dte
rin
g af
sm
erte
rne
i sta
rten
af
epis
od
en e
r vi
gtig
. Se
nge
leje
i m
ere
en
d é
n d
ag e
ller
to d
age
har
ikke
no
gen
gav
nlig
ef
fekt
på
smer
tern
e. T
vært
imo
d, -
det
kan
fak
tisk
væ
re
med
virk
end
e ti
l at
per
iod
en m
ed s
me
rter
, sti
vhed
og
ind
skræ
nke
de
bev
æge
lser
fo
rlæ
nge
s.
Din
ryg
er
skab
t ti
l bev
æge
lse
– d
en h
ar b
rug
for
bev
æge
lse
– m
ege
t b
evæ
gels
e. J
o h
urt
iger
e, d
u b
egyn
der
at
bev
æge
dig
og
ven
de
tilb
age
til d
it v
anlig
e ak
tivi
tets
niv
eau
, jo
hu
rtig
ere
får
du
d
et b
edre
.
Den
bed
ste
måd
e at
hån
dte
re læ
nd
eryg
smer
ter
på
er a
t fo
rbliv
e ak
tiv
i det
om
fan
g, d
et k
an la
de
sig
gøre
og
un
dgå
at
foku
sere
på
smer
tern
e.
Mo
dsa
t h
vad
de
fles
te t
ror.
.
- M
ange
ryg
smer
ter
kom
mer
fra
det
væ
v, d
er s
kab
er
bev
æge
lse
i ryg
gen
– m
usk
ler,
sen
er, l
edb
ånd
og
små
led
. Sm
ert
ern
e er
et
ud
tryk
fo
r, a
t d
er m
idle
rtid
ig e
r gå
et k
uk
i ry
ggen
s ’b
evæ
geap
par
atu
r’. I
såd
an e
n s
itu
atio
n e
r b
evæ
gels
e m
ed t
il at
sti
mu
lere
kro
pp
ens
evn
e ti
l at
gen
fin
de
bal
ance
n m
elle
m d
e ar
bej
den
de
mu
skle
r, le
d o
sv.
-
An
dre
sm
erte
r sk
yld
es f
orm
en
tlig
at
vi a
lle f
år n
ogl
e n
atu
rlig
e fo
ran
dri
nge
r i r
ygge
n m
ed t
iden
, so
m k
an g
ive
smer
ter
i per
iod
er. H
vord
an f
ora
nd
rin
gern
e u
dvi
kler
sig
og
hvo
rnår
er
bes
tem
t af
vo
res
gen
etik
. Lid
t lig
eso
m m
ed g
råt
hår
.
- D
in læ
ge/b
ehan
dle
r vi
l oft
e ik
ke k
un
ne
ud
peg
e ki
lden
til
smer
tern
e, n
år d
et d
reje
r si
g o
m a
lmin
de
lige
læn
der
yg-
smer
ter.
Hel
ler
ikke
sel
v o
m h
an/h
un
sen
der
dig
til
røn
tgen
/MR
. Ige
n, d
et k
an v
ære
fru
stre
ren
de
ikke
at
vid
e p
ræci
s h
vad
der
giv
er s
mer
tern
e. M
en o
mve
nd
t ka
n d
u
tæn
ke, a
t d
u s
å ve
d a
t d
et ik
ke e
r u
dtr
yk f
or
at d
in r
yg e
r i
no
gen
alv
orl
ig t
ilsta
nd
.
- A
f d
e år
sage
r vi
ken
der
til,
så
er g
enet
ik, d
en d
er b
etyd
er
mes
t fo
r o
m m
an f
år d
isku
s-p
rola
ps
i læ
nd
en. B
elas
tnin
ger
bet
yder
der
imo
d m
eget
lid
t fo
r u
dvi
klin
gen
af
såd
an é
n. D
vs.
at d
u a
ltså
ikke
slid
er d
ig t
il en
dis
kusp
rola
ps
med
de
bel
astn
inge
r, d
u e
r u
dsa
t fo
r et
no
rmal
t ar
bej
ds-
elle
r fr
itid
sliv
. Du
kan
sag
ten
s h
ave
en
pro
lap
s d
u ik
ke m
ærk
er
no
get
til o
g lig
eso
m e
n s
mer
tegi
ven
de
pro
lap
s fo
rsvi
nd
er
den
oft
est
af s
ig s
elv
igen
.
