Implementation of Early Intervention Protocol in Australia for 'High Risk' Injured Workers is Associated with Fewer Lost Work Days Over 2 Years Than Usual (Stepped) Care.

Purpose To evaluate whether a protocol for early intervention addressing the psychosocial risk factors for delayed return to work in workers with soft tissue injuries would achieve better long-term outcomes than usual (stepped) care. Methods The study used a controlled, non-randomised prospective design to compare two case management approaches. For the intervention condition, workers screened within 1-3 weeks of injury as being at high risk of delayed returned to work by the Örebro Musculoskeletal Pain Screening Questionnaire-short version (ÖMPSQ-SF) were offered psychological assessment and a comprehensive protocol to address the identified obstacles for return to work. Similarly identified injured workers in the control condition were managed under usual (stepped) care arrangements. Results At 2-year follow-up, the mean lost work days for the Intervention group was less than half that of the usual care group, their claim costs were 30% lower, as was the growth trajectory of their costs after 11 months. Conclusions The findings supported the hypothesis that brief psychological risk factor screening, combined with a protocol for active collaboration between key stakeholders to address identified psychological and workplace factors for delayed return to work, can achieve better return on investment than usual (stepped) care.

Correction to: Implementation of Early Intervention Protocol in Australia for 'High Risk' Injured Workers is Associated with Fewer Lost Work Days Over 2 Years Than Usual (Stepped) Care.

The original version of this article unfortunately contained a spelling error in one of the co-authors's names. The family name of the co-author was incorrectly displayed as "James McCauley" instead of "James McAuley. The original article has been corrected.

Predicting Return to Work in a Heterogeneous Sample of Recently Injured Workers Using the Brief ÖMPSQ-SF.

Purpose (1) to examine the ability of the Örebro Musculoskeletal Pain Screening Questionnaire-short version (ÖMPSQ-SF) to predict time to return to pre-injury work duties (PID) following a work-related soft tissue injury (regardless of body location); and (2) to examine the appropriateness of 50/100 as a suitable cut-off score for case identification. Methods Injured workers (IW) from six public hospitals in Sydney, Australia, who had taken medically-sanctioned time off work due to their injury, were recruited by insurance case managers within 5-15 days of their injury. Eligible participants (N = 213 in total) were administered the ÖMPSQ-SF over the telephone by the case manager. For objective (1) Cox proportional hazards regression analysis was used to predict days to return to PID using the ÖMPSQ-SF. For objective (2) receiver operator characteristic (ROC) analysis was used to determine the ÖMPSQ-SF total score that optimises sensitivity and specificity in detecting whether or not participants had returned to PID within 2-7 weeks. Results The total ÖMPSQ-SF score significantly predicted number of days to return to PID, such that for every 1-point increase in the total ÖMPSQ-SF score the predicted chance of returning to work reduced by 4% (i.e., hazard ratio = 0.96), p < 0.001. Sensitivity and specificity for the ROC analysis comparing ÖMPSQ-SF total score to return to PID within 2-7 weeks suggested 48 as the optimal cut off (sensitivity = 0.65, specificity = 0.79). Conclusion The results provide strong support for the use of the ÖMPSQ-SF in an applied setting for identifying those IW likely to have delayed RTW when administered within 15 days of the injury. While a score of 48/100 was the optimal cut point for sensitivity and specificity, pragmatically, 50/100 should be acceptable as a cut-off in future studies of this type.

A longitudinal view of rumination, poor sleep and psychological distress in adolescents.

