[The Continuing Training Courses of Medical Assessors and Legal Medical Advisors in Swiss Insurance Medicine (SIM)]. / Die Weiter- und Fortbildungskurse von medizinischen Gutachtern in der Swiss Insurance Medicine (SIM).

The Continuing Training Courses of Medical Assessors and Legal Medical Advisors in Swiss Insurance Medicine (SIM) Abstract. In the context of insurance medicine, the medical assessor has the task of clarifying the state of health in a professional manner and making a medical assessment. The medical appraisal is to be carried out in the context of the legal context based on legislation and case law. With the professional expert clarification of the state of health and the medical assessment, the medical expert places his knowledge in the service of the jurisdiction. Around the turn of the millennium, it became apparent that specialization and medical experience alone were not sufficient to meet the increasing requirements of a medical expert in a legal context. For this reason, Swiss Insurance Medicine (SIM), on behalf of the FMH, established and, over time, expanded a structured continuing education program for medical experts. In recent years, further training opportunities have been created for the early assessments and second opinions necessary for rapid and sustainable professional integration, as well as for continuing education.

[Instruments and Tools in the Medical Evaluation of Work Capacity]. / Instrumente und Arbeitshilfen bei der Einschätzung der Arbeitsfähigkeit.

Instruments and Tools in the Medical Evaluation of Work Capacity Abstract. In the event of absence from work due to illness or accident, the attending physician is responsible for confirming the connection between absence from work (or, if applicable, reduced performance) and a health disorder (illness or accident) and subsequently issuing a certificate of incapacity for work. The certificates have the legal status of a deed and must accordingly satisfy certain legal requirements. This article presents suitable tools and instruments for this important medical task.

Evidence needs, training demands, and opportunities for knowledge translation in social security and insurance medicine: A European survey.

OBJECTIVE: To perform a European survey of the evidence needs and training demands of insurance medicine professionals related to professional tasks and evidence-based practice. DESIGN: International survey. SUBJECTS: Professionals working in insurance medicine. METHODS: Experts designed an online questionnaire including 26 questions related to 4 themes: evidence needs; training demands; evidence-seeking behaviour; and attitudes towards evidence-based medicine. Descriptive statistics were presented by country/conference and the total sample. RESULTS: A total of 782 participants responded. Three-quarter of participants experienced evidence needs at least once a week, related to mental disorders (79%), musculoskeletal disorders (67%) and occupational health (65%). Guidelines (76%) and systematic reviews (60%) were the preferred types of evidence and were requested for assessment of work capacity (64%) and prognosis of return-to-work (51%). Evidence-based medicine was thought to facilitate decision-making in insurance medicine (95%). Fifty-two percent of participants felt comfortable finding, reading, interpreting, and applying evidence. Countries expressed similar needs for reviews on typical topics. CONCLUSION: This study reveals evidence gaps in key areas of insurance medicine, supporting the need for further research, guidelines and training in evidence-based insurance medicine. Importantly, insurance medicine professionals should recognize that evidence-based practice is crucial in producing high-quality assessments.

Development and Validation of a Pain Behavior Assessment in Patients with Chronic Low Back Pain.

PURPOSE: High levels of pain behavior adversely affect the success of multidisciplinary rehabilitation of patients with chronic nonspecific low back pain (CNSLBP). Functional capacity evaluation (FCE) assessment should detect high levels of pain behavior to prevent the inclusion of unsuitable patients to functional rehabilitation programs. The aim of this study was to develop a Pain Behavior Assessment (PBA) and to evaluate its construct validity. METHODS: The PBA was developed by experts in the field and is literature-based. Inclusion criteria for participants of the validation study were: CNSLBP, age 20-60 years, referral for fitness-for-work evaluation. The PBA was applied by physiotherapists during FCE. Rasch analysis was performed to evaluate the construct validity of the PBA. Internal consistency was indicated by the person separation index (PSI), which corresponds to Cronbach's alpha. RESULTS: 145 male (72.5%) and 55 female patients were included. Rasch analysis removed 11 items due to misfit and redundancy, resulting in a final PBA of 41 items. Item mean fit residual was -0.33 (SD 1.06) and total item Chi square 100.39 (df = 82, p = 0.08). The PSI value was 0.83. DIF analysis for age and gender revealed no bias. CONCLUSIONS: The PBA is a valid assessment tool to describe pain behavior in CNSLBP patients. The high PSI-value justifies the use of the PBA in individuals. The PBA may help to screen patients for high levels of pain behavior.