Hvo
rnår
sø
ge læ
ge?
Læge
n k
an a
fkla
re o
m d
er e
r ta
le o
m a
lmin
del
ige
rygs
mer
ter
elle
r en
mer
e a
lvo
rlig
tils
tan
d. E
r d
u b
ekym
ret
for
din
e
rygs
mer
ter,
og
usi
kker
på
hvo
rdan
du
ska
l hån
dte
re d
em, s
å ka
n
det
væ
re e
n g
od
idé
at o
psø
ge læ
gen
, så
du
får
afk
lari
ng.
Hvi
s d
u h
ar s
være
sm
erte
r d
er e
r ti
ltag
end
e o
g so
m e
vt. g
ør
dig
uti
lpas
Hvi
s d
u h
ar p
rob
lem
er m
ed a
t ko
ntr
olle
re v
and
lad
nin
g el
ler
affø
rin
g
Hvi
s d
u f
x ve
d t
oile
tbes
øg
mæ
rker
at
du
er
føle
lses
løs
om
krin
g
end
etar
m e
ller
køn
sorg
aner
Hvi
s d
u o
ple
ver
føle
lses
løsh
ed, p
rikk
en, s
nu
rren
elle
r st
ikke
n
elle
r sv
agh
ed i
ben
ene
Hvi
s d
u o
ple
ver
plu
dse
lige
pro
ble
mer
med
at
styr
e d
ine
ben
Hvi
s d
u p
lud
selig
t o
ple
ver
ned
sat
kraf
t i b
enen
e
Gen
ere
l uti
lpas
hed
og/
elle
r p
lud
selig
t væ
gtta
b
Når
uh
eld
et e
r u
de.
.
Ved
aku
tte
ryg
smer
ter
kan
du
med
fo
rdel
:
Bru
ge d
e m
idle
r ti
l at
kon
tro
llere
sm
erte
n m
ed, s
om
du
erfa
rer
virk
er; f
x sm
erte
still
end
e m
edic
in, u
dst
rækn
ing
og
kuld
e/va
rme.
Du
kan
ogs
å p
røve
beh
and
ling
såso
m
mas
sage
, man
ipu
lati
on
(fx
kir
op
rakt
or)
, aku
pu
nkt
ur
etc.
Vir
ker
beh
and
linge
n ik
ke e
fte
r 3
-4 g
ange
, så
virk
er d
en
san
dsy
nlig
vis
ikke
.
Mo
der
ere
din
e ak
tivi
tete
r lid
t d
e fø
rste
par
dag
e, h
vis
det
er
nø
dve
nd
igt.
Forb
live
op
peg
åen
de
og
i gan
g o
g i d
et h
ele
tag
et f
ort
sætt
e
med
dit
liv
som
no
rmal
t
Væ
re a
lsid
ig i
din
e ak
tivi
tete
r, s
å d
u ik
ke f
orb
liver
i én
sti
llin
g
for
læn
ge (
fx s
idd
er o
ver
lan
g ti
d).
Fo
rker
te b
evæ
gels
er e
ller
still
inge
r fi
nd
es ik
ke –
hel
ler
ikke
sel
vom
de
gør
on
dt,
- b
are
sørg
fo
r at
var
iere
din
e b
evæ
gels
er o
g sk
ift
still
ing
oft
e.
Appendix 2:
Pamphlet with general stretching exercises
(Study I)
Træningsvejledning
Det er vigtigt, at du er instrueret af en fysio- eller ergoterapeut i at udføre øvelserne.
Bevægelighedsøvelser til patienter med lænderygsmerter
Rigshospitalet-GlostrupKlinik for Ergo- og Fysioterapi
1
August 2017
.
