Narrative review of occupational exposures and noncommunicable diseases.

OBJECTIVE: Within the scope of the Exposome Project for Health and Occupational Research on applying the exposome concept to working life health, we aimed to provide a broad overview of the status of knowledge on occupational exposures and associated health effects across multiple noncommunicable diseases (NCDs) to help inform research priorities. METHODS: We conducted a narrative review of occupational risk factors that can be considered to have "consistent evidence for an association," or where there is "limited/inadequate evidence for an association" for 6 NCD groups: nonmalignant respiratory diseases; neurodegenerative diseases; cardiovascular/metabolic diseases; mental disorders; musculoskeletal diseases; and cancer. The assessment was done in expert sessions, primarily based on systematic reviews, supplemented with narrative reviews, reports, and original studies. Subsequently, knowledge gaps were identified, e.g. based on missing information on exposure-response relationships, gender differences, critical time-windows, interactions, and inadequate study quality. RESULTS: We identified over 200 occupational exposures with consistent or limited/inadequate evidence for associations with one or more of 60+ NCDs. Various exposures were identified as possible risk factors for multiple outcomes. Examples are diesel engine exhaust and cadmium, with consistent evidence for lung cancer, but limited/inadequate evidence for other cancer sites, respiratory, neurodegenerative, and cardiovascular diseases. Other examples are physically heavy work, shift work, and decision latitude/job control. For associations with limited/inadequate evidence, new studies are needed to confirm the association. For risk factors with consistent evidence, improvements in study design, exposure assessment, and case definition could lead to a better understanding of the association and help inform health-based threshold levels. CONCLUSIONS: By providing an overview of knowledge gaps in the associations between occupational exposures and their health effects, our narrative review will help setting priorities in occupational health research. Future epidemiological studies should prioritize to include large sample sizes, assess exposures prior to disease onset, and quantify exposures. Potential sources of biases and confounding need to be identified and accounted for in both original studies and systematic reviews.

Long-term follow-up study of work status among patients with work-related mental disorders referred to departments of occupational medicine in Denmark.

OBJECTIVES: To describe the 5 year work status in patients referred for suspected work-related common mental disorders. To develop a prognostic model. DESIGN: Register-based nationwide longitudinal follow-up study. SETTING: All departments of occupational medicine in Denmark. PARTICIPANTS: 17 822 patients aged 18-67 years, seen for the first time at a Department of Occupational Medicine in Denmark from 2000 to 2013 and diagnosed with stress, depression, post-traumatic stress disorder, anxiety or other mental disorders. INTERVENTIONS: All patients were seen for diagnostic assessment and causal evaluation of the work-relatedness of their disorders. Some departments offered patients with stress disorders psychological treatment, which, however, was not organised according to patient selection or type of treatment. PRIMARY AND SECONDARY OUTCOME MEASURES: Register data were collected for 5 year periods before and after the patients' first assessment at a department. Weekly percentages of patients are presented according to work status. The outcome in the prognostic model was a high Work Participation Score (ie, working>75% of potential work weeks/year) at 5 year follow-up. RESULTS: For all subgroups of patients, a high proportion were working (>75%) 1-5 years before assessment, and all experienced a large reduction in work status at time of assessment. At 1 year follow-up, almost 60% of patients with stress were working, whereas in the other patient subgroups, less than 40% were working. In the following years, practically no increase was observed in the percentage of patients working in any of the subgroups. Based on these 5 year follow-up data, we developed a work participation model with only moderate discrimination and calibration. CONCLUSIONS: In Denmark, not all return to previous work status 5 years after a referral due to a suspected work-related common mental disorder. We developed a prognostic model with only moderate discrimination and calibration for long-term work participation after suggested work-related common mental disorders.

Estimating the causal effects of work-related and non-work-related stressors on perceived stress level: A fixed effects approach using population-based panel data.