BACKGROUND: Given the high prevalence and negative impact of psychological problems during adolescence, examining transdiagnostic factors that may have scope to positively influence a variety of psychological problems is imperative. The main purpose of this study was to investigate the longitudinal relationship between rumination and psychological distress and whether sleep mediated this relationship over a 2 year period. METHODS: Participants were 1620 high school students in the 7th and 8th grade at baseline from 17 public schools in three middle Sweden communities. Students completed questionnaires at school during the spring of 2014, 2015 and 2016. Rumination and psychological distress were self-reported, and sleep duration was calculated from reported bed-times, wake-times and sleep onset latencies. RESULTS: Sleep duration declined with age, whereas rumination and psychological distress increased. Rumination was predictive of future psychological distress and distress at a given time was predictive of concurrent rumination. Sleep duration did not consistently mediate the reciprocal relationships between rumination and psychological distress over time. LIMITATIONS: Stronger longitudinal associations may have been obtained by using smaller measurement intervals or further delineation of outcome constructs. CONCLUSIONS: Reducing rumination, rather than targeting sleep patterns, may work towards preventing the development of a number of psychological problems and is a strategy anticipated to function across disorders to improve young people's mental wellbeing.

Longitudinal associations between time spent using technology and sleep duration among adolescents.

Technology use has been the focus of much concern for adolescents' sleep health. However, few studies have investigated the bidirectional association between sleep duration and time spent using technology. The aim of this study was to test whether time spent using technology predicted shorter sleep duration, and/or vice versa using cross-lagged analyses over one year. Participants were 1620 high school students in the 8th and 9th grade at baseline from 17 public schools in three middle Sweden communities. Students completed questionnaires at school during the spring of 2015 and 2016. Time spent using technology was self-reported and sleep duration was calculated from reported bed-times, wake-times and sleep onset latency. Time spent using technology significantly predicted shorter subsequent sleep duration and vice versa. Public health advocates educating others about the negative impacts of technology on sleep must also be mindful of the opposite, that many young people may turn to technological devices when experiencing difficulty sleeping.

Avoiding or enduring painful sex? A prospective study of coping and psychosexual function in vulvovaginal pain.

BACKGROUND: Recurring vulvovaginal pain is common, with evident effects on affected women's lives. Little is known about how affected women cope with painful sexual activities and how coping relates to pain intensity and psychosexual functioning over time. This prospective study explored the impact of avoidance and endurance on sexual function over time. Additionally, patterns of coping were studied on an individual level to increase knowledge about coping and its relation to psychosexual functioning. METHODS: One hundred and seventeen women, 18-35 years old, with recurring vulvovaginal pain answered questionnaires at two measurement points, five months apart, assessing avoidance and endurance coping, pain intensity and psychosexual functioning. A multiple regression model explored the predictive value of avoidance and endurance on sexual function over time. Cluster analyses investigated patterns of coping and stability within the clusters. These subgroups were compared on psychosexual outcomes. RESULTS: Avoidance at baseline was the only significant predictor of sexual function five months later. Distinct and stable subgroups with different patterns of coping were identified, where avoidance and endurance coping were used both separately and combined. Women who both avoided and endured had the most unfavourable outcomes in terms of psychosexual functioning. CONCLUSIONS: Avoidance of sexual activities was related to reduced sexual function over time, which calls for attention and clinical interventions targeting avoidance. Additionally, women who both avoid and endure sexual activities despite pain possibly need tailored interventions, as women with this coping pattern reported the lowest levels of psychosexual functioning. SIGNIFICANCE: In this prospective study, avoidance of sexual activities predicted sexual function over time, when controlling for pain intensity. Subgroups of women using distinct patterns of coping were identified. Those who both avoided and endured had the lowest levels of psychosexual functioning.

Sleep duration and patterns in adolescents: correlates and the role of daily stressors.

