Individual supported work placements (ReISE) for improving sustained return to work in unemployed people with persistent pain: an internal pilot study of a cohort randomised controlled approach.

BACKGROUND: Persistent pain is a frequent cause of sick leave and work disability in Norway. A return-to-work intervention featuring supported work placements, developed in the UK, demonstrated feasibility, and a return-to-work rate of 20% within 6 months was observed in the sample. We sought to adapt the intervention for delivery in Norway and to confirm feasibility prior to a full-scale trial. METHODS: In this internal pilot, we used a pragmatic cohort randomised controlled approach with national recruitment in Norway. We recruited people who were unemployed (for at least 1 month), having persistent pain (for at least 3 months), aged between 18 and 64, and wanting to return to work. We initially recruited people to an observational cohort study of the impact of being unemployed with persistent pain. After baseline measurement, we randomly sub-sampled participants to whom we offered the intervention, which featured individual case management and support, work-familiarisation sessions, and the offer of a 6-week part-time unpaid work placement. We assessed recruitment rates (aiming to recruit 66, and sub-sample 17 within 6 months); optimal recruitment pathways; intervention acceptance rates; the feasibility of data collection; using video links for work-familiarisation sessions and remote case manager support. RESULTS: The pilot ran from June to November 2022. Of 168 people expressing interest, 94 consented. Recruitment posts on Facebook yielded the most 'expressions of interest' (66%, n = 111). After screening for eligibility, we included 55 participants. Of these, 19 were randomised to be offered the intervention. Of these, less than half (n = 8) consented to intervention participation. Remote case manager and work-familiarisation sessions appeared feasible. Following a delay in identifying placements, three participants received offers of work placements, with one starting and completing during the pilot period. Data collection methods were feasible, and no adverse events were reported. CONCLUSIONS: Recruitment and logistical processes, such as remote management by video link, are feasible. However, delivery of the intervention is challenging. In particular, sourcing placements and the time required for identifying appropriate placements was more challenging than anticipated. A full-scale trial is feasible but will require improvements to the placement identification processes. TRIAL REGISTRATION: ISRCTN85437524 (Referring to the ReISE trial, of which this internal pilot was a part), Registered 31 of May 2022 https://doi.org/10.1186/ISRCTN85437524 TRIAL FUNDING: Norwegian Research Council.

Individual supported work placements (ReISE) for improving sustained return to work in unemployed people with persistent pain: study protocol for a cohort randomised controlled trial with embedded economic and process evaluations.

BACKGROUND: Around one-third of workdays lost in Norway are due to musculoskeletal conditions, with persistent (chronic) pain being the most frequent cause of sick leave and work disability. Increasing work participation for people with persistent pain improves their health, quality of life, and well-being and reduces poverty; however, it is not clear how to best help unemployed people who have persistent pain to return to work. The aim of this study is to examine if a matched work placement intervention featuring case manager support and work-focused healthcare improves return to work rates and quality of life for unemployed people in Norway with persistent pain who want to work. METHODS: We will use a cohort randomised controlled approach to test the effectiveness and cost-effectiveness of a matched work placement intervention featuring case manager support and work-focused healthcare compared to those receiving usual care in the cohort alone. We will recruit people aged 18-64, who have been out of work for at least 1 month, had pain for more than 3 months, and want to work. Initially, all (n = 228) will be recruited to an observational cohort study on the impact of being unemployed with persistent pain. We will then randomly select one in three to be offered the intervention. The primary outcome of sustained return to work will be measured using registry and self-reported data, while secondary outcomes include self-reported levels of health-related quality of life and physical and mental health. Outcomes will be measured at baseline and 3, 6, and 12 months post-randomisation. We will run a process evaluation parallel to the intervention exploring implementation, continuity of the intervention, reasons for participating, declining participation, and mechanisms behind cases of sustained return to work. An economic evaluation of the trial process will also be conducted. DISCUSSION: The ReISE intervention is designed to increase work participation for people with persistent pain. The intervention has the potential to improve work ability by collaboratively navigating obstacles to working. If successful, the intervention may be a viable option for helping people in this population. TRIAL REGISTRATION: ISRCTN Registry 85,437,524 Registered on 30 March 2022.

Health systems strengthening to arrest the global disability burden: empirical development of prioritised components for a global strategy for improving musculoskeletal health.