OBJECTIVES: Prolonged or excessive stress can have a negative impact on health and well-being, and stress therefore constitutes a major public health issue. A central question is what are the main sources of stress in contemporary societies? This study examines the effects of work-related and non-work-related stressors and perceived social support on perceived stress within a causal framework. METHODS: Panel data were drawn from two waves (2013 and 2017) of the population-based health survey "How are you?" conducted in the Central Denmark Region. The analytical sample comprised 9,194 subjects who had responded to both surveys. Work-related and non-work-related stressors included major life events, chronic stressors, daily hassles and lack of social support. Perceived stress was measured with the 10-item Perceived Stress Scale (PSS). Data were analysed using fixed effects regression in a fully balanced design. RESULTS: The largest effects on PSS were seen in own disease, work situation and lack of social support. Other stressors affecting the perceived stress level were financial circumstances, relationship with partner, relationship with family and friends, and disease among close relatives. Most variables had a symmetrical effect on PSS. CONCLUSIONS: The results point to the need for comprehensive policies to promote mental health that span life domains and include both the individual and the group as well as organizational and societal levels. The study indicates that there are multiple potential entry points for stress prevention and stress management. However, it also shows that disease, work situation and social support weigh heavily in the overall picture. This points to the healthcare system and workplace as key institutional venues for action.

Developing prognostic models for health care utilization in patients with work-related mental health problems.

BACKGROUND: The long-term prognosis for employees with work-related mental health problems is unclear. We aim to describe long-term trends in health care utilization (HCU) and develop multivariable prognostic models for long-term mental health care utilization. METHODS: From the Danish Occupational Medicine Cohort we included mental health patients (N = 17,822) assessed from 2000 to 2013 at Departments of Occupational Medicine. Outcomes were general health (general practitioner, somatic hospital) and mental health (psychiatrist/psychologist, psychiatric hospital) HCU obtained from registries five years before/after assessment. The 10-year period was divided into phases relative to assessment: 5 - 3 years before, 2 years before/after, and 3-5 years after. We developed gender-stratified Lasso-penalized multivariable prognostic models for HCU 3-5 years after assessment assessing both calibration and discrimination. RESULTS: Prevalent HCU for general practitioner, psychiatrist/psychologist and psychiatric hospital services was relatively stable 5 - 3 years prior to assessment, then rising during the 2 years before/after. At 3-5 years after assessment prevalent general practitioner HCU declined to previous levels, while prevalent HCU for psychologist/psychiatrist and psychiatric hospital services remained elevated compared to previous levels during years 5 - 3. Prognostic models for long-term psychologist/psychiatrist and psychiatric hospital HCU indicated acceptable calibration and modest discrimination. CONCLUSIONS: Prevalent HCU rose two years before/after assessment and remained elevated for psychiatrist/psychologist and psychiatric hospital HCU 3-5 years after. Gender-stratified prognostic models were developed for long-term mental health HCU, but discrimination and calibration should be further improved before out-of-sample application for personal prognosis. TRIAL REGISTRATION: The study was registered at clinicaltrials.gov (Identifier: NCT04459793) prior to analyses.

The relative importance of work-related and non-work-related stressors and perceived social support on global perceived stress in a cross-sectional population-based sample.

BACKGROUND: High levels of perceived stress have a negative bearing on health and well-being, and stress is a major public health issue. According to the Stress Process Model, stressors are socially patterned and combine to produce strain. Despite this, most studies on stress have focused on work-related stressors leaving non-work determinants under-investigated. The aim of the present study was to determine the relative importance of work-related and non-work-related stressors and perceived social support for the overall perceived stress level. METHODS: Self-reported data were drawn from the 2017 population-based health survey "How are you?" conducted in the Central Denmark Region (N = 32,417). Data were linked with data drawn from national administrative registers. Work- and non-work-related stressors assessed included major life events, chronic stressors and daily hassles. Perceived social support was assessed using a single question. Overall perceived stress was assessed by the 10-item Perceived Stress Scale. We conducted dominance analyses based on a multiple linear regression model to determine the most important explanatory variables of overall perceived stress. Analyses were weighted and adjusted. RESULTS: Work- and non-work-related stressors along with perceived social support explained 42.5% of the total variance (R2) in overall perceived stress. The most important explanatory variables were disease, perceived social support and work situation. The stratified analyses produced slightly varying results ("dominance profiles") of perceived stress between subgroups. Work situation was the most important explanatory variable in the employed group. However, adding non-work-related explanatory variables to the analysis tripled the explained variance. CONCLUSIONS: The overall level of perceived stress can be statistically explained by a combination of work- and non-work-related stressors and perceived social support both at population level and in subgroups. The most important explanatory variables of overall perceived stress are disease, perceived social support and work situation. Results indicate that public health strategies aiming to reduce stress should take a comprehensive approach and address a variety of stressor domains rather than focus on a single domain. TRIAL REGISTRATION: The study was approved by the Danish Data Protection Agency (r. no. 2012-58-0006) and registered in the Central Denmark Region (r. no. 1-16-02-593-16).

