The reliability and validity of a measure of perceived functional capacity for work in chronic back pain

Psychosocial factors, including perceived disability and self-efficacy, are important determinants of outcome for individuals with chronic back pain. Consequently, there is a need for an evaluation and consideration of such factors in occupational rehabilitation. This study evaluated the reliability and validity of a tool, the Spinal Function Sort, as a measure of perceived capacity for work-related tasks with 42 rehabilitation clients with chronic back pain. Results provided support for the internal consistency (Cronbach's alpha of 0.97), test-rest reliability (ICC of 0.89) and construct validity of the Spinal Function Sort as a measure of perceived capacity for work-related tasks in persons with chronic back pain. Measures of similar constructs were significantly correlated with the Spinal Function Sort and were highly predictive of the Spinal Function Sort on multiple regression. Relationships between perceived work capacity and pain intensity and gender are discussed. The need for the consideration of perceived capacity in the evaluation and rehabilitation of persons with chronic back pain is highlighted.     

Spinal troubles in sewage workers: epidemiological data and work disability due to low back pain

Objectives: To determine the prevalence of spinal troubles (i.e., neck, upper back and low back pain) in a population of sewage workers, and to establish the effect of sociodemographic, work-related, physical, and psychosocial factors on the reported work disability due to low back pain (LBP) during the previous 12 months. Methods: Data from 255 sewage workers were obtained by standardized questionnaire, structured interview, and standardized physical examination. Data on the prevalence of neck, upper back and low back pain were obtained with the use of the Nordic Questionnaire. The level of disability was assessed from a modified Low-Back Outcome Scale. Work history included physical factors and job perception based on a modified Work APGAR Score. Other questionnaires recorded the psychosocial aspects of the work environment. In addition, we compared the risk factors between sewage workers who had been prevented from doing their normal work, at any time during the preceding 12 months, as a result of LBP (n=92), and those without any history of work disability during the previous 12 months (n=157). Results: The 12-month prevalence rates of neck, upper back and low back pain were 52.4%, 54.8%, and 72.8%, respectively. The prevalence of spinal troubles increased with age. Work disability during the preceding 12 months due to LBP was significantly positively associated with age, disability, the weekly duration of stooping and lifting 5 years previously and higher abnormal illness-behavior scores (odds ratio between 1.26 and 0.94). Moreover, when adjusted for age, the results showed that the subjects in the work disability group were more likely to report higher pain intensities, decreased participation in sports activities, higher levels of physical impairment, the belief that their LBP was related to the physical demands of their job, and a lack of drive (P < 0.05). Conclusions: This study revealed a high incidence of spinal troubles among sewage workers. In a multidisciplinary approach, we demonstrated that not one factor alone but a combination of sociodemographic, work-related and psychosocial factors have shown associations with work disabilities due to LBP. Additional studies evaluating the relative importance of individual risk factors are warranted. Received: 12 May 1999 / Accepted: 27 November 1999     

Long-Term Effectiveness of Combined Spine Surgery and Functional Restoration: A Prospective Study

The present study was designed to evaluate whether chronic low back pain patients who underwent surgery combined with functional restoration (n = 43) would demonstrate comparable 1-year socioeconomic outcomes, relative to those patients who had not undergone surgery (n = 25). This represents the first investigation of patients who underwent spine surgery, followed immediately by a comprehensive functional restoration program. The study prospectively evaluated these two groups of consecutive patients, culminating in a structured clinical interview 1 year after program completion in order to assess socioeconomic outcomes. Results demonstrated that the two groups were comparable in terms of return-to-work rates, as well as self-reported satisfaction and perceived helpfulness of the treatment program. Thus, in spite of the common assumption that spine surgery patients fare poorly, especially in a workers' compensation environment, these findings show that such patients will display successful objective outcomes if surgery is accompanied by effective rehabilitation such as functional restoration.     