Identifying fallers and nonfallers with the maximal base of support width (BSW): a one-year prospective study.

The purpose of this prospective cohort study was to determine whether the maximal width of the base of support (BSW) measure is able to predict the risk of multiple falls in community-dwelling women. Thirty-eight community-dwelling women (mean age of 72 ± 8 years old) participated. Falls were prospectively recorded during the following year. Overall, 29 falls were recorded; six (16%) women were multiple fallers and 32 (84%) were nonfallers. There was a significant difference in the BSW between the fallers and nonfallers (F[1, 37] = 5.134 [p = .030]). A logistic regression analysis indicated a significant contribution of the BSW test to the model (odds ratio = 0.637; 95% CI [0.407, 0.993]; p = .046 per 1 cm).The cut-off score was determined to be 27.8 cm (67% sensitivity and 84% specificity). These results indicate that women with a smaller BSW at baseline had a significantly higher risk of sustaining a fall.

[Back pain in the working age population]. / Rückenschmerzen im Erwerbstätigenalter.

Back pain in the working age population can coincide with work-related activities and may lead to temporary or permanent work disability in the case of functional impairment that interacts with workplace demands. This can lead to economic if not existential problems for the affected individual. Although neurogenic or inflammatory back pain may be the cause, the big majority of all cases is caused by "common" low back pain with or without irradiating pain, the main problem being frequent recurrencies of acute pain episodes (periodic or relapsing course). After early exclusion of specific causes (i. e. "red flags": usually identified through history and simple laboratory findings!) repetitive examinations should be avoided. Structural changes and physical job demands should not be overestimated as causal factors. In the early phase of a work disability more emphasis should be laid however on appropriate information and medication and, in case of persistent impairment, active treatment (after 3 weeks or relapse). Longtime workplace absence has important individual and socioeconomic consequences. The risk for chronification can be estimated through evaluation of "yellow flags" and observation of characteristics of the course in the individual case. An early return to work and to activities of daily life is urgent. In cases at risk for chronification and/or with obstacles to reintegration at work an interdisciplinary work-oriented rehabilitation or social and occupational reintegration should be organised.

The maximal width of the base of support (BSW): clinical applicability and reliability of a preferred-standing test for measuring the risk of falling.

The aim of this study was to test the reliability and validity of a preferred-standing test for measuring the risk of falling. The preferred-standing position of elderly fallers and non-fallers and healthy young adults was measured. The maximal BSW was measured. The absolute and relative reliability and discriminant validity were assessed. The expanded timed get-up-and-go test (ETGUG), one-leg stance test (OS), tandem stance (TS), and falls efficacy scale international version (FES-I) were used to determine criterion validity. In total, 146 persons (102 females, 44 males; mean age 55±22 years, range 20-94) were recruited. Forty elderly community dwellers (8 fallers) and 26 young adults were tested twice to determine the test-retest reliability. The BSW showed acceptable test-retest reliability (Intraclass correlation coefficient, ICC2,1=0.77-0.83) and inter-rater reliability (ICC3,1=0.77-0.95) for all groups. The standard error of measurement (SEM) was between 0.77 and 1.87, and the smallest detectable change (SDC) was between 2.14cm and 5.19cm. The Bland-Altman plot revealed no systematic errors. There was significant difference between elderly fallers and non-fallers (F(1/75)=11.951; p=0.001. Spearman's rho coefficient values showed no correlation between the BSW and the ETGUG (-0.17, p=0.47), OLS (-0.04, p=0.65), TS (-0.11, p=0.21), and FES-I (-0.10; p=0.27). Only the BSW was a significant predictor for falling (odds ratio=0.736, p=0.007). The reliability and validity of the BSW protocol were acceptable overall. Prospective studies are warranted to evaluate the predictive value of the BSW for determining the risk of falling.