Does Workplace Bullying Affect Long-Term Sickness Absence Among Coworkers?

AIM: To examine if non-bullied employees at work units (WUs) with workplace bullying have more long-term sickness absence (LTSA) than employees in non-bullying WUs. METHODS: We included 7229 public health employees from 302 WUs and 3158 responders to a questionnaire on working conditions and health in 2007. WUs were classified into three categories of WUs; (1) no bullying (0% bullied); (2) moderate prevalence of bullying (less than 10% bullied); and (3) high prevalence of bullying (more than or equal to 10% bullied). LTSA (more than or equal to 30 consecutive days of sickness absence) during the following 2 years was obtained by linkage to the Danish register of sickness absence compensation benefits and social transfer payments. RESULTS: Non-bullied coworkers in WUs, where bullying was reported had 15% to 22% more LTSA compared with non-bullying WUs. CONCLUSION: Workplace bullying may be associated with LTSA in the entire WU.

Work-focused cognitive behavioral intervention for psychological complaints in patients on sick leave due to work-related stress: Results from a randomized controlled trial.

BACKGROUND: Work-related stress is a global problem with negative implications for individuals and society. The purpose of the current study was to evaluate a stress management intervention for patients on sick leave due to work-related stress complaints using a three-armed randomized controlled design. METHODS: Participants were patients referred from three municipalities to the regional Department of Occupational Medicine. Inclusion criteria were: 1) sick leave due to work-related stress complaints, 2) a diagnosis of adjustment disorder or reactions to severe stress (ICD 10 code: F43,2 - F 43,9 not PTSD) or mild depressive episode (F 32.0). Through a double randomization procedure patients (n = 163) were randomized to either an intervention group (n = 58), a 'control group A' receiving a clinical examination (n = 56), or 'control group B' (n = 49) receiving no offers at the department. The intervention comprised six sessions of individual cognitive behavioral therapy and the offer of a small workplace intervention. Questionnaire data were analyzed with multivariate repeated measurements analysis. Primary outcomes assessed were perceived stress and general mental health. Secondary outcomes were sleep quality and cognitive failures. Follow-up was at four and 10 months after baseline. RESULTS: Complaints were significantly reduced in all groups over time. No group effects were observed between the intervention group and control group A that was clinically assessed. Significant group effects were found for perceived stress and memory when comparing the intervention group to group B, but most likely not due to an intervention effect. CONCLUSION: Psychological complaints improved substantially over time in all groups, but there was no significant treatment effect on any outcomes when the intervention group was compared to control group A that received a clinical assessment. TRIAL REGISTRATION: ISRCTN ISRCTN91404229. Registered 03 August 2012 (retrospectively registered).

Cross-cultural adaptation and validation of the Danish 10-item Connor-Davidson Resilience Scale among hospital staff.

OBJECTIVES: The 10-item Connor-Davidson Resilience Scale (CD-RISC 10) is a brief instrument measuring resilience in adults. The scale has shown sound psychometric properties in different populations and cultures. Our objectives were to cross-culturally adapt the CD-RISC 10 into Danish and to establish the psychometric properties of the Danish version in terms of internal consistency, construct validity and longitudinal validity. METHODS: The CD-RISC 10 was translated using established guidelines. Employees ( N=272) at hospitals in the Central Denmark Region completed questionnaires at baseline and three months follow-up. Questionnaires included the translated Danish version of the CD-RISC 10 and the 10-item Perceived Stress Scale (PSS-10). Internal consistency was assessed by Cronbach's alpha and construct and longitudinal validity by correlating CD-RISC 10 and PSS-10 baseline scores and change scores from baseline to follow-up. RESULTS: The Danish CD-RISC 10 provides acceptable internal consistency (Cronbach's alpha = 0.87). Analysis of construct validity revealed a negative correlation with the PSS-10 at baseline ( r=-.63 [95%CI: -.70; -.55], p<.0001). Analysis of longitudinal validity similarly demonstrated a negative correlation on change scores from baseline to follow-up ( r=-.51 [95%CI: -.62; -.39], p<.0001). CONCLUSIONS: The scale has acceptable psychometric properties as an instrument for measuring resilience in a Danish-speaking population.