OBJECTIVES: The first aim of this study was to assess the prevalence of sleep deficit in a large sample of adolescents. Second, the study aimed to assess whether short sleep duration in the sample was associated with emotional and behavioral problems. Lastly, the study aimed to investigate the association between daily stressors--bedtime activities and sleep duration. DESIGN: Cross-sectional survey. SETTING: The questionnaires were completed during school hours in 17 municipal junior high schools in Sweden. PARTICIPANTS: A total of 2767 adolescents aged 12 to 16 years, 48% girls. MEASUREMENTS AND RESULTS: Sleep measures included total sleep time (TST) for schooldays and weekends, obtained as combined measures of self-reported bed-time, wake-time, and sleep onset latency. We used the new National Sleep Foundation's guidelines to operationalize sleep duration. Overall 12% of younger adolescents (age 12-13 years) and 18% of older adolescents (14-16 years) slept less than recommended (TST < 7 hours). Adolescents reporting nonrecommended TST also reported more behavioral (ie, norm-breaking behaviors) and emotional problems (ie, depression, anxiety, and anger), with effects in the small-medium range. Finally, adolescents reporting bedtime arousal and use of information and communication technology in bed were more likely to report TST < 7 hours. Stress at home (for younger adolescents) and stress of school performance (for older adolescents) were also associated with TST less than 7 hours. CONCLUSIONS: The new National Sleep Foundation's recommendations were informative in this context. Future sleep interventions need to target barriers to good sleep practices, such as use of information and communication technology, stress, and worry that may contribute to arousal at bedtime.

Treating youth in pain: Comparing tailored behavioural medicine treatment provided by physical therapists in primary care with physical exercises.

OBJECTIVES: To study the efficacy of tailored behavioural medicine treatment within a physical therapy framework. METHODS: The study was a randomized controlled study (RCT): tailored behavioural medicine treatment (EXT) delivered by physical therapists (PTs) was compared with exercise-based treatment (CT). Thirty-two adolescents (mean age 14.3 years) with persistent pain participated. Data on pain-related disability and school attendance (primary outcomes), pain intensity, catastrophizing, fear of movement and self-efficacy were collected. RESULTS: The pain-related disability measured by the Functional Disability Inventory (FDI) resulted in mean score change of EXT = -18 and CT = -11, respectively. A significant change within both groups was found (EXT p = 0.003, CT p = 0.001), and a large effect size for FDI between the conditions was demonstrated (AUC of 0.77). For school attendance post-treatment, no difference was found between conditions. For secondary outcomes, a significant improvement in pain intensity and pain catastrophizing was found for the EXT and self-efficacy for the CT groups but no statistically significant difference between the two conditions was detected. Caution should be given to the small sample size, as it may affect the interpretation and generalizability of the results. CONCLUSION: In this study, differences between tailored behavioural medicine treatment delivered by PTs and exercise-based treatment could not be demonstrated, although the effect size was large. Patients who received either treatment demonstrated significant changes over time in pain-related disability. The low number of participants and suboptimal tailoring of the psychological components may partly explain the failure to demonstrate differences between groups, and future studies are warranted.

Too tired for school? The effects of insomnia on absenteeism in adolescence.

OBJECTIVES: Sleep has important consequences for a person's daytime functioning. Numerous studies have shown that insomnia predicts work absenteeism and work disability in adults, but only a few studies have examined this association in adolescents. This study aims to explore whether symptoms of insomnia in adolescents predict school absenteeism 1 year later, over and above known psychological risk factors for absenteeism. DESIGN: The study used a longitudinal design with 2 measurement points over 1 year. SETTING: The students completed questionnaires during school hours at baseline and again at follow-up. PARTICIPANTS: Students in the 10th to 12th grades in a Swedish upper secondary school were followed prospectively for 1 year (age, 16-20 years; N = 353; 48.1% girls). MEASUREMENTS AND RESULTS: We used logistic regression analyses, controlling for the known effects of psychological factors, and arrived at a model elucidating the role of insomnia. That is, besides symptoms of insomnia, the model included previous absenteeism, alcohol intoxication, school-related social phobia, social anxiety, depressive symptoms, somatic symptoms, and bully victimization. Symptoms of insomnia predicted school absenteeism 1 year later, over and above known risk factors for absenteeism. Adolescents reporting severe symptoms of insomnia were almost 3 times more likely than adolescents reporting no or low symptoms to report problematic absenteeism 1 year later. We did not find any gender difference. CONCLUSIONS: Our findings underscore the importance of sleep problems on adolescents' daytime functioning as measured by school absenteeism. Therefore, sleep may be an important target for preventive interventions with adolescents.