Is the work ability index useful to evaluate absence days in ankylosing spondylitis patients? A cross-sectional study.

BACKGROUND: The work incapacity of ankylosing spondylitis (AS) ranges between 3% and 50% in Europe. In many countries, work incapacity is difficult to quantify. The work ability index (WAI) is applied to measure the work ability in workers, but it is not well investigated in patients. AIMS: To investigate the work incapacity in terms of absence days in patients with AS and to evaluate whether the WAI reflects the absence from work. HYPOTHESIS: Absence days can be estimated based on the WAI and other variables. DESIGN: Cross-sectional design. SETTING: In a secondary care centre in Switzerland, the WAI and a questionnaire about work absence were administered in AS patients prior to cardiovascular training. The number of absence days was collected retrospectively. The absence days were estimated using a two-part regression model. PARTICIPANTS: 92 AS patients (58 men (63%)). INCLUSION CRITERIA: AS diagnosis, ability to cycle, age between 18 and 65 years. EXCLUSION CRITERIA: severe heart disease. PRIMARY AND SECONDARY OUTCOME MEASURES: Absence days. RESULTS: Of the 92 patients, 14 received a disability pension and 78 were in the working process. The median absence days per year of the 78 patients due to AS alone and including other reasons was 0 days (IQR 0-12.3) and 2.5 days (IQR 0-19), respectively. The WAI score (regression coefficient=-4.66 (p<0.001, CI -6.1 to -3.2), 'getting a disability pension' (regression coefficient=-106.8 (p<0.001, 95% CI -141.6 to -72.0) and other not significant variables explained 70% of the variance in absence days (p<0.001), and therefore may estimate the number of absence days. CONCLUSIONS: Absences in our sample of AS patients were equal to pan-European countries. In groups of AS patients, the WAI and other variables are valid to estimate absence days with the help of a two-part regression model.

Running speed during training and percent body fat predict race time in recreational male marathoners.

BACKGROUND: Recent studies have shown that personal best marathon time is a strong predictor of race time in male ultramarathoners. We aimed to determine variables predictive of marathon race time in recreational male marathoners by using the same characteristics of anthropometry and training as used for ultramarathoners. METHODS: Anthropometric and training characteristics of 126 recreational male marathoners were bivariately and multivariately related to marathon race times. RESULTS: After multivariate regression, running speed of the training units (ß = -0.52, P < 0.0001) and percent body fat (ß = 0.27, P < 0.0001) were the two variables most strongly correlated with marathon race times. Marathon race time for recreational male runners may be estimated to some extent by using the following equation (r (2) = 0.44): race time ( minutes) = 326.3 + 2.394 × (percent body fat, %) - 12.06 × (speed in training, km/hours). Running speed during training sessions correlated with prerace percent body fat (r = 0.33, P = 0.0002). The model including anthropometric and training variables explained 44% of the variance of marathon race times, whereas running speed during training sessions alone explained 40%. Thus, training speed was more predictive of marathon performance times than anthropometric characteristics. CONCLUSION: The present results suggest that low body fat and running speed during training close to race pace (about 11 km/hour) are two key factors for a fast marathon race time in recreational male marathoner runners.

Identification of relevant ICF categories in vocational rehabilitation: a cross sectional study evaluating the clinical perspective.

INTRODUCTION: Vocational rehabilitation (VR) emphasizes a need for medical support, rehabilitation and biopsychosocial approach to enable individuals to successfully participate in the workforce. Optimal rehabilitation management relies on an in-depth knowledge of the typical spectrum of problems encountered of patients in VR. The International Classification of Functioning, Disability and Health (ICF) is based on a universal conceptual model and provides a holistic view of functioning of the lived experience of people such as those undergoing VR. The objectives of this study are to describe the functioning and health of persons undergoing VR and to identify the most common problems around work and in VR using the ICF as the reference framework. METHODS: An empirical cross-sectional multicenter study was conducted using convenience sampling from March 2009 to March 2010. Data were collected using a Case Record Form rated by health professionals which was based on an extended version of the ICF Checklist containing 292 ICF categories and sociodemographic information. RESULTS: 152 patients with various health conditions participated. We identified categories from all four ICF components: 24 for body functions, six for body structures, 45 for activities and participation, and 25 for environmental factors. CONCLUSIONS: Our study identified a multitude of ICF categories that describe functioning domains and which represent the complexity of VR. Such a comprehensive approach in assessing patients in VR may help to understand and customize the process of VR in the clinical setting and to enhance multidisciplinary communication.