Return to work after work-related stress: a randomized controlled trial of a work-focused cognitive behavioral intervention.

Objectives This study aimed to evaluate the effect of a stress management intervention (SMI) on lasting return to work (RTW) among patients with work-related stress complaints. Methods Sickness benefit departments from three local municipalities referred patients on sick leave with work-related adjustment disorders or mild depression to the Department of Occupational Medicine, Regional Hospital West Jutland. A 2× randomization procedure allocated patients into one of three groups: intervention (N=58), control A (which received a clinical assessment; N=56), or control B (no assessment; N=49). Treatment comprised individual work-focused cognitive behavioral therapy (CBT) with an optional workplace intervention. The outcome was time until lasting RTW (16 and 44 weeks follow-up) using register data. Results Median number of weeks until lasting RTW was 15, 19, and 32 for the intervention group, control A, and control B respectively. However, for group B, clinical assessment was not part of the inclusion process, which may have introduced selection bias. In the fully-adjusted Cox regression model, the intervention group exhibited significantly faster lasting RTW at 44 weeks; hazard ratio (HR) 1.57 [95% confidence interval (95% CI) 1.01-2.44] relative to control group A, with a non-significant trend evident at 16 weeks; HR 1.70 (95% CI 0.94-3.10), when controlling for age, gender, occupation, sick leave during previous year, full or partial sick leave, and diagnosis. Unadjusted analyses remained directionally consistent but were reduced to marginal significance. Conclusions There was a tendency towards faster lasting RTW in the intervention group compared to control A, which received clinical assessment, in all analyses. The intervention group returned to work about 4 weeks earlier than control A, which could translate into substantial financial gains.

Relationship Between Changes in Workplace Bullying Status and the Reporting of Personality Characteristics.

OBJECTIVE: To examine whether a shift in work-related bullying status, from being non-bullied to being bullied or vice versa, was associated with changes in reporting of personality characteristics. METHODS: Data on bullying and personality (neuroticism, extraversion, and sense of coherence) were collected in three waves approximately 2 years apart (N = 4947). Using a within-subjects design, personality change scores that followed altered bullying status were evaluated with one-sample t tests. Sensitivity analyses targeted depressive symptoms. RESULTS: Shifts from non-bullied to frequently bullied were associated with increased neuroticism or decreased sense of coherence manageability scores. Shifts from bullied to non-bullied were associated with decreasing neuroticism and increasing extraversion scores, or increasing sense of coherence meaningfulness and comprehensibility scores. Excluding depressive cases had minor effects. CONCLUSIONS: Bullying seems to some extent to affect personality scale scores, which thus seem sensitive to environmental and social circumstances.

Negative Acts at Work as Potential Bullying Behavior and Depression: Examining the Direction of the Association in a 2-Year Follow-Up Study.

OBJECTIVE: This study investigates the 2-year prospective association between exposure to negative acts at work and depression. METHODS: A questionnaire study was carried out among 3363 employees and followed up 2 years later. Negative acts as potential bullying behavior were assessed by the Revised Negative Acts Questionnaire and depression by The Major Depression Inventory or Schedule for Clinical Assessment in Neuropsychiatry interviews. Logistic regression analyses tested potential associations between depression and negative acts. RESULTS: Exposure to negative acts was associated with depression 2 years later; however, when adjusting for Sense of Coherence and depressive symptoms at baseline the association was no longer significant. Conversely, depression at baseline predicted self-reported exposure to negative acts at follow-up. CONCLUSIONS: Depression predicts exposure to negative acts at a 2-year follow-up, whereas negative acts do not predict depression after adjustment for Sense of Coherence and baseline depressive symptoms.