When the wind goes out of the sail - declining recovery expectations in the first weeks of back pain.

BACKGROUND: Expectations for recovery are a known predictor for returning to work. Most studies seem to conclude that the higher the expectancy the better the outcome. However, the development of expectations over time is rarely researched and experimental studies show that realistic expectations rather than high expectancies are the most adaptive. This study aims to explore patterns of stability and change in expectations for recovery during the first weeks of a back-pain episode and how these patterns relate to other psychological variables and outcome. METHODS: The study included 496 volunteer patients seeking treatment for work-related, acute back pain. The participants were measured with self-report scales of depression, fear of pain, life impact of pain, catastrophizing and expectations for recovery at two time points. A follow-up focusing on recovery and return to work was conducted 3 months later. A cluster analysis was conducted, categorizing the data on the trajectories of recovery expectations. RESULTS: Cluster analysis revealed four clusters regarding the development of expectations for recovery during a 2-week period after pain onset. Three out of four clusters showed stability in their expectations as well as corresponding levels of proximal psychological factors. The fourth cluster showed increases in distress and a decrease in expectations for recovery. This cluster also has poor odds ratios for returning to work and recovery. CONCLUSION: Decreases in expectancies for recovery seem as important as baseline values in terms of outcome, which has clinical and theoretical implications.

Painfully reassuring? The effects of validation on emotions and adherence in a pain test.

Communicating reassurance to patients with musculoskeletal pain complaints, but no red flags, presents a dilemma of dampening worry while refraining from reinforcing undue pain behaviors. Previous research shows that reassurance does not decrease negative affect and may be perceived as not taking the symptoms seriously. Validation offers an alternative where the patient's experiences and feelings are acknowledged and has demonstrated, for other problems, a decrease in arousal which may set the stage for behavioral change. The purpose of this study was to investigate experimentally whether validation, as compared to invalidation, impacts on emotions and adherence during repeated pain tests. To this end, 50 participants were randomized to either a validation or invalidation condition. Each participant was told they would undergo four pain trials involving holding a bucket at arm's length to tolerance. During the inter-trial interval, the experimenter provided validating or invalidating responses according to the randomization. As a proxy measure of adherence subjects were asked to engage in an additional pain test. Results indicated that validation relative to invalidation resulted in significantly more positive affect and significantly less worry. Both groups had reductions in negative affect over the trials, but there were no difference between the groups on negative affect or pain. However, adherence was more than twice as high in the validation group as compared to invalidation. These results show that a relatively simple validation procedure had significant and positive effects on emotion and increased adherence. Further research should extend these findings and explore their clinical application.

The effect of validating and invalidating communication on satisfaction, pain and affect in nurses suffering from low back pain during a semi-structured interview.

When physicians interview patients with ambiguous or nonspecific symptoms, they often try to reassure them with the purpose of explaining that no dangerous illness or disease is causing the symptoms. Unfortunately the evidence suggests that patients with benign (back) pain instead feel misunderstood, frustrated and unsatisfied with the consultation. Validation is a communication method that focuses on understanding and empathy as a platform for problem solving and it may be applicable for interviews in medical settings. The aim of this study was to examine the effects of validation on patient satisfaction, pain and affect. To this end 28 nurses with (re)current back pain were recruited and randomly assigned to be interviewed in a validating or invalidating condition. Patient satisfaction, affect, pain, disability, pain catastrophizing, and fear of movement were assessed immediately after the interview. The results show that the participants in the validated group were more satisfied with the interview than participants in the invalidating condition. Moreover, they showed a significant decrease on all measures of negative affect as well as for pain. For example, there was a significant between group difference in frustration where frustration decreased in the validation group, while it increased in the invalidation condition. A validating communication style seems to be beneficial for enhancing patient satisfaction, as well as diminishing negative affect and pain intensity ratings. Our results suggest that validation might be a viable technique to use in clinical examinations of patients suffering pain.