Isokinetic performance in low back pain patients: The predictive power of the Self-Efficacy Scale

The Self-Efficacy Scale (SES) has been found to predict isokinetic performance better than anthropometric variables. This study tests the predictive power of SES further against other measures of efficacy expectancies as well as measures of depression and perceived disability. A group of 105 chronic back pain patients was administered Beck's Depression Inventory (BDI), SES, the Pain Self-Efficacy Questionnaire (PSEQ), and the Oswestry low back pain disability questionnaire (OSWESTRY). Total isokinetic work done was measured at slow, medium and high speeds, for which multiple regression models were fitted controlling for sex, age, weight and height. The results confirmed SES to be the best overall predictor of isokinetic performance. BDI was not significant as a predictor of isokinetic performance. The models also revealed that SES predicts less well with increases in the test speed, particularly in extension. These results provide further evidence of the diagnostic value of SES relative to OSWESTRY and PSEQ.     

Chronic back pain and work disability: Vocational outcomes following multidisciplinary rehabilitation

Studies indicate that work disabled chronic back pain patients out of work for longer than three months have a reduced probability of returning to work. The escalating personal and economic costs (indemnity and health care) associated with such long term disability have facilitated efforts at multiple levels to prevent and more effectively manage work disability. Multidisciplinary rehabilitation (MDR) targeted at return to work represents one such approach. The approach is based upon a multidimensional conceptualization of work disability and integrates medical, physical, psychological, educational and vocational interventions to increase physical function, reduce pain, increase stress coping skills and facilitate return to work. Seven outpatient multidisciplinary rehabilitation outcome studies for chronic back pain were identified that met the following selection criteria: 1) diagnosis of back pain, low back pain, spinal disorder (specific and nonspecific diagnosis), 2) chronic back pain of either longer than three months since injury or longer than three months absence from work, 3) use of an outpatient multidisciplinary rehabilitation approach that included some combination of medical management, physical conditioning, pain and stress management, vocational counseling/placement and education regarding back safety and health, and 4) work reentry was the primary focus of outcome. These were reviewed to determine the effectiveness of MDR in terms of return to work outcome. Analyses revealed that an average of 71 percent of work disabled chronic back pain patients who completed a multidisciplinary rehabilitation program were working or involved in vocational rehabilitation efforts at 12 month follow-up in contrast to an average of 44 percent in corresponding comparison groups. While these studies suggest the clinical utility of a multidisciplinary approach as compared to usual care in facilitating return to work for chronic back pain patients, the literature was characterized by several methodological limitations including the absence of randomization in the majority of studies, use of insurance company denials as control groups, heterogenous samples in terms of duration of work disability, job availability at discharge, extent of impairment and disability, age and duration of pain disorder, lack of specification as to exact treatment delivered in the control or usual care groups and varying definitions of return to work outcome. Research on predictors of return to work outcome following MDR were identified and included variables in five categories: demographics, medical history, physical findings, pain and psychological characteristics. The literature provides support for the use of integrated approaches that target the medical, physical, ergonomic and psychosocial factors that can exacerbate and/or maintain work disability. Future research should address current methodological limitations in the literature and focus on: 1) identifying critical treatment components of such approaches, 2) developing innovative screening methods to identify high risk cases to facilitate earlier more targeted efforts to assist such individuals, and 3) consider variations in the staging of various combinations of interventions in an effort to develop more cost-effective variations in the multidisciplinary approach.     

Effects of work-oriented fitness courses in lumberjacks with low back pain

This prospective controlled study examined changes in fitness, health, and work ability after a work-oriented physical fitness course arranged for lumberjacks experiencing low back pain but being still at work. The 1-week courses were designed to activate exercising during leisure time and consisted of fitness tests, various types of exercise, and lectures. Eighty-seven lumberjacks participated in the courses and 61 subjects served as controls. Questionnaire data obtained before and 1 year after the course were available for 78 (90%) of the course participants and 41 (67%) of the controls. In the intervention group, perceived fitness, health, and work ability improved and ergonomic strain at work decreased. Both groups reported an increased frequency of leisure-time physical activity. There were between- group differences in the development of fitness, health, distress symptoms, and subjective work ability, whereas the changes in physical activity, back and musculoskeletal symptoms, or ergonomic strain did not differ between the groups. In a 6-month follow up, muscle function improved in the intervention group, but no change was observed in aerobic capacity. There was a tendency of the number of back pain-related sickness leaves, but not of their duration, to develop more favorably in the intervention group, when data from the year before and the year after the course were compared.     