Value of predictive instruments to determine persisting restriction of function in patients with subacute non-specific low back pain. Systematic review.

Low back pain (LBP) can restrict function with all the personal, interpersonal, and social consequences, such as a loss of independence and the inability to fulfil diverse roles in social life. Therefore, the prevention of the consequences of LBP would reduce costs, individual burdens and social burdens. Being able to fulfil the requirements of daily living is a cornerstone of quality of life. Early identification of patients who are likely to develop chronic pain with persistent restricted function is important, as effective prevention needs informed allocation of health care and social work. The aim of this study was to report and discuss the predictive value of instruments used to identify patients at risk of chronic LBP. Medline, Embase, CINAHL, Central, PEDro, Psyndex, PsychInfo/PsycLit, and Sociofile were systematically searched up to July 2004. Reference lists of systematic reviews on risk factors, and reference lists of the studies included were also searched. The selected studies evaluated predictive values of tools or predictive models applied 2-12 weeks after an initial medical consultation for a first or a new episode of non-specific LBP with restriction in function. Instruments had to predict function-related outcomes. Because of the heterogeneity of the instruments used we did not pool the data. Sixteen publications on function-related outcomes were included. The predictive instruments in these studies showed only moderate ability to predict or explain function-related outcome (maximal 51% of the variability). There was great variability in the predictors included and not all known risk factors were included in the models. The reviewed tools showed a limited ability to predict function-related outcome in patients with risk of chronic low back pain. Future instruments should be based on models with a comprehensive set of known risk factors. These models should be constructed and validated by international, coordinated research teams.

Symptomatology of recurrent low back pain in nursing and administrative professions.

The aim of the present study was to explore if (a) recurrent low back pain (LBP) has different symptomatologies in cases from occupations with predominantly sitting postures compared to cases from occupations involving dynamic postures and frequent lifting and (b) if in the two occupational groups, different factors were associated with the presence of recurrent LBP. Hundred and eleven female subjects aged between 45 and 62 years with a long-standing occupation either in administrative or nursing professions, with and without recurrent LBP were examined. An extensive evaluation of six areas of interest (pain and disability, clinical examination, functional tests, MR examination, physical and psychosocial workplace factors) was performed. The variables from the six areas of interest were analyzed for their potential to discriminate between the four groups of subjects (administrative worker and nurses with and without recurrent LBP) by canonical discriminant analysis. As expected, the self-evaluation of physical and psychosocial workplace factors showed significant differences between the two occupational groups, which holds true for cases as well as for controls (P < 0.01). The functional tests revealed a tendency for rather good capacity in nurses with LBP and a decreased capacity in administrative personnel with LBP (P = 0.049). Neither self completed pain and disability questionnaires nor clinical examination or MR imaging revealed any significant difference between LBP cases from sedentary and non-sedentary occupations. When comparing LBP cases and controls within the two occupational groups, the functional tests revealed significant differences (P = 0.0001) yet only in administrative personnel. The clinical examination on the other hand only discriminated between LBP cases and controls in the nurses group (P < 0.0001). Neither MRI imaging nor self reported physical and psychosocial workplace factors discriminated between LBP cases and controls from both occupational groups. Although we used a battery of tests that have broad application in clinical and epidemiological studies of LBP, a clear difference in the pattern of symptoms between LBP cases from nursing and hospital administration personnel could not be ascertained. We conclude that there is no evidence for different mechanisms leading to non-specific, recurrent LBP in the two occupations, and thus no generalizable recommendations for the prevention and therapy of non-specific LBP in the two professions can be given.

