Increased overall and cause-specific mortality associated with disability among workers' compensation claimants with low back injuries.

BACKGROUND: Mortality tends to be higher among people who do not work than among workers, but the impact of work-related disability on mortality has not been well studied. METHODS: The vital status through 2015 was ascertained for 14 219 workers with an accepted workers' compensation claim in West Virginia for a low back injury in 1998 or 1999. Mortality among the cohort compared with the West Virginia general population was assessed using standard life table techniques. Associations of mortality and disability-related factors within the cohort were evaluated using Cox proportional hazards regression. RESULTS: Compared to the general population, mortality from accidental poisoning was significantly elevated among the overall cohort and lost-time claimants. Most deaths from accidental poisoning in the cohort were due to drug overdoses involving opioids. Mortality from intentional self-harm was also significantly elevated among lost-time claimants. In internal analyses, overall mortality and mortality from cancer, heart disease, intentional self-harm, and drug overdoses involving opioids was significantly associated with lost time. Overall mortality and mortality from drug overdoses involving opioids were also significantly associated with amount of lost time, permanent partial disability, and percent permanent disability. Heart disease mortality was also significantly associated with the amount of lost time. CONCLUSIONS: The results suggest that disability itself may impact mortality risks. If confirmed, these results reinforce the importance of return to work and other efforts to reduce disability.

Relationship between early prescription dispensing patterns and work disability in a cohort of low back pain workers' compensation claimants: a historical cohort study.

OBJECTIVES: To examine and compare whether dispensing of prescription opioids, non-steroidal anti-inflammatory drugs (NSAIDs) and skeletal muscle relaxants (SMRs) within 8 weeks after a work-related low back pain (LBP) injury is associated with work disability. METHODS: A historical cohort study of 55 571 workers' compensation claimants with LBP claims in British Columbia from 1998 to 2009 was conducted using linked compensation, dispensing and healthcare data. Four exposures were constructed to estimate the effect on receipt of benefits and days on benefits 1 year after injury: drug class(es) dispensed, days' supply, strength of opioids dispensed and average daily morphine-equivalent dose. RESULTS: Compared with claimants receiving NSAIDs and/or SMRs, the incidence rate ratio (IRR) of days on benefits was 1.09 (95% CI 1.04 to 1.14) for claimants dispensed opioids only and 1.26 (95% CI 1.22 to 1.30) for claimants dispensed opioids with NSAIDs and/or SMRs. Compared with weak opioids only, the IRR for claimants dispensed strong opioids only or strong and weak opioids combined was 1.21 (95% CI 1.12 to 1.30) and 1.29 (95% CI 1.20 to 1.39), respectively. The incident rate of days on benefits associated with each 7-day increase in days supplied of opioids, NSAIDs and SMRs was 10%, 4% and 3%, respectively. Similar results were seen for receipt of benefits, though effect sizes were larger. CONCLUSIONS: Findings suggest provision of early opioids leads to prolonged work disability compared with NSAIDs and SMRs, though longer supplies of all drug classes are also associated with work disability. Residual confounding likely partially explains the findings. Research is needed that accounts for prescriber, system and workplace factors.

The association between a lifetime history of low back injury in a motor vehicle collision and future low back pain: a population-based cohort study.

PURPOSE: This population-based cohort study investigated the association between a lifetime history of a low back injury in a motor vehicle collision (MVC) and future troublesome low back pain. Participants with a history of a low back injury in a motor vehicle collision who had recovered (no or mild low back pain) were compared to those without a history of injury. Current evidence from two cross-sectional and one prospective study suggests that individuals with a history of a low back injury in a MVC are more likely to experience future LBP. There is a need to test this association prospectively in population-based cohorts with adequate control of known confounders. METHODS: We formed a cohort of 789 randomly sampled Saskatchewan adults with no or mild LBP. At baseline, participants were asked if they had ever injured their low back in a MVC. Six and 12 months later, participants were asked about the presence of troublesome LBP (grade II-IV) on the Chronic Pain Grade Questionnaire. Multivariable Cox proportional hazards regression analysis was used to estimate the association while controlling for known confounders. RESULTS: The follow-up rate was 74.8% (590/789) at 6 months and 64.5% (509/789) at 12 months. There was a positive crude association between a history of low back injury in a MVC and the development of troublesome LBP over a 12-month period (HRR = 2.76; 95% CI 1.42-5.39). Controlling for arthritis reduced this association (HRR = 2.25; 95% CI 1.11-4.56). Adding confounders that may be on the casual pathway (baseline LBP, depression and HRQoL) to the multivariable model further reduced the association (HRR = 2.20; 95% CI 1.04-4.68). CONCLUSION: Our analysis suggests that a history of low back injury in a MVC is a risk factor for developing future troublesome LBP. The consequences of a low back injury in a MVC can predispose individuals to experience recurrent episodes of low back pain.