Concurrent validity of questionnaire and performance-based disability measurements in patients with chronic nonspecific low back pain

This study aimed to investigate the concurrent validity of two approaches to disability measurement in patients with chronic nonspecific low back pain (CLBP). It was hypothesized that if both are measuring the same construct, the instruments would lead to similar disability results and would correlate strongly (r > 0.75). The study compared the results of self-reported and performance-based measures of disability in 64 consecutive patients with CLBP. Participants mean age was 38.0 years, the mean duration of the current episode of back pain 9.9 months, and 90% were off work due to CLBP. The self-report measures used were: the Roland Disability Questionnaire (Roland); the Oswestry Disability Questionnaire (Oswestry); and the Quebec Back Pain Disability Questionnaire (Quebec). Performance was measured using the Isernhagen Work Systems Functional Capacity Evaluation (FCE). The mean scores from the self-report measure are as follows: Roland 13.5 (scale 0–24), Oswestry 28.2 (scale 0–100), Quebec 37.8 (scale 0–100) consistent with moderate to severe disability. In contrast the results from the performance-based measures suggested that the subjects should be able to work at a physical intensity level of moderate to heavy. Little to moderate correlation was observed between the self-report and performance-based measures (Spearman rank correlations: Roland-FCE (–0.20), p > 0.05; Oswestry-FCE (–0.52), p < 0.01; Quebec-FCE (–0.50), p < 0.01). Results are interpreted to suggest that both performance-based and self-report measures of disability should be used in order to obtain a comprehensive picture of the disability in patients with CLBP.     

Treatment- and cost-effectiveness of early intervention for acute low-back pain patients: a one-year prospective study

In an attempt to prevent acute low-back pain from becoming a chronic disability problem, an earlier study developed a statistical algorithm which accurately identified those acute low-back pain patients who were at high risk for developing such chronicity. The major goal of the present study was to evaluate the clinical effectiveness of employing an early intervention program with these high-risk patients in order to prevent the development of chronic disability at a 1-year follow-up. Approximately 700 acute low-back pain patients were screened for their high-risk versus low-risk status. On the basis of this screening, high-risk patients were then randomly assigned to one of two groups: a functional restoration early intervention group (n = 22), or a nonintervention group (n = 48). A group of low-risk subjects (n = 54) who did not receive any early intervention was also evaluated. All these subjects were prospectively tracked at 3-month intervals starting from the date of their initial evaluation, culminating in a 12-month follow-up. During these follow-up evaluations, pain disability and socioeconomic outcomes (such as return-to-work and healthcare utilization) were assessed. Results clearly indicated that the high-risk subjects who received early intervention displayed statistically significant fewer indices of chronic pain disability on a wide range of work, healthcare utilization, medication use, and self-report pain variables, relative to the high-risk subjects who do not receive such early intervention. In addition, the high-risk nonintervention group displayed significantly more symptoms of chronic pain disability on these variables relative to the initially low-risk subjects. Cost-comparison savings data were also evaluated. These data revealed that there were greater cost savings associated with the early intervention group versus the no early intervention group. The overall results of this study clearly demonstrate the treatment- and cost-effectiveness of an early intervention program for acute low-back pain patients.     

Self-Report Measure of Low Back-Related Biomechanical Exposures: Clinical Validation

