Non-pharmacological management of persistent headaches associated with neck pain: A clinical practice guideline from the Ontario protocol for traffic injury management (OPTIMa) collaboration.

OBJECTIVES: To develop an evidence-based guideline for the non-pharmacological management of persistent headaches associated with neck pain (i.e., tension-type or cervicogenic). METHODS: This guideline is based on systematic reviews of high-quality studies. A multidisciplinary expert panel considered the evidence of clinical benefits, cost-effectiveness, societal and ethical values, and patient experiences when formulating recommendations. Target audience includes clinicians; target population is adults with persistent headaches associated with neck pain. RESULTS: When managing patients with headaches associated with neck pain, clinicians should (a) rule out major structural or other pathologies, or migraine as the cause of headaches; (b) classify headaches associated with neck pain as tension-type headache or cervicogenic headache once other sources of headache pathology has been ruled out; (c) provide care in partnership with the patient and involve the patient in care planning and decision making; (d) provide care in addition to structured patient education; (e) consider low-load endurance craniocervical and cervicoscapular exercises for tension-type headaches (episodic or chronic) or cervicogenic headaches >3 months duration; (f) consider general exercise, multimodal care (spinal mobilization, craniocervical exercise and postural correction) or clinical massage for chronic tension-type headaches; (g) do not offer manipulation of the cervical spine as the sole form of treatment for episodic or chronic tension-type headaches; (h) consider manual therapy (manipulation with or without mobilization) to the cervical and thoracic spine for cervicogenic headaches >3 months duration. However, there is no added benefit in combining spinal manipulation, spinal mobilization and exercises; and (i) reassess the patient at every visit to assess outcomes and determine whether a referral is indicated. CONCLUSIONS: Our evidence-based guideline provides recommendations for the conservative management of persistent headaches associated with neck pain. The impact of the guideline in clinical practice requires validation. SIGNIFICANCE: Neck pain and headaches are very common comorbidities in the population. Tension-type and cervicogenic headaches can be treated effectively with specific exercises. Manual therapy can be considered as an adjunct therapy to exercise to treat patients with cervicogenic headaches. The management of tension-type and cervicogenic headaches should be patient-centred.

Exploring Chiropractic Services in the Canadian Forces Health Services - Perceptions of Facilitators and Barriers Among Key Informants.

INTRODUCTION: Musculoskeletal (MSK) conditions have a significant impact on the health and operational readiness of military members. The Canadian Forces Health Services (CFHS) provides a spectrum of health services in managing Canadian Armed Forces (CAF) personnel health care needs with on-base and off-base services provided by civilian and uniformed health care professionals, including chiropractors. Although chiropractic services are available in US DoD and VA systems, little is known about the facilitators and barriers to integrating on-base chiropractic services within the CFHS. This study explored key informants' perceptions of facilitators and barriers to the integration of on-base chiropractic services within the CFHS. METHODS: We conducted a qualitative study to describe and understand how an integrated chiropractic service could be designed, implemented, and evaluated within the current interdisciplinary CFHS. Telephone interviews were conducted, using a semi-structured interview guide, to explore key informants' perceptions and experiences of chiropractic care within the CFHS. In total, we invited 27 individuals across Canada to participate; 15 were identified through purposeful sampling, 12 through a snowball sampling technique, and 2 declined. The 25 participants included military personnel (52%), public servants and contractors employed by the Department of Defense (24%), as well as civilian health care providers (24%). All participants were health care providers [physicians (MD) (7), physiotherapists (PT) (13), chiropractors (DC) (5)]. Interviews were audio-recorded and transcribed verbatim. Transcripts were prepared and analyzed using an interpretivist approach that explored key informants' perceptions and experiences. RESULTS: Qualitative analysis revealed numerous facilitators and barriers to chiropractic services in the CFHS. These were categorized under three broad themes: base-to-base variations, variable gatekeeper roles, and referral processes. Barriers to integrating chiropractic services included: lack of clarity about a chiropractor's clinical knowledge and skills; CFHS team members' negative prior experiences with chiropractors (e.g., inappropriate patient-focused communication, clinical management that was not evidence-based, ignorance of military culture); suboptimal bi-directional communication between CAF personnel and DCs across bases; and wide-ranging perspectives pertaining to duplication of services offered by PTs and DCs in managing MSK conditions. Facilitators associated with the integration of chiropractic services within a collaborative and interdisciplinary CAF environment included: patient benefits associated with multiple approaches utilized by different providers; adoption of up-to-date, high-quality evidence and guidelines to standardize care