INTRODUCTION: Despite the profound burden of disease, a strategic global response to optimise musculoskeletal (MSK) health and guide national-level health systems strengthening priorities remains absent. Auspiced by the Global Alliance for Musculoskeletal Health (G-MUSC), we aimed to empirically derive requisite priorities and components of a strategic response to guide global and national-level action on MSK health. METHODS: Design: mixed-methods, three-phase design.Phase 1: qualitative study with international key informants (KIs), including patient representatives and people with lived experience. KIs characterised the contemporary landscape for MSK health and priorities for a global strategic response.Phase 2: scoping review of national health policies to identify contemporary MSK policy trends and foci.Phase 3: informed by phases 1-2, was a global eDelphi where multisectoral panellists rated and iterated a framework of priorities and detailed components/actions. RESULTS: Phase 1: 31 KIs representing 25 organisations were sampled from 20 countries (40% low and middle income (LMIC)). Inductively derived themes were used to construct a logic model to underpin latter phases, consisting of five guiding principles, eight strategic priority areas and seven accelerators for action.Phase 2: of the 165 documents identified, 41 (24.8%) from 22 countries (88% high-income countries) and 2 regions met the inclusion criteria. Eight overarching policy themes, supported by 47 subthemes, were derived, aligning closely with the logic model.Phase 3: 674 panellists from 72 countries (46% LMICs) participated in round 1 and 439 (65%) in round 2 of the eDelphi. Fifty-nine components were retained with 10 (17%) identified as essential for health systems. 97.6% and 94.8% agreed or strongly agreed the framework was valuable and credible, respectively, for health systems strengthening. CONCLUSION: An empirically derived framework, co-designed and strongly supported by multisectoral stakeholders, can now be used as a blueprint for global and country-level responses to improve MSK health and prioritise system strengthening initiatives.

The Nordic back pain subpopulation program: a 1-year prospective multicenter study of outcomes of persistent low-back pain in chiropractic patients.

OBJECTIVES: The aims of the study are to describe the low-back pain and disability status at baseline, the fourth visit, and at 3 and 12 months in Norwegian patients treated by chiropractors for persistent low back pain (LBP) and to describe movements between various subgroups over time. DESIGN: Prospective uncontrolled multicenter study. METHODS: Self-reported pain was measured with a 0-10 box scale and disability with the revised Oswestry LBP questionnaire. The main outcome measures were mean pain or disability values and numbers of LBP-free patients. LBP status was assessed through patient questionnaires at baseline, the fourth visit, and after 3 and 12 months. STUDY SUBJECTS AND SETTING: Of 205 invited chiropractors, 115 Norwegian chiropractors were each willing to recruit 10 consecutive patients who had LBP for at least 2 weeks at the time of consultation and a minimum of 30 days altogether within the preceding year. The numbers of participants were 875 (baseline), 799 (fourth visit), 598 (3 months), and 512 (12 months). RESULTS: Considerable improvement was noted between baseline and the fourth visit both for mean values and in numbers of LBP-free patients. There was virtually no further mean improvement up to the third month, whereas the number of LBP-free individuals doubled. At 12 months, no additional improvement was noted, and 80% reported that they had experienced recurrent problems. Less than 1% reported considerable worsening. Severity of symptoms at baseline determined the subsequent outcome, mild symptoms tending to worsen, and severe symptoms tending to improve. CONCLUSION: The outcome pattern is similar to that found in other clinical studies. Treatment outcome should be measured early with follow-up at 3 rather than at 12 months, because patients will improve or recover quickly but may experience recurring problems. Numbers "cured" appear to be a feasible outcome variable in this type of study population.

The nordic back pain subpopulation program: demographic and clinical predictors for outcome in patients receiving chiropractic treatment for persistent low back pain.

OBJECTIVE: To identify demographic and clinic-related predictors for successful outcome in patients with persistent low-back pain who received chiropractic treatment. DESIGN: Prospective uncontrolled multicenter study with internal control groups. SUBJECTS: Each of 115 Norwegian chiropractors, out of 205 invited, were asked to recruit 10 consecutive patients who had low-back pain for at least 2 weeks at the time of consultation and a minimum of 30 days altogether within the preceding year. In all, 875 patients were included at baseline. The response rates at the fourth visit and at 3 and 12 months were 799, 598, and 512, respectively. METHODS: Baseline data were obtained through questionnaires administered to chiropractic patients and to their treating chiropractors; clinical information was obtained through questionnaires at the fourth visit from patients and chiropractors. Outcome was obtained from patients at the fourth visit. Mail surveys of patients were conducted after 3 and 12 months, and additional information was obtained from chiropractors at 12 months in relation to treatment history. POTENTIAL PREDICTORS: Demography and information on past and present history, clinical findings, and prognosis. OUTCOME VARIABLE: Number of low-back pain"free patients (defined as those with a maximum pain score of 1/10 and a maximum Oswestry score of 15/100). DATA ANALYSIS: Positive predictive values and relative risks were calculated for each categorized predictor variable singly and in combination in relation to being low-back pain free at the 3 follow-up surveys. RESULTS: Treatment outcome at the fourth visit was best predicted by a model containing the following 5 variables: sex, social benefit, severity of pain, duration of continuous pain at first consultation, and additional neck pain (odds ratios between 2.2 and 4.3). A similar profile was found at 3 months, but 2 different variables (relating to disability) were the final variables in relation to the 12-month status. These final models were best at predicting absence of treatment success. Being low-back pain free at the fourth visit was a strong predictor for being low-back pain free both at 3 months and 12 months, with relative risks of 3.0 (2.2-4.8) and 3.1 (1.5-6.5), respectively. CONCLUSION: In patients with persistent low-back pain, it is possible to exclude from treatment those who are unlikely to become low-back pain free after chiropractic care and to do this before they have been examined clinically. Early recovery is a strong predictor for outcome up to 1 year later.