Low back pain and symptoms are major contributors to ambulatory visits, economic burden, and reduced readiness among military personnel and employers in the civilian workplace as well. While a link between low back pain and biomechanical exposures has been established, efficient surveillance methods of such exposures are still needed. Furthermore, the utility of self-report measures for biomechanical exposures has not been examined extensively. The present cross-sectional study analyzed questionnaire data from US Army soldiers (n = 279) working in previously identified occupational specialties that were associated with high risk for low back pain and/or low back pain disability. Demographic characteristics, physical workload, health behaviors, and psychosocial factors were assessed in addition to self-reported workplace biomechanical exposures using the Job Related Physical Demands (JRPDs). Outcomes included self-reported low back pain severity, low back symptoms, functional limitations, and general physical health. The results indicated that the self-report measure of biomechanical exposure had a high degree of internal consistency (Cronbach alpha, 0.95). The JRPD index correlated with low back symptoms, pain intensity, function, and perceived work load using the Borg scale. Regression analyses indicated statistically significant associations between the JRPD and back pain specific pain severity and physical function, but not for general physical health (SF-12) after controlling for age, gender, educational level, job type, and reported exercise and work stress. Specifically, higher JRPD scores (representing greater biomechanical exposure) were associated with higher levels of pain intensity and functional limitations. Higher JRPD scores were found to place an individual at a greater likelihood for being a case with low back pain within the past 12 months (OR = 1.01 per point increase in scale-95%; range 38–152; CI = 1.00–1.02, p 0.05). While future longitudinal studies of the JRPD determining the predictive validity of the measure are needed, the present study provides evidence of the utility of the JRPD for assessing biomechanical exposures associated with low back pain within high-risk jobs. The findings suggest that the JRPD may assist with surveillance efforts and be useful as a process and/or outcome measure in research related to occupational rehabilitation.     

Use of osteopathic or chiropractic services among people with back pain: a UK population survey

Questionnaires covering health and the use of complementary, alternative and conventional health services were mailed to a random sample of 14 868 adults aged 18–64 years living in four counties of England in 1997. The present study examined the use of osteopathy/chiropractic among the 15% (n = 1377) of respondents reporting back pain. Osteopaths/chiropractors were seen by 13.4% (n = 184) of respondents with back pain during the past 3 months compared with 9.8% (n = 135) who consulted physiotherapists. The presence of back pain and non‐manual social class were the strongest predictors of consultation with both types of practitioner. Women, older respondents, non‐smokers and those who exercised for 30 minutes at least once a week were more likely to use osteopathy/chiropractic. The only other significant predictor of physiotherapy use was desire for more physical exercise. While those reporting back pain had Short‐Form 36 (SF‐36) scores suggesting very significant levels of disability, respondents with back pain who consulted osteopaths/chiropractors reported better health in all dimensions of the SF‐36 than those using physiotherapy services. Although they reported worse pain scores than people not consulting any practitioners, their mental health, physical functioning, energy and health perception were better. It is impossible to disentangle cause and effect in this cross‐sectional study, but the data suggest that people who can afford to pay are more likely to choose osteopath/chiropractor treatments than physiotherapy. The possibility that osteopath/chiropractor treatment has a generalised positive effect on health, allowing people with back pain to function better than those not receiving such treatment, warrants further investigation.     

Prevalence of low back pain among handloom weavers in West Bengal,India

Background:

Handloom is one of the oldest industries in India, particularly in West Bengal, where a considerable number of rural people are engaged in weaving.

Objectives:

The purpose of this study was to evaluate the prevalence of low back pain among the handloom weavers in India.

Methods:

A modified Nordic Musculoskeletal Disorder Questionnaire and Oswestry Low Back Pain Disability Questionnaire along with a body part discomfort scale were administered to handloom weavers (n = 175). Working posture of the participants was assessed using the Ovako Working Posture Analysis System (OWAS).

Results:

Sixty eight per cent of the participants reported suffering from low back pain, making it the most prevalent disorder in our sample. Analysis of the Oswestry Low Back Pain Disability Questionnaire data revealed that among those with low back pain (n = 119), 2% had severe disabilities, 46% had moderate disabilities, and 52% had minimal disabilities. Statistical analyses revealed a positive significant association between the intensity of pain in the lower back and an increased number of years of work experience (P<0.05).

Conclusions:

The study underlines the need for further research regarding the postural strain of weavers and also suggests the implementation of ergonomic design into weaver workstations to minimize the adverse effect of their current working postures. Improving upon the weaver’s work-posture could improve their quality of life.     