Do MRI findings correlate with mobility tests? An explorative analysis of the test validity with regard to structure.

To find out whether segmental magnetic resonance imaging (MRI) findings such as intervertebral disc degeneration (DD) and facet joint osteoarthritis (FJO) are associated with motion deficiencies as seen in common mobility tests and observed range of motion (ROM). A total of 112 female subjects, nurses and office workers, with and without low back pain, were examined by clinical experts, and lumbar mobility was measured including modified Schober, fingertip-to-floor distance (FTFD) and ZEBRIS motion analysis. An MRI of the lumbar spine was made. Mobility findings were correlated with segmental morphologic changes as seen on MRI at the levels of L1-2 through L5-S1. Only a few statistically significant correlations between MRI findings and the results of the mobility tests could be found. Lateral bending was weakly and negatively correlated to DD and FJO but only on the level of L5-S1. The FTFD showed a weak positive correlation to endplate changes on the level of L4-5. When ROM is observed by clinical experts, there are several significant relationships between MRI findings and the observed motion. There is a highly significant segmental correlation between DD and disc form alteration as seen on MRI on the level of single motion segments. Pain history and current pain level did not moderate any association between MRI and mobility. There is no clear relationship between the structural changes represented by MRI and the measured mobility tests used in this study. Our findings suggest that close observation of spinal motion may provide at least equal information about the influence of spinal structures on motion than the commonly used measured mobility tests do.

Validity of pressure pain thresholds in female workers with and without recurrent low back pain.

Recurrent low back pain (LBP) is a common pain condition in elderly workers in a variety of occupations, but little is known about its origin and the mechanisms leading to an often disabling sensation of pain that may be persistent or intermittent. In the present study we evaluated the pressure pain thresholds (PPTs) in subjects suffering from recurrent LBP, as well as in healthy controls, to investigate if recurrent LBP is associated with an increased sensitivity of the muscular and ligamentous structures located on the lower back. One hundred and six female workers, aged between 45 and 62 years and working either in administrative or nursing professions were examined. The subjects were classified into LBP cases and controls based on the Nordic questionnaire. Subjects indicating 8-30 or more days with LBP during the past 12 months were graded as cases. PPTs were measured on 12 points (six on each side of the body) expected to be relevant for LBP (paravertebral muscles, musculus quadratus lumborum, os ilium, iliolumbar ligament, musculus piriformis and greater trochanter), as well as on a reference point (middle of the forehead) using a digital dolorimeter. The PPTs on all points on the lower back highly correlated with each other and a high internal consistency was found with a Cronbach alpha coefficient > 0.95. There was a moderate and significant correlation of the PPT on the forehead with the PPT on the lower back with correlation coefficients ranging from 0.36 to 0.49. In LBP cases from administrative professions, the PPT on the forehead was significantly decreased (P < 0.05). The PPT on the lower back did not significantly differ between the four groups studied, namely nurses and administrative workers with and without recurrent LBP. These results give evidence that recurrent LBP is not associated with an altered sensitivity of the muscular and myofascial tissues in the lumbar region. Furthermore, they raise questions about the value of reference point measurements in recurrent LBP.

Magnetic resonance imaging of the lumbar spine: findings in female subjects from administrative and nursing professions.