Matrix metalloproteinase-3, vitamin D receptor gene polymorphisms, and occupational risk factors in lumbar disc degeneration.

BACKGROUND: Lumbar disc degeneration (LDD) is a process that begins early in life, contributing to the development of low back pain. LDD is a consequence of a variety of factors, and its etiology remains poorly understood. Objectives to investigate occupational and genetic risk factors inducing lumbar disc degeneration, and to evaluate the possible association of genetic polymorphisms of matrix metalloproteinase 3 (MMP-3) and vitamin D receptor (VDR) with the severity of LDD in an Egyptian population. SUBJECTS AND METHODS: A case control study involving 84 LDD and 60 controls was carried out. Five types of work related factors were investigated by questionnaire, complete neurological examination for all subjects and MRI for the cases. Polymerase chain reaction and restriction fragment length polymorphism methods were applied to detect polymorphisms in MMP-3 Promoter (-1,171 6A/5A) (rs 731236) and VDR-Apa (rs 35068180). RESULTS: We found that family history, back injury, smoking, high level of sitting, bending/twisting, physical workload, lifting, whole body vibration, mutant allele 5A of MMP-3 and mutant allele T of VDR were significantly associated with LDD (OR = 2.9, 3.1, 2.1, 11.1, 15.9, 11.7, 8.2, 12.6, 2.5 and 3.1 respectively, p < 0.05). Cases that carry allele 5A and/or allele T were associated with LDD severity. CONCLUSION: LDD is closely associated in occurrence and severity with occupational, environmental risk factors and susceptibility genes namely MMP-3, and VDR (ApaI). This study throws light on the importance of screening for early detection of susceptible individuals and disease prevention.

Effect of customized foot orthotics in addition to usual care for the management of chronic low back pain following work-related low back injury.

OBJECTIVE: The objective of this study was to compare the effect of customized foot orthotics in addition to usual care (UC) compared with UC alone for the treatment of patients with chronic low back pain after work-related injury. METHODS: Sixty-two consecutive patients presenting with chronic (>3 months), nonspecific, low back pain following work-related low back injury were included in the study. A total of 30 patients in the UC group were given a 6-week exercise therapy program along with prescription analgesics. The intervention group, composed of 32 patients, received UC in addition to customized foot orthotics (orthotics group). All subjects completed the Oswestry Disability Index at the initiation of the study and at 8-week follow-up. Work disability, as defined by working at usual, preinjury job labor level, was recorded at baseline and 8-week follow-up. RESULTS: A total of 28 subjects in the UC group and 32 in the orthotics group completed the study. The 2 groups were well matched in terms of age, sex distribution, and duration of low back pain as well as baseline Oswestry Disability Index score. At 8 weeks, both groups had improved. The orthotics group had a lower Oswestry Disability Index than the UC group (P < .01), with a smaller proportion of the orthotics group using any form of prescribed analgesics for back pain (P < .05). CONCLUSIONS: The findings showed that patients in this study with chronic, nonspecific low back pain following work-related low back injury had greater improvement in short-term outcomes with orthotics and UC than with UC alone.

Injury type and incidence among elite level curlers during world championship competition.

Our objective was to investigate the incidence of musculoskeletal injuries sustained by elite level curling athletes during international competition. This study was conducted during the 2008 World Men's Curling Championships. All registered athletes and the tournament medical team were given report forms for documenting injuries that occurred during the tournament. Report form information included demographics, area injured, types of injuries sustained, and curling-specific aggravating conditions. During the competition five injuries were reported, resulting in an injury rate of .07 injuries per game. Only one reported injury resulted in missed competition (.014 injuries per game). All reported injuries involved increased pain during curling-specific activities. At the elite international competitive level, injury incidence in curling was found to be low. Future exploration over the course of a season may be beneficial to identify risk factors and to assist with formulating training strategies to decrease injury risk.

Determinants of sickness absence duration after an occupational back injury in the Belgian population.

BACKGROUND: This study aimed at assessing factors associated to the duration of sickness absence after a back injury in the Belgian working population, with a special emphasis on cultural factors. METHODS: The data were retrieved from the Belgian Fund for Work Accidents database over a 3-year period (2001-2003). The population source involved all Belgian workers under a job contract in the private sector registered as compensated cases for an accident that occurred at the workplace (n = 558,276). From that database, all back injury cases involving a complete data set and registered during the first 6 months of each year (n = 11,262) were selected and eight factors (gender, age, seniority in the current job, job category, accident regional location, enterprise size, sector of activity, and accident circumstances) were analyzed in relation to the outcome variable, sick leave duration recorded as ordered time intervals between 0 and 183-366 days. RESULTS: Sick leave duration was strongly associated in a multivariate model to age (≥40 years: OR = 2.18), blue-collar job (1.55), work in building industry (1.32), and enterprise size (>100: 0.85), and to a less extent to seniority (>10y: 0.88), and circumstance of accident (falls: 1.26). Injuries occurring in the French-speaking part of the country were associated to a longer sick leave (1.07; P = 0.034). CONCLUSIONS: This study shows that besides well-known risk factors, subtle cultural language-linked factors and/or regional differences in economic climate may significantly influence the length of disability period after a back injury.