Subjective Quality of Life According to Work Status Following Interdisciplinary Work Rehabilitation Consequent to Musculoskeletal Disability

Introduction Individualized subjective quality of life (ISQoL) is the appraisal of quality of life according to personal values, desired goal attainment and life priorities. “Gap” is a way to operationalize ISQoL. ISQoL is rarely measured by interdisciplinary work rehabilitation (IWR) programs attended by the musculoskeletal disorder (MSD) population. These programs commonly measure pain intensity, physical capacity, perceived disability, distress and return to work. Objectives The aims of this study were to compare ISQoL according to work status and reference values and to explore the relationships between ISQoL and common IWR measures. Methods Six months after completing an IWR program, 40 working and 31 not-working participants completed questionnaires documenting work status, pain, ISQoL gap, health-related quality of life (SF-36, PCS and MCS), perceived disability and distress. Results No significant difference in global ISQoL gap was found between working and not-working participants. When compared to reference values considerable variability exists but globally, for both groups, ISQoL gap scores were below average. The following clinical variables were related to global ISQoL (P < 0.05): pain (r = −0.42), PCS (r = −0.37), MCS (r = −0.56), perceived disability (r = 0.37) and distress (r = 0.61). High distress, present in both groups, explains 38% of the global ISQoL gap variance and PCS adds 4%. Conclusion Following IWR programs for the chronic MSD population, global ISQoL gap is not related to work status. The use of a client-centered interactive computerized measure of ISQoL reveals that domains related to emotional well-being are likely the most problematic for the persistently disabled MSD population.     

Back problems are for life: Perceived vulnerability and its implications for chronic disability

As part of a qualitative research study of the experience of work-related back problems, a series of in-depth ethnographic interviews were conducted with 15 workers receiving treatment for back injuries. Analysis of these data revealed that the workers perceived their back problems as lifelong problems. Many believed that their back injuries had permanently heightened their vulnerability to reinjury and chronic disability. Accommodating this sense of physical vulnerability required a redefinition of one's self and one's future. For some workers, the perceived threat of future back problems was itself disabling and appeared to discourage a return to normal social roles. Workers' interactions with the health care system shaped their perceptions of their bodies and their notions of the appropriate means to cope with their physical vulnerability. Implications of the perception of permanence for the development of chronic disability among workers who experience back problems are examined.     

Prevalence of psychopathology in acute and chronic low back pain patients

This study assessed the differential prevalence rates of psychopathology in chronic and acute low back pain patients. Psychopathology was assessed with the Structured Clinical Interview for the DSM-III-R (SCID). The results showed that chronic low back pain patients (n=90), had much higher rates of psychopathology than did patients in the acute back pain group (n=90), and much higher than general population base rates. In particular, chronic low back pain patients had high rates of major depression, substance abuse, and personality disorders. Moreover, the chronic low back patients also had high rates of premorbid psychopathology. It was concluded that psychopathology is a major concomitant of chronic low pack pain, and that treating the psychological problems, along with the physical aspects of the chronic low back pain may increase the patient's chance of a successful therapeutic outcome.     

Functional Capacity Evaluations in Persons with Spinal Disorders: Predicting Poor Outcomes on the Functional Assessment Screening Test (FAST)

This study determines how performance on the simple, low exertion Functional Assessment Screening Test (FAST) relates to performance on more extensive physical and psychological testing. One hundred eighty-eight persons with chronic back disability and 17 spine healthy volunteers underwent the FAST (three 2-min static tests [kneeling, stooping, and squatting] and two 5-min tests [repetitive stooping and repetitive twisting while standing]), the Progressive Isoinertial Lifting Evaluation (PILE), trunk extension endurance, submaximal bicycle ergometry, and psychological profiles. All FAST components were completed by 88% of spine healthy subjects, but only by 19.7% (n = 37) of the back patients. Internal consistency for overall test performance was 0.82 (alpha coefficient). Back pain noncompleters had poorer performance on the PILE and trunk extension endurance despite similar cardiovascular fitness and perceived exertion during testing. They had more dysfunctional coping mechanisms, pain avoidance, depression, and self-reported disability. Since performance on nonstrenuous testing is so poor, and psychosocial variables relate strongly to test performance, extensive Functional Capacity Evaluations may not be necessary or valid in assessing the physical performance of this population of chronic back pain patients.     