Health correlates of workplace bullying: a 3-wave prospective follow-up study.

OBJECTIVE: This study aimed to examine the course of workplace bullying and health correlates among Danish employees across a four-year period. METHODS: In total, 7502 public service and private sector employees participated in a 3-wave study from 2006 through 2011. Workplace bullying over the past 6-12 months and data on health characteristics were obtained by self-reports. We identified major depression using Schedules for Clinical Assessment in Neuropsychiatry interviews and the Major Depression Inventory. We performed cross-sectional and longitudinal analyses of outcomes according to self-labelled bullying at baseline using logistic regression. RESULTS: Reports of bullying were persistent across four years in 22.2% (57/257) of employees who initially reported bullying. Baseline associations between self-labelled bullying and sick-listing, poor self-rated health, poor sleep, and depressive symptoms were significant with adjusted odds ratios (OR) ranging from 1.8 [95% confidence interval (95% CI) 1.5-2.4] for poor sleep quality among those bullied "now and then" to 6.9 (95% CI 3.9-12.3) for depression among those reporting being bullied on a daily to monthly basis. In longitudinal analyses adjusting for bullying during follow-up, all health correlates except poor sleep quality persisted up to four years. CONCLUSION: Self-reported health correlates of workplace bullying including sick-listing, poor self-rated health, depressive symptoms, and a diagnosis of depression tend to persist for several years regardless of whether bullying is discontinued or not. Independent measures of bullying and outcomes are needed to learn whether these findings reflect long lasting health consequences of workplace bullying or whether self-labelled workplace bullying and health complaints are correlated because of common underlying factors.

Workplace bullying, sleep problems and leisure-time physical activity: a prospective cohort study.

OBJECTIVES: Workplace bullying is a potent stressor that may increase sleep problems. Since physical fitness improves resilience to stress, it seems plausible that recreational physical activities may moderate the association between bullying and sleep. The study aimed to examine prospectively whether (i) bullying increases the risk of sleep problems, and (ii) the association between bullying and sleep problems is moderated by leisure-time physical activity (LTPA). METHODS: The study sample comprised a cohort of public and private sector employees, who were enrolled into the Work Bullying and Harassment (WBH) cohort (N=3278) or the Psychosocial Risk Factors for Stress and Mental Disease (PRISME) cohort (N=4455). We measured workplace bullying using one question that was preceded by a definition of bullying. We used the Karolinska sleep questionnaire to assess sleep problems. The number of hours per week spent on LTPA estimated the degree of physical activity. RESULTS: Workplace bullying at baseline (T1) was associated with awakening problems and lack of restful sleep at follow-up (T2) but not with overall sleep problems and disturbed sleep. T1-LTPA did not moderate the association between T1-workplace bullying and T2-sleep problems. CONCLUSION: We found support that workplace bullying is related to development of T2-sleep problems, but this association seems not to be modified by LTPA.

Exposure to workplace bullying and risk of depression.

OBJECTIVE: We examined the prospective association between self-labeled and witness-reported bullying and the risk of newly onset of depression. METHODS: Employees were recruited from two cohorts of 3196 and 2002 employees, respectively. Participants received a questionnaire at baseline in 2006 to 2007 with follow-up in 2008 to 2009 and 2011. New cases of depression were diagnosed in the follow-up using Schedules for Clinical Assessment in Neuropsychiatry interviews and the Major Depression Inventory questionnaire. RESULTS: We identified 147 new cases of depression. The odds ratio for newly onset depression among participants reporting bullying occasionally was 2.17 (95% confidence interval [CI]: 1.11 to 4.23) and among frequently bullied 9.63 (95% CI: 3.42 to 27.1). There was no association between percentage witnessing bullying and newly onset depression. CONCLUSIONS: Frequent self-labeled bullying predicts development of depression but a work environment with high proportion of employees witnessing bullying does not.

Changes in self-reported sleep and cognitive failures: a randomized controlled trial of a stress management intervention.