Rigshospitalet-Glostrup Fysioterapiafsnittet
Tlf. nr: 38 63 30 92E-mail: [email protected]: www.rigshospitalet.dk
UdspændingsøvelserI denne pjece finder du forskellige strækøvelser. Strækøvelserne kan være med til at opretholde din normale bevægelighed, og de kan lindre smerten i stram og opspændt muskulatur.
I samråd med fysioterapeuten udvælges øvelser specielt til dig. Øvelserne skal ses som et sup-plement til dine almindelige dagligdags bevægelser. Du kan vælge at lave øvelserne hver dag eller en gang i mellem, når du har overskud og energi til det. Husk at: ’Selv den længste rejse begynder med et skridt…’
Bevægelighedsøvelser for ryggen
Øvelse 1Sid yderst på en stol. Rund så meget du kan og hold stillingen et par sekunder. Svaj så meget du kan og hold stillingen et par sekunder.
Rigshospitalet-GlostrupKlinik for Ergo- og Fysioterapi
2
Øvelse 2.1Stå på alle fire. Rund så meget du kan og hold stillingen et par sekunder.
Øvelse 2.2Svaj så meget du kan og hold stillingen et par sekunder.
Øvelse 3.1Knæalbuestående. Rund så meget du kan og hold stillingen et par sekunder.
Øvelse 3.2Svaj så meget du kan og hold stillingen et par sekunder.
Rigshospitalet-GlostrupKlinik for Ergo- og Fysioterapi
3
Øvelse 4Stå på alle fire. Træk hofte op mod skulder i den ene side. Kig efter den optrukne hofte. Gentag til modsat side.
Udspænding af ryggens muskulatur
Øvelse 5Rygliggende. Træk begge knæ mod maven.
Øvelse 6Sid på knæ. Før kroppen frem ned mod underlaget. Lad hovedet hvile mod underla-get. Armene kan placeres bagud eller fremad.
Rigshospitalet-GlostrupKlinik for Ergo- og Fysioterapi
4
Øvelse 7Sid på en stol. Bøj forover og forsøg at få fat i begge ankler/stoleben.
Øvelse 8Rygliggende med bøjede ben. Før højre ben over venstre og træk mod højre. Gentag til modsat side.
Øvelse 9Stå med det ene ben krydset foran det andet. Løft armen over hovedet og læn kroppen over til modsat side.
Rigshospitalet-GlostrupKlinik for Ergo- og Fysioterapi
5
Øvelse 10Rygliggende med bøjede ben. Roter begge ben til en side og hold modsatte skulder i underlaget.
Udspænding af haser
Øvelse 11Sid yderst på en stolekant. Stræk det ene ben frem med hælen i underlaget. Hæld kroppen frem.
Udspænding af lårets forside
Øvelse 12Sideliggende med nederste ben bøjet. Tag fat om anklen på det øverste ben og træk benet bagud. Gentag på modsat side.
Udspænding af ballens muskulatur
Øvelse 13Rygliggende med bøjede ben. Sæt den ene fod på en væg og læg den anden fod på knæet.
Rigshospitalet-GlostrupKlinik for Ergo- og Fysioterapi
6
Øvelse 14Rygliggende med bøjede ben. Læg den ene fod på modsatte bens knæ. Løft knæet mod maven og hold om låret.
Udspænding af mavens muskulatur
Øvelse 15Maveliggende med albuerne i underlaget. Før ryggen bagud.
Udspænding af brystmuskulatur
Øvelse 16Stående i dørkarm med armene placeret vandret. Før brystkassen frem.
Udspænding af hoftens forside
Øvelse 17Stående med det ene ben på stol. Før hoften frem.
Appendix 3:
Baseline questionnaire
(Study I)
Appendix 4:
Interview guide
(Study II)
Appendix 5:
Example of an Evidence Table
(Study III)
Evid
en
ce
ta
ble
s
Ta
ble
1:
Wo
rke
r’s
co
mp
en
sa
tio
n
Ta
ble
1:
Wo
rke
r’s
co
mp
en
sa
tio
n (
n=
22
)
Au
tho
rs
Ke
y f
ind
ing
s
[R
evie
we
rs’ co
mm
ents
in
ita
lics in
sq
ua
re b
rackets
] S
pare
co
lum
n
C
ord
en A
&
Sa
insbu
ry R
(200
1)
Q
ual.