Association of Low Back Pain,Impairment, Disability &; Work Limitations in Nurses

Introduction: Health care professionals use measures of pain and impairment to identify potential disability and subsequently to predict workers’ ability to do their work. However, there is little evidence that measures used are associated with ability to do one’s job. Methods: A cross-sectional study was conducted. Nurses (n = 100) were classified into either off/modified work (due to LBP) or regular work groups. Trunk ROM, trunk muscular endurance, pain and disability were measured relative to the outcomes work status and Work Limitations Questionnaire (WLQ) score. Results: Regression analyses which included Roland Morris Questionnaire (RMQ, disability) and Sørenson (back extensor endurance) in the final models correctly classified the work status of 87% of the participants and accounted for 60% of variance in the WLQ score. Conclusions: Use of the RMQ and Sørenson test as diagnostic and prognostic tools should be considered in assisting return to work and treatment decision-making in female nurses with LBP.     

Barriers to patient information provision in primary care: patients' and general practitioners' experiences and expectations of information for low back pain

Background As patient involvement in health‐care increases, the role of information is crucial, especially in conditions where self‐management is considered an integral part of care. However, the suitability and applicability of much patient information has not been appraised in terms of how far it meets patients' information needs. Aims To ascertain patients' and clinicians' experiences and expectations of information in low back pain in order to suggest a suitable ‘patient‐centred’ content for a patient information pack to be used in a primary care setting. Methods A qualitative study using semi‐structured interviews with General Practitioners (GPs) (n = 15) and focus groups comprising patients with low back pain (n = 37). Results Barriers to information‐giving for low back pain in primary care exist. Patients are dissatisfied with the information they receive from their GPs, especially regarding diagnosis and treatment. Patients tend to access information from a variety of other sources, which is often contradictory, conflicts with research evidence and leads to unreasonable expectations. GPs have varying views regarding the value of patient information and are equivocal about their roles as information providers. Although The Back Book is generally acceptable as a patient information leaflet for low back pain, attention to the tone of the text is required. Conclusions Barriers exist to patient information provision, both generally and for low back pain, which need to be addressed in order to close the gap between strategy and implementation. Improving clinician communication skills and involving patients in developing information materials which meet their needs are crucial to this process.     

Self-reported Severity Measures as Predictors of Return-to-work Outcomes in Occupational Back Pain

Introduction We test an array of biopsychosocial, cognitive-behavioral, and work-related factors to identify the best predictors of work disability following a back injury. Methods We test the validity of alternative severity measures in predicting the likelihood of four distinct, mutually exclusive patterns of post-injury employment in the first year after onset of back pain. The study sample includes 959 participants in the ASU Healthy Back Study, a prospective cohort study of workers who filed claims for occupational back pain between 1999 and 2002. Self-reported severity measures include: NRS-101 measures of the intensity of back or leg pain, Roland–Morris scale of functional disability, and mental and physical components of the SF-12. Results All the severity measures have significant predictive power on return-to-work outcomes even after 1 year. Baseline physical functioning and overall mental and physical health status are more predictive of specific patterns of post-injury employment than pain intensity measures, possibly because there is considerable idiosyncratic variation in the pain intensity measures. The mental component of the SF-12, in particular, is relatively robust to alternate specifications, consistently statistically significant, and has the lowest probability significance level in explaining patterns of employment 1 year after injury.     

Body image assessment in patients with bulimia nervosa and normal controls

A video image distortion technique was used to assess differences in the perceived (actual) and ideal body size and shape among female patients with bulimia nervosa (n = 12) and two groups of nondepressed, non-eating-disordered women classified as restrained (n = 12) or unrestrained (n = 12) eaters. On the majority of measures of body image the bulimic patients and restrained eaters differed from the unrestrained eaters but did not differ significantly from each other. The results do not show that body image disturbance, at least as it was assessed in this study, discriminates bulimics from appropriate nonclinical controls. In absolute terms the bulimics were more accurate than the controls in estimating their current body size. The latter underestimated their body size. However, the bulimics' estimates were higher in relation to the controls. The discrepancy between perceived body size and ideal body size also differentiated the groups, with the bulimic and restrained subjects exhibiting significantly more discrepancy between perceived and ideal than the unrestrained subjects. Significant correlations between body size estimation and self-report of body satisfaction suggests that evaluation and perception of body are closely associated.