STUDY DESIGN: Cross-sectional magnetic resonance imaging (MRI) study. OBJECTIVE: To find out whether different patterns of lumbar disc degeneration related to different physical work types (static vs. dynamic) can be found. SUMMARY OF BACKGROUND DATA: The association of lumbar disc degeneration with physical workload as well as the association of disc degeneration with low back pain (LBP) has been debated controversially. Nevertheless, many of the mainly invasive treatment concepts are based on disc degeneration models. METHODS: An MRI study was performed in female subjects aged 45 to 62 years with persistent LBP and in age-matched controls. Subjects (n = 109) were selected from nursing and administrative professions. A questionnaire was used to assess the subjects' exposure to physical workplace factors. Disc degeneration, disc herniation, nerve root compromise, high intensity zones, endplate changes, and facet joint osteoarthritis were evaluated based on sagittal T1- and T2-weighted as well as axial T2-weighted images. RESULTS: The two occupational groups could clearly be distinguished by the physical workplace factors: administrative work was associated with predominantly sitting postures whereas nursing work was associated with frequent walking, pushing, pulling, and lifting. Except for endplate (Modic) changes at L5-S1, MRI findings did not differ between the four groups, namely, nurses and secretaries with and without LBP. When analyzing the MRI findings within the two vocational groups, nerve root compromise and endplate changes in the lower lumbar spine were found to be significant (P < 0.05) risk factors for LBP. Disc degeneration, disc herniation, nerve root compromise, and facet joint osteoarthritis were present in more than 50% of the intervertebral spaces studied. CONCLUSIONS: These findings give evidence that in subjects performing nonheavy work, patterns of lumbar disc degeneration are not associated with the job type and characteristic physical loadings.

The role of back muscle endurance, maximum force, balance and trunk rotation control regarding lifting capacity.

Evaluation of lifting capacity is widely used as a reliable instrument in order to evaluate maximal and safe lifting capacity. This is of importance in regard to planning rehabilitation programs and determining working ability. The aim of this study was to investigate the influence of basic functions on the lifting capacity measured by the progressive isoinertial lifting evaluation (PILE) and the functional capacity evaluation (FCE) tests in a lower (floor to waist) and an upper (waist to shoulder) setting and compare the two test constructs. Seventy-four female subjects without acute low back pain underwent an examination of their lifting capacities and the following basic functions: (1) strength and endurance of trunk muscles, (2) cardiovascular endurance, (3) trunk mobility and (4) coordination ability. A linear regression model was used to predict lifting capacity by means of the above-mentioned basic functions, where the F statistics of the variables had to be significant at the 0.05 level to remain in the model. Maximal force in flexion showed significant influence on the lifting capacity in both the PILE and the FCE in the lower, as well as in the upper, lifting task. Furthermore, there was a significant influence of cardiovascular endurance on the lower PILE and also of endurance in trunk flexion on the lower FCE. Additional inclusion of individual factors (age, height, weight, body mass index) into the regression model showed a highly significant association between body height and all lifting tasks. The r (2) of the original model used was 0.19/0.18 in the lower/upper FCE and 0.35/0.26 in the lower/upper PILE. The model r (2) increased after inclusion of these individual factors to between 0.3 and 0.4. The fact that only a limited part of the variance in the lifting capacities can be explained by the basic functions analyzed in this study confirms the assumption that factors not related to the basic functions studied, such as lifting technique and motor control, may have a strong influence on lifting capacity. These results give evidence to suggest the inclusion of an evaluation of lifting capacity in clinical practice. Furthermore, they raise questions about the predictive value of strength and endurance tests in regard to lifting capacity and work ability.

Trapezius muscle motor unit activity in symptomatic participants during finger tapping using properly and improperly adjusted desks.

Work-related musculoskeletal disorders in the neck-shoulder area and upper extremities are common among computer users, especially women. We compared temporal changes of motor unit (MU) activation in the trapezius muscle during finger tapping using both appropriate and inappropriate ergonomic desk adjustments. Sixteen intensive and nonintensive computer users with either moderate or severe musculoskeletal disorders participated in the study. Six-channel intramuscular electromyographic (EMG) signals and 2-channel surface EMG were recorded from 2 positions of the trapezius muscle. A statistically significant increase in activity was observed with a desk adjusted 5 cm higher than appropriate and was attributable mainly to increased duration of MU activity. Participants with severe symptoms activated more MUs, and these were also active longer. In women, on average, MUs were active nearly twice as long as in men during the same tapping task. This study demonstrates that it is possible to evaluate ergonomic topics on the MU level and that incorrectly adjusted office equipment, in addition to motor demands imposed by the work task, results in prolonged activity of MUs. A potential application of this research is an increased awareness that certain individuals who work with incorrectly adjusted office equipment may be at greater risk of developing work-related musculoskeletal disorders.