Evaluation of the athlete with buttock pain.

Buttock (gluteal) pain is commonly experienced by athletes of all ages and activity levels. Evaluation of buttock pain can be challenging because the differential diagnoses are extensive. Symptoms may originate from the pelvis or hip or be referred from the lumbosacral spine or neurovascular structures. Few articles in the literature are dedicated to the primary complaint of buttock pain. The purpose of this article is to provide a clinical algorithm to assist the sports clinician in reaching an accurate diagnosis and initiating the appropriate treatment.

Sport specialization of female figure skaters: cumulative effects on low back injuries.

Objective: 1) to determine the proportion of sport specialization among female figure skaters, 2) to compare proportion of low back injuries between specialized female figure skaters and non-specialized female figure skaters, and 3) to identify an independent risk factor(s) for low back injuries in female figure skaters.Methods: A cross-sectional questionnaire study was used. Young female figure skaters were asked questions related to sport specialization and any history of low back injuries. The primary outcome variables were status of sport specialization, weekly training hours, and low back injury. Descriptive statistics, t-test, chi-square analyses, and binary logistic regressions were used.Results: Responses from 132 female figure skaters (mean age: 16.3 ± 2.7 years, age range: 8-22 years) were analyzed. Sixty-two percent (82/132) of figure skaters were specialized. Specialized female figure skaters spent more time in training (11.3 ± 6.5 hours/week) than non-specialized skaters (7.6 ± 4.9 hours/week, p = 0.001). No statistical differences were found in proportion of low back injury history between specialized (25.6%) and non-specialized female figure skaters (24.0%, p = 0.836). Chronological age was also identified as an independent risk factor for low back injuries in female figure skaters (aOR: 1.24, 95%CI: 1.00, 1.54, p = 0.048).Conclusions: The majority of female figure skaters in this cohort were specialized. An association between chronological age and low back injuries, found in the current study, may be a result of cumulative effects of participating in figure skating over time.

Medical malpractice allegations of iatrogenic addiction in chronic opioid analgesic therapy: forensic case reports.

OBJECTIVES: The objectives for presenting these medico-legal forensic case reports are the following: 1) detail three cases where chronic opioid analgesic therapy (COAT) was alleged to cause iatrogenic addiction and/or re-addiction; 2) detail the plaintiff's and defendant's medical experts' opinions on these allegations; and 3) through analyzing these cases, develop some recommendations for future prevention of such allegations during COAT. METHODS: Case Reports. RESULTS: Medico-legal issues surrounding the allegation of iatrogenic addiction were identified in each case. CONCLUSIONS: Before starting COAT, physicians should obtain and document patient informed consent for the risk of addiction/re-addiction with COAT treatment. Patients with a history of addictions pre-COAT should be placed on adherence monitoring immediately on beginning COAT.

The years after an injury: long-term consequences of injury on self-rated health.

BACKGROUND: Knowledge on long-term consequences of injury on health is vital when injury prevention policies and emergency care are planned. However, few studies have described lasting health consequences associated with injury. This study analyses the relationship between injury and self-assessed health up to 10 years after the injury. METHODS: The study makes use of a public health research database linking health interview survey information with data from national health registries. Using this database, the health of a group of Danish patients with injury events during 1995 to 2005 was compared with a noninjured group up to 10 years after the injury. The association between self-assessed general health and self-reported depression and injury-related factors were estimated using logistic regression analysis. RESULTS: When patients with injuries compared with noninjured, the odds ratios of poor self-assessed general health and self-reported depression were 1.83 (confidence level, 1.53-2.19) and 1.33 (confidence level, 1.14-1.54), respectively. Although decreasing with time, the effect of injury on general health was significant up to 10 years after the injury. The injury type was significantly related to health, and in particular, patients with back, head, and neck injuries reporting poor general health. No gender differences were found in the effect of injury on self-assessed health. CONCLUSIONS: Injuries have lasting consequences for physical and mental health up to 10 years after the injury event, in particular, for people sustaining head, neck, and back injuries. Sustaining an injury has the same effect on general health in men and women.

Spinal cord stimulation as a method of reducing opioids in severe chronic pain: a case report and review of the literature.