OBJECTIVES: This study evaluated the effectiveness of a stress management intervention combining individual cognitive behavioral therapy (CBT) with a brief workplace intervention on self-reported measures of sleep and cognitive functioning among patients on sick leave due to work-related stress complaints. METHODS: Participants were patients referred to the regional Department of Occupational Medicine. Inclusion criteria were (i) sick leave due to work-related stress complaints and (ii) a diagnosis of adjustment disorder/reactions to stress or mild depression. Participants (N=137) were randomized to either an intervention (N=57) or control (N=80) group. The intervention comprised six sessions with a psychologist and the offer of a small workplace intervention. Questionnaires were answered at baseline and after 4, and 10 months. RESULTS: Symptoms were significantly reduced over time in both groups but there was no significant treatment effect on sleep or cognitive outcomes at any time point. From 0-4 months, there was a tendency for larger improvements in the intervention group with regards to sleep and cognitive failures in distraction. Although neither was significant, the results came close to significance depicting a small effect size (Cohen's d) on sleep complaints and distractions (but not memory). CONCLUSIONS: The specific intervention was not superior to the control condition in reducing symptoms of sleep problems and cognitive difficulties at any time point during the 10-month follow-up period. Substantial improvements in symptoms over time were seen in both groups.

Rehabilitation of individuals on long-term sick leave due to sustained stress-related symptoms: a comparative follow-up study.

AIMS: Nature-assisted therapy for mental health problems receives increased attention. However, quantitative evaluations are rare. This study evaluates the effects of an all-outdoors vocational rehabilitation program for individuals on long-term sick leave due to sustained stress-related symptoms. METHODS: In a comparative pre-post intervention design the intervention group contained 48 participants from Mariendal Gardens (MG), while 45 participants at Stress- & Jobmanagement (SJ) formed the comparison group. At MG all activities took place outdoors, while activities at SJ were mainly indoors. Questionnaires were completed at baseline, 3- and 6-month follow-up. Outcomes included Perceived Stress Scale (PSS-10) and measures of sleep, mindfulness, self-efficacy, daily functioning, and work ability. Data were analyzed using mixed model repeated measures analysis of variance. RESULTS: At baseline the MG-group PSS-10 mean score was 25.15 points (SD=7.20), while the SJ-group mean score was 23.91 (SD=7.48). At 3-months the MG within-group score dropped 4.61 [2.71; 6.52] points (p<0.01), corresponding to at standardized mean difference (Cohen's d) of d=0.64 [0.38; 0.91], while the SJ within-group score dropped 4.16 [1.73; 6.59] points (p<0.01), corresponding to d=0.56 [0.23; 0.88]. The between-group mean difference was not significant (p=0.77). Similarly, results for sleep, mindfulness, self-efficacy, daily functioning, and work ability demonstrated significant within-group effects and minimal between-group differences. CONCLUSIONS: Both interventions demonstrated small to large pre-post effect sizes. Negligible differences were observed between the effects of the two interventions, indicating no added effect of the all-outdoors setting. Results should be interpreted with caution as unequal lost to follow-up rates threatens the comparability of changes in the two groups.

Description and design considerations of a randomized clinical trial investigating the effect of a multidisciplinary cognitive-behavioural intervention for patients undergoing lumbar spinal fusion surgery.

BACKGROUND: The ideal rehabilitation strategy following lumbar spinal fusion surgery has not yet been established. This paper is a study protocol, describing the rationale behind and the details of a cognitive-behavioural rehabilitation intervention for lumbar spinal fusion patients based on the best available evidence. Predictors of poor outcome following spine surgery have been identified to provide targets for the intervention, and the components of the intervention were structured in accordance with the cognitive-behavioural model. The study aims to compare the clinical and economical effectiveness of a cognitive-behavioural rehabilitation strategy to that of usual care for patients undergoing lumbar spinal fusion surgery. METHODS/DESIGN: The study is a randomized clinical trial including 96 patients scheduled for lumbar spinal fusion surgery due to degenerative disease or spondylolisthesis. Patients were recruited in the period October 2011 to July 2013, and the follow-up period is one year from date of surgery. Patients are allocated on a 1:2 ratio (control: intervention) to either treatment as usual (control group), which implies surgery and the standard postoperative rehabilitation, or in addition to this, a patient education focusing on pain behaviour and pain coping (intervention group). It takes place in a hospital setting, and consists of six group-based sessions, managed by a multidisciplinary team of health professionals.The primary outcomes are disability (Oswestry Disability Index) and sick leave, while secondary outcomes include coping (Coping Strategies Questionnaire), fear-avoidance belief (Fear Avoidance Belief Questionnaire), pain (Low Back Pain Rating Scale, pain index), mobility during hospitalization (Cumulated Ambulation Score), generic health-related quality of life (EQ-5D) and resource use. Outcomes are measured using self report questionnaires, medical records and national registers. DISCUSSION: It is expected that the intervention can provide better functional outcome, less pain and earlier return to work after lumbar spinal fusion surgery. By combining knowledge and evidence from different knowledge areas, the project aims to provide new knowledge that can create greater consistency in patient treatment. We expect that the results can make a significant contribution to development of guidelines for good rehabilitation of patients undergoing lumbar spinal fusion. TRIAL REGISTRATION: Current Controlled Trials ISRCTN42281022.