Pro
ject:
• d
iscu
ssio
ns
with
ke
y
adm
in. sta
ff
• in
terv
iew
s
with
clie
nts
(n=
34
)
• g
roup
exe
rcis
es w
ith
adm
in. sta
ff
Inca
pa
cit
y b
en
efi
ts a
nd
wo
rk in
ce
nti
ve
s
Indiv
. In
terv
iew
s:
Pa
rtic
ipan
ts i
n w
ere
peo
ple
wh
o h
ad
bee
n d
oin
g s
om
e k
ind o
f th
era
pe
utic w
ork
fo
r som
e
tim
e a
t th
e p
oin
t of th
e inte
rvie
w.
’Th
e w
ork
in
centive
me
asu
res c
ove
red
in
th
e r
ese
arc
h a
re d
esig
ned p
art
ly t
o r
edu
ce r
isk a
nd u
nce
rta
inty
. C
lients
em
ph
asis
ed t
he im
port
ance
of m
ain
tain
ing
inco
me s
ecurity
and
ade
qu
acy,
and o
bsta
cle
s p
erc
eiv
ed
inclu
de
d:
• th
e r
isk o
f lo
sin
g in
cap
acity b
en
efits
alto
ge
ther
• a r
isky tra
nsitio
n p
erio
d in
movin
g o
ff in
cap
acity b
en
efits
onto
earn
ings
• b
elie
f th
at th
ey w
ere
una
ble
to
aff
ord
wo
rk
• b
elie
f th
at
wo
rk w
ill n
ot le
ad
to
be
ing
be
tte
r off
•
bein
g u
na
ble
to s
usta
in p
aid
wo
rk
• n
ot u
nd
ers
tand
ing th
e o
ppo
rtu
nitie
s a
nd
co
nstr
ain
ts o
f th
e b
en
efits
/ ta
x c
redits s
yste
ms’
[O
bst
acl
es f
or e
ng
ag
ing
in
wo
rk u
po
n r
ecei
vin
g b
enef
its
com
pri
sed
of
asp
ects
co
nce
rnin
g f
ina
nci
al
situ
ati
on
, b
elie
fs
tha
t it
wa
s n
ot
hel
pfu
l to
the
ir o
vera
ll si
tua
tio
n, u
nd
erst
an
din
g t
he
com
pen
sato
ry s
yste
ms,
ta
x a
nd
wo
rk r
egul
ati
on
s]
Fro
m O
penG
rey
Ole
inic
k A
et
al.
(
199
6)
Co
ho
rt
Fac
tors
aff
ecti
ng
fir
st
retu
rn t
o w
ork
fo
llo
win
g a
co
mp
en
sab
le o
cc
up
ati
on
al
bac
k i
nju
ry
Pa
rtic
ipan
ts h
ad
be
en d
isa
ble
d e
ith
er
</>
8 w
eeks d
ue
to
back inju
ry.
Be
yo
nd
8 w
eeks,
ag
e,
esta
blis
hm
en
t siz
e a
nd
, to
a le
sser
deg
ree,
wa
ge
co
mp
en
satio
n r
ate
pre
dic
t d
ura
tion
of
wo
rk d
isa
bili
ty.
Orig
inal se
arc
h
Ta
ble
1:
Wo
rke
r’s
co
mp
en
sa
tio
n (
n=
22
)
Au
tho
rs
Ke
y f
ind
ing
s
[R
evie
we
rs’ co
mm
ents
in
ita
lics in
sq
ua
re b
rackets
] S
pare
co
lum
n
(n=
86
28
)
Follo
w u
p a
t 4
ye
ars
’Th
e e
ffe
ct of
co
mp
ensa
tio
n r
ate
, a
lth
oug
h n
ot
sig
nific
ant fo
r a
ny s
ing
le s
ub
cate
go
ry o
f w
eekly
co
mp
en
satio
n,
sug
ge
sts
th
at h
igh a
nd
low
co
mp
en
satio
n r
ate
s influ
en
ce r
etu
rn t
o w
ork
. W
ork
ers
in t
he
tw
o
low
est g
roup
s r
etu
rn e
arlie
r th
an t
he 6
4.4
% o
f w
ork
ers
in t
he r
ang
e $
15
0-3
49,
wh
ile t
hose
at th
e u
pp
er
end
retu
rn late
r.’