Opioid addiction and abuse are growing problems in the United States, particularly in Appalachian areas, which has led to a major social health problem costing millions of dollars in lost wages, medical care and lost productivity. In some patients with chronic moderate to severe pain, opioids are indicated and can be successfully used with proper monitoring. In this report, we present a case where the use of spinal cord stimulation (SCS) led to an elimination of opioids, a return to work, and to productive function. We also review the literature on the use of SCS to reduce opioid use and improve function based on objective criteria.

Back Injuries.

When searching for evidence-based answers about treating athletes with low back injury/pain, there are some difficulties. The first is defining who is an athlete. The second problem is that the lifetime prevalence of low back pain in the general population in our country approaches 100. Last, most studies published only deal with a narrow population of athletes, often performing very different types of physical activity. We searched the literature for studies that specifically evaluated athletes longitudinally. This article reviews the demographics, diagnostic challenges, history and physical examination, imaging choices, treatment, and controversies encountered when treating this population.

A preliminary retrospective survey of injuries occurring in dogs participating in canine agility.

OBJECTIVES: Little is known about the risks of injury to dogs participating in the relatively new sport of canine agility. The purpose of this study was to identify the factors that put the participating dog at risk as well as determine the anatomical sites that were most commonly injured. METHODS: A retrospective survey using a paper and web-based data collection instrument was used to evaluate dogs participating in the sport of canine agility. RESULTS: Of the 1627 dogs included in the study, 33% were injured, and of those 58% were injured in competition. Most injuries occurred on dry outdoor surfaces. Border Collies were the most commonly injured, and injuries were in excess of what would be expected from their exposure. For all dogs, soft tissue injuries were most common. The shoulders and backs of dogs were most commonly injured. Dogs were most commonly injured by contact with an obstacle. The A-frame, dogwalk and bar jump obstacles were responsible for nearly two-thirds of injuries that resulted from contact with the obstacle. CONCLUSIONS: Border Collies are at higher risk for injury than would be expected from their exposure. The A-frame, dogwalk and bar jump obstacles put the shoulders and backs of dogs at risk. CLINICAL RELEVANCE: For the first time, this study gives us insight into injuries occurring in dogs participating in canine agility. This will help direct prospective studies that evaluate the safety of individual obstacles, direct rule changes and enable practitioners to understand the risks of the sport.

Is a history of work-related low back injury associated with prevalent low back pain and depression in the general population?

BACKGROUND: Little is known about the role of prior occupational low back injury in future episodes of low back pain and disability in the general population. We conducted a study to determine if a lifetime history of work-related low back injury is associated with prevalent severity-graded low back pain, depressive symptoms, or both, in the general population. METHODS: We used data from the Saskatchewan Health and Back Pain Survey - a population-based cross-sectional survey mailed to a random, stratified sample of 2,184 Saskatchewan adults 20 to 69 years of age in 1995. Information on the main independent variable was gathered by asking respondents whether they had ever injured their low back at work. Our outcomes, the 6-month period prevalence of severity-graded low back pain and depressive symptoms during the past week, were measured with valid and reliable questionnaires. The associations between prior work-related low back injury and our outcomes were estimated through multinomial and binary multivariable logistic regression with adjustment for age, gender, and other important covariates. RESULTS: Fifty-five percent of the eligible population participated. Of the 1,086 participants who responded to the question about the main independent variable, 38.0% reported a history of work-related low back injury. A history of work-related low back injury was positively associated with low intensity/low disability low back pain (OR, 3.66; 95%CI, 2.48-5.42), with high intensity/low disability low back pain (OR, 4.03; 95%CI, 2.41-6.76), and with high disability low back pain (OR, 6.76; 95%CI, 3.80-12.01). No association was found between a history of work-related low back injury and depression (OR, 0.85; 95%CI, 0.55-1.30). CONCLUSION: Our analysis shows an association between past occupational low back injury and increasing severity of prevalent low back pain, but not depression. These results suggest that past work-related low back injury may be an important risk factor for future episodes of low back pain and disability in the general population.

[Persistent vegetative state caused by non-brain damage and its forensic assessment].

Persistent vegetative state (PVS) is described as one of the complications of brain damage in the current forensic science literatures. PVS unrelated to brain damage, however, is not uncommon in daily forensic practice. Currently, only "Assessment for Body Impairment of the Injured in Road Traffic Accident" designates PVS as one of its items under the section of "Brain, Spinal Cord, and Nerves Injury." Therefore, it is difficult to assess the damage and disability in PVS, especially PVS due to non-brain damage. Based on a case of PVS caused by chest injury in combination with relevant literature review, this paper provides a summary on the general information, etiology, pathogenesis, clinical manifestation, diagnosis and differential diagnosis of PVS, as well as a guideline for its forensic assessment.