The research team also found strong evidence that the following factors do not influence return-to-work (RTW) among those with acute low-back pain: • lifestyle (e.g. smoking, drinking); • pain catastrophizing (e.g. an individual’s de-scription of pain as aw-ful, horrible and unbear-able); and • level of education. There was moderate evi-dence that the following fac-tors influence RTW among those with acute low-back pain: • workplace psychosocial environment (i.e. factors related to work pace, control and social sup-port); • claim-related issues (i.e. type, timeliness and per-ceived fairness of claims for disability benefits); • job tenure; prior claim or injury; • and • treatment-related issues (e.g. health-care pro-vider response to patient pain). There was moderate evi-dence that the following fac-tors do not influence RTW among those with acute low-back pain: • findings from clinical examinations; and • depression. In an IWH systematic re-view, “strong evidence” means consistent findings came from more than one high quality study. Findings that are consistent across multiple medium-quality studies, or from at least one high-quality study and at least one medium-quality study, are considered “mod-erate evidence.” Findings that are not consistent, or that come from low-quality studies, are reported as “in-26 Canadian Chiropractor June 2016 sufficient evidence.” In sum, workers’ recovery expectations are the strong-est predictor of return to work. As supported by many high-quality studies, those who expect to recover and return to work more quickly, do so. Therefore, a simple question asking about recov-ery expectations during the screening or assessment of workers in the early stages of acute low-back pain could help identify those at high risk of long work absences and, consequently, in need of extra attention to help them recover and return to work more quickly. The next factor supported by strong evidence is the nature of the treatment or care workers receive for their acute low-back pain. The type of health-care provider and the type of care provided matter. For example, some studies show that seeking care from a chiropractor re-sults in shorter time on disa-bility. There is strong evidence to show workers’ reports about their pain intensity and func-tional limitations are predic-tive of return to work: the greater the self-reported pain and physical limitations, the slower the return to work. Since both can be easily measured in several ways with well-validated question-naires, they should be in-cluded in assessments to de-termine those at high risk of long-duration absences. There is strong evidence to show that the presence of radiating pain is associated with longer periods off work. However, radiating pain – often used as a meas-ure of injury severity – is usually considered to be a “red flag” during clinical assessments, an indication of potential neurological SCREENING TOOL The ability of individuals to recover from low-back pain and return to work is influenced by psychological issues and their interaction with social factors. It sometimes helps to have a tool to screen for these “psychosocial issues” – especially a tool that can indicate what the specific problems are and the types of targeted interventions needed to help them recover and return to work sooner. Dr. Ivan Steenstra, IWH associate scientist at the time and lead author of the systematic review on factors affecting return to work following acute low-back pain, was more recently part of a team that developed a psychosocial screening tool to estimate the likelihood that workers with acute low-back pain can quickly recover and return to work within three months after an injury. This tool, a questionnaire of 46 items, called the Pain Recovery Inventory of Concerns and Expectations (PRICE) also groups workers into four risk categories, allowing clinicians to target interventions. Research shows it’s a valid and reliable tool for identifying what intervention programs may help them most. The research examined the four groupings of patients: those at minimal risk, those with emotional distress (e.g. for depressive symptoms, pain intensity, pain catastrophizing, activity avoidance, functional limitations and life impact of pain), those with activity limitations, and those with organiza-tional concerns. It found among the four risk subgroups, those scoring high for emotional distress were seven times less likely than those in the low-risk group to be back at work within three months. Those in the other two subgroups – high physical limitations and workplace concerns – stood only a slightly higher chance than those in the low-risk group of not being back at work. “This tool looks at low-back pain patients as different subgroups, which most other prognostic studies tend not to do,” Steenstra says. “Using this approach, we find certain factors may be important for certain subgroups, but not for all. That may be why pain catastrophizing appears to be an important factor with this tool but not in the IWH systematic review.” As a result of these findings, Steenstra says, clinicians can target interventions needed to help prevent long-term disabil-ity. For example, for patients lacking organizational support, interventions might include participatory ergonomics interventions, facilitated communication with supervisors or problem-solving to address workplace barriers. For patients with severe emotional distress, interventions might include group or individual sessions applying cognitive-behavioural strategies to address unhelpful pain beliefs, strengthen coping skills and learn pain self-management. For patients with severe pain and activity limitations but without emotional distress, interventions might focus on pain education, graded exercise and exposure to gradual activity. www.canadianchiropractor.ca
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