Effects of a stress management intervention on absenteeism and return to work--results from a randomized wait-list controlled trial.

OBJECTIVE: High levels of work-related stress are associated with increased absenteeism from work and reduced work ability. In this study, we investigated the effects of a stress management intervention on absenteeism and return to work. METHODS: We randomized 102 participants into either the intervention or wait-list control (WLC) group. The intervention group received the intervention in weeks 1-16 from baseline, and the WLC group received the intervention in weeks 17-32. Self-reported data on absenteeism (number of days full- or part-time absent from work within the previous three months) were obtained at 16, 32, and 48 weeks follow-up. Register-based data on long-term absence from work were drawn from the Danish public transfer payments (DREAM) database from baseline and 48 weeks onwards. The DREAM database contains weekly information on long-term sickness absence compensation. The threshold to enter DREAM is sick leave for two consecutive weeks. RESULTS: At follow-up in week 16, self-reported absenteeism in the intervention group [median 11 days (range 3-25)] was lower (P=0.02) than in the WLC group [median 45 days (range 19-60)], corresponding to a 29% [95% confidence interval (95% CI) 5-52] reduction. On register-based data (cumulated weeks in DREAM, weeks 1-16), the intervention group median [6 weeks (range 0-11)] was lower than that of the WLC group [median 12 weeks (range 8-16)], though not significantly (P=0.06), corresponding to a 21% (95% CI 0-42) reduction. For return to work, a hazard ratio of 1.58 (95% CI 0.89-2.81) favoring the intervention group was found (P=0.12). CONCLUSIONS: The intervention reduces self-reported absenteeism from work. A similar trend was found from register-based records. No conclusive evidence was found for return to work.

Changes in stress and coping from a randomized controlled trial of a three-month stress management intervention.

OBJECTIVES: To investigate whether a group-based stress management intervention, based on principles from cognitive behaviour therapy, can reduce stress and alter coping strategies in an occupationally diverse population with extensive symptoms of work-related stress. METHODS: Using a randomized wait list control design, 102 participants were divided into two groups: intervention and wait list control (WLC). The intervention was a three-month group-based stress management program. Outcomes measures were the Perceived Stress Scale (PSS-10, range 0-40 points) and five dimensions from the Brief COPE questionnaire (range 2-8 points) at baseline and three-, six- and nine-months follow-up. Data were analyzed with a univariate analysis of variance. RESULTS: On the PSS-10 from baseline to three months, the intervention group changed -6.45 (95% CI -8.25--4.64) points, compared to -1.12 (95% CI -2.94-0.70) points in the WLC group. The between-groups difference was -5.32 (95% CI -7.89--2.76) points, equalling a standardized mean difference of -0.84 (95% CI -1.27--0.42) favouring the intervention. One coping dimension, positive reframing, differed between the two groups. Here the intervention group changed -0.86 (95% CI -1.25--0.48) points from baseline to three months, compared to -0.18 (-0.58-0.22) points in the WLC-group. We found a between-groups difference of -0.67 (95% CI -1.24--0.11) points, equalling a standardized mean difference of -0.48 (95% CI -0.89--0.07) favouring the intervention. The gains achieved during treatment were maintained when followed up three months later. CONCLUSIONS: Treatment is superior to the control condition in positively affecting perceived stress and positive reframing. When followed up, the gains achieved are maintained.