[Hig
h w
ag
e co
mp
ensa
tio
n r
ate
s m
ay
be
an
ob
sta
cle
for
RTW
. Es
tab
lish
men
t si
ze m
ay
als
o i
nfl
uen
ce d
ura
tio
n o
f d
isa
bili
ty.]
Me
rrill
A.P
(1
99
7)
Critica
l re
vie
w
Wo
rke
r's c
om
pe
ns
ati
on
, liti
gati
on
, a
nd
em
plo
ym
en
t fa
cto
rs in
re
turn
to
wo
rk
Qu
ote
: ‘O
ve
rall,
th
e lite
ratu
re e
xa
min
ing
th
e e
ffect of
wo
rkers
' com
pen
sation
on
re
turn
to
wo
rk is
incon
clu
siv
e.’
Stu
die
s in
clu
de
d in
th
e r
evie
w v
ary
in
te
rms o
f o
utc
om
e v
ariab
les, m
eth
ods a
nd
de
sig
n a
nd
ha
ve
ob
vio
us
fla
ws o
r sh
ort
com
ing in
ord
er
to d
ete
rmin
e w
heth
er
or
not
an a
ssocia
tion e
xis
ts.
[Wo
rker
’s c
om
pen
sati
on
can
no
t b
e d
eter
min
ed t
o b
e a
n o
bst
acl
e fo
r R
TW b
ase
d o
n t
he
retr
ieve
d e
vide
nce
bec
au
se
this
is in
con
clu
sive
an
d t
he
qu
alit
y o
f th
e in
clu
ded
stu
dies
is p
oor
.]
Orig
inal se
arc
h
To
lliso
n D
et
al.
(1
99
3)
Co
ho
rt w
ith
6
mo
nth
s f
ollo
w-
up
(n=
61
)
Co
mp
en
sa
tio
n s
tatu
s a
s a
pre
dic
tor
of
ou
tco
me
in
no
n-s
urg
icall
y t
rea
ted
lo
w b
ac
k in
jury
Pa
rtic
ipan
ts w
ere
e
ith
er
receiv
ers
o
r n
on
re
ceiv
ers
o
f co
mp
en
satio
n w
ag
e,
sig
ned
u
p fo
r a
fu
nctio
na
l re
sto
ration
pro
gra
m.
At
6 m
onth
s f
ollo
w-u
p,
pain
ra
tes h
ad
decre
ased
mo
re a
mo
ng
non
-com
pen
sate
d w
ork
ers
(sig
nific
ant
diff)
a
lth
ou
gh m
edic
ine inta
ke w
as h
igh
er
am
ong
com
pen
sate
d w
ork
ers
(d
iff no
t sig
nific
ant)
.
Mo
re w
ork
ers
in
th
e n
on-c
om
pe
nsa
ted
gro
up
retu
rne
d t
o w
ork
at
dis
ch
arg
e t
han
in
th
e c
om
pe
nsate
d g
roup
(31%
vs. 1
3%
P=
0.0
8)
bu
t n
o d
iffe
rence w
as s
een
at 6
mo
nth
s (
52%
vs. 50
%).
[Up
on
dis
cha
rge
fro
m a
fu
nct
ion
al r
esto
rati
on
pro
gra
m,
sig
nif
ica
ntl
y m
ore
wo
rker
s fr
om
th
e n
on
-co
mp
ensa
ted
gro
up
re
turn
ed t
o w
ork
how
ever
, no
dif
fere
nce
exi
sted
at
6 m
on
ths.
Th
us,
bei
ng
co
mp
ensa
ted
ma
y b
e a
n o
bst
acl
e fo
r ti
mel
y R
TW b
ut
no
t fo
r R
TW in
gen
era
l]
Fro
m E
xp
ert
Lis
t
Published Studies
Paper I