Do psychosocial factors predict disability and health at a 3-year follow-up for patients with non-acute musculoskeletal pain? A validation of the Orebro Musculoskeletal Pain Screening Questionnaire.

PURPOSE: Early identification and intervention with those that run the risk of developing long-term disability would offer a great opportunity for reducing costs and personal suffering associated with long-term work absenteeism. The Orebro Musculoskeletal Pain Screening Questionnaire (OMPSQ) has been used and validated in several studies for participants with mainly acute pain problems. The aim of this study was to validate the OMPSQ for patients with non-acute pain problems (e.g. 1-6 months sick leave) and compare to other relevant questionnaires. METHOD: One hundred and fifty-eight patients with musculoskeletal pain and disability recruited to a multidisciplinary rehabilitation project completed a battery of questionnaires at baseline and at 3-year follow-up visits. The main analysis involved the relationship between risk levels in the questionnaire and sick leave and perceived health after 3 years. RESULTS: The OMSPQ predicted future sick leave and health and was found to have six factors. The function and pain factors were the best predictors of sick leave after 3 years, while the distress factor was the best predictor of perceived mental health and return to work-expectancy was borderline significant. Perceived physical health at 3 years was best predicted by the function and pain factors with the fear-avoidance factor being marginally significant. CONCLUSION: The results demonstrate that psychosocial factors as measured by OMPSQ are related to work disability and perceived health even 3 years after treatment for patients with non-acute pain problems. The OMSPQ was a good predictor of outcome.

Quality of life and maintenance of improvements after early multimodal rehabilitation: a 5-year follow-up.

PURPOSE: There is a paucity of long-term evaluations on rehabilitation of musculoskeletal disorders, e.g., neck, shoulder or back pain. The aim of this study was to assess quality of life and the effect of early multimodal rehabilitation on 91 patients with musculoskeletal pain and disability at a 5-year follow-up. METHOD: The follow-up assessment, which included questions on pain, function, quality of life, perceived health, sick leave and psychosomatic symptoms, was performed 5 years after the assessment of baseline status. RESULTS: Improvements in pain, perceived health and psychosomatic symptoms were maintained at the 5-year follow-up. In addition, improvements in function, quality of life, and level of acceptable pain were significant in comparison to baseline. At the time of the baseline assessment all patients were on sick leave (13% were on partial sick leave). At the 5-year follow-up, 58% of the patients were at work part or full time. The results show that those working differed significantly from those not working at the 5-year follow-up on almost all variables, indicating that those working enjoy better health. The most salient prognostic factors for return to work were perceived health and educational level at the time of the baseline evaluation. CONCLUSIONS: These results show that treatment improved quality of life and the effects were basically maintained at 5 years. Work capacity as reflected in return to work increased greatly (81%) at a 1-year follow-up and was substantial (58%) at the 5-year follow-up. Moreover, perceived health and educational levels were important prognostic factors. Finally, the fact that patients working reported better health underscores the probable importance of return to work. Our results imply that it may be feasible to obtain long-term benefits from such a primary care-based intervention.

Behavioural treatment for chronic low-back pain.

BACKGROUND: Behavioural treatment, commonly used in the treatment of chronic low-back pain (CLBP), is primarily focused at reducing disability through the modification of environmental contingencies and cognitive processes. In general, three behavioural treatment approaches are distinguished: operant, cognitive and respondent. OBJECTIVES: To determine if behavioural therapy is more effective than reference treatments for CLBP, and which type of behavioural treatment is most effective. SEARCH STRATEGY: We searched the CENTRAL, MEDLINE, EMBASE, and PsycLIT databases up to October 2003. References of identified randomised trials and relevant systematic reviews were screened. SELECTION CRITERIA: Only randomised trials on behavioural treatment for non-specific CLBP were included. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed the methodological quality and extracted the data. The magnitude of effect was assessed by computing a pooled effect size for post-treatment and long-term results for each comparison, for each domain (i.e., behavioural outcomes, overall improvement, back pain specific and generic functional status, return to work, and pain intensity) using the random effects model. MAIN RESULTS: Seven studies (33%) were considered high quality. Comparing behavioural treatment to waiting list control (WLC) revealed strong evidence (4 trials, 134 people) in favour of a combined respondent-cognitive therapy for a medium positive effect on pain, and moderate evidence (2 trials, 39 people) in favour of progressive relaxation for a large positive effect on pain and behavioural outcomes (short-term only). When comparing operant treatment to WLC no significant differences could be detected on general functional status (strong evidence: 2 trials, 87 people) or on behavioural outcomes (moderate evidence; 3 trials, 153 people) (short-term only). There is limited evidence (1 trial, 98 people) that a graded activity program in an industrial setting is more effective than usual care for early return to work and reduced long-term sick leave. There is limited evidence (1 trail, 39 people) that there are no differences between behavioural treatment and exercises. Finally, there is moderate evidence (6 trials, 210 people) that there are no significant differences in short-term and long-term effectiveness when behavioural components are added to usual treatment programs for CLBP (i.e. physiotherapy, back education) on pain, generic functional status and behavioural outcomes. AUTHORS' CONCLUSIONS: Combined respondent-cognitive therapy and progressive relaxation therapy are more effective than WLC on short-term pain relief. However, it is unknown whether these results sustain in the long term. No significant differences could be detected between behavioural treatment and exercise therapy. Whether clinicians should refer patients with CLBP to behavioural treatment programs or to active conservative treatment cannot be concluded from this review.

Requests for body computed tomography: increasing workload, increasing indications and increasing age.

Increasing numbers of increasingly elderly patients were being examined in our Body CT department. At the same time, some of our clinical colleagues perceived that their patients might be discriminated against on the basis of their age when allocating CT time. We therefore studied the population trends in our department over a 10-year period. The ages of patients attending the Body CT department were collected from the hospital's computer information system from 1995 to 2000 and from handwritten logbooks for the months of September 1988 and 1998. Comparison was made with population trends within the hospital and local demographic data. There has been an average increase of 11% per annum in the number of examinations performed in the Body CT unit. The average age of patients examined increased from 52.7 years in 1988 to 58.9 years in 1998. The largest increase occurred in the over 75-year population (18% rise per annum). Hospital and local demographic population profiles changed little during the same period. We are performing increasing numbers of body CT examinations on increasingly elderly patients. This is probably due to an increased willingness to investigate and treat elderly patients, rather than changes in the local population. There is no evidence of a general discriminatory policy on the basis of age.

Occupational psychological factors increase the risk for back pain: a systematic review.

The purpose of this review was to summarize current knowledge concerning the role of psychological workplace variables in back pain. To this end the literature on psychological factors and back pain was systematically searched and analyzed. Psychological and medical databases and cross-referencing were used to locate 975 studies. To be included in this review, studies had to have a prospective design, include a psychological predictor variable, report on back pain, and be published in English. Twenty-one studies fulfilled the criteria for psychological workplace factors. The results showed a clear association between psychological variables and future back pain. There was strong evidence that job satisfaction, monotonous tasks, work relations, demands, stress, and perceived ability to work were related to future back pain problems. Further, moderate evidence was established for work pace, control, emotional effort at work, and the belief that work is dangerous. There was inconclusive evidence about work content. The attributable fraction indicated that substantial reductions in the number of cases of back pain could be achieved if the exposure to the psychological risk factor was eliminated. Although the methodological quality of the studies varied, they were deemed to provide "best evidence," and the consistency of the findings suggests that they are relatively robust. It is concluded that psychological work factors play a significant role in future back pain problems. However, there is still a lack of knowledge concerning the mechanisms by which these operate. These results suggest that a change in the way we view and deal with back pain is needed. Applying knowledge about psychological factors at work might enhance prevention as well as rehabilitation.

Preventive interventions for back and neck pain problems: what is the evidence?

STUDY DESIGN: A review of controlled trials. OBJECTIVES: To determine which interventions are used to prevent back and neck pain problems as well as what the evidence is for their utility. SUMMARY OF BACKGROUND DATA: Given the difficulty in successfully treating long-term back and neck pain problems, there has been a call for preventive interventions. Little is known, however, about the value of preventive efforts for nonpatients, e.g., in the general population or workplace. METHODS: The literature was systematically searched to locate all investigations that were: 1) specifically designed as a preventive intervention; 2) randomized or nonrandomized controlled trials; and, 3) using subjects not seeking treatment. Outcome was evaluated on the key variables of reported pain, report of injury, dysfunction, time off work, health-care utilization, and cost. Conclusions were drawn using a grading system. RESULTS: Twenty-seven investigations meeting the criteria were found for educational efforts, lumbar supports, exercises, ergonomics, and risk factor modification. For back schools, only one of the nine randomized trials reported a significant effect, and there was strong evidence that back schools are not effective in prevention. Because the randomized trials concerning lumbar supports were consistently negative, there is strong evidence that they are not effective in prevention. Exercises, conversely, showed stable positive results in randomized controlled trials, giving consistent evidence of relatively moderate utility in prevention. Because no properly controlled trials were found for ergonomic interventions or risk factor modification, there was not good quality evidence available to draw a conclusion. CONCLUSIONS: The results concerning prevention for subjects not seeking medical care are sobering. Only exercises provided sufficient evidence to conclude that they are an effective preventive intervention. There is a dire lack of controlled trials examining broad-based multidimensional programs. The need for high quality outcome studies is underscored.

A cognitive-behavioral return-to-work program: effects on pain patients with a history of long-term versus short-term sick leave.

A cognitive-behavioral return-to-work focused program was evaluated in a randomized controlled design, and the effects were compared between two groups of women with musculoskeletal pain. One group of patients (n=36) had a history of long-term sick leave (>12 months) at the start of the program and the other (n=36) had a history of short-term sick leave (2-6 months). The outpatient treatment program, conducted by a psychologist, included 12 sessions with the primary aim to help the patients return-to-work. The treatment first included teaching of coping strategies such as applied relaxation, stress management, graded activity training and pacing. Thereafter the patients were taught how to manage difficulties at their return-to-work and how to generalize coping strategies to different risk factors at their work places. The control condition received treatment-as-usual. The results showed that the cognitive-behavioral return-to-work program was more effective than the treatment-as-usual control condition in reducing the number of days on sick leave for patients on short-term sick leave, but not for patients on long-term sick leave. The treatment program also helped the patients on short-term sick leave to increase their ability to control and decrease pain and to increase their general activity level compared to the control condition. These results underscore the need for an early return-to-work focused rehabilitation to prevent long-term sick leave and disability.

A cognitive-behavioral group intervention as prevention for persistent neck and back pain in a non-patient population: a randomized controlled trial.

Given the demand for interventions that may prevent the development of persistent musculoskeletal pain problems, we investigated the effects of a cognitive-behavioral program in a group of non-patients with neck or back pain symptoms. Two hundred and fifty-three people selected from a population study were invited to participate. These people had experienced four or more episodes of relatively intense spinal pain during the past year but had not been out of work more than 30 days. Participants were randomly assigned to either a cognitive-behavioral group intervention or a treatment as usual comparison group. The experimental group received a standardized six-session program, provided by a trained therapist according to a manual. A significant overall analysis at the 1-year follow-up showed that the cognitive-behavioral group produced better results on 26 of the 33 outcome variables. Group comparisons indicated that the cognitive-behavioral group, relative to the comparison group, had significantly better results with regard to fear-avoidance beliefs, number of pain-free days, as well as the key variable of sick leave. Participation in the cognitive behavioral group reduced the risk for long-term sick leave during the follow-up by threefold. Thus, despite the strong natural recovery rate for back pain, the cognitive-behavioral intervention produced a significant preventive effect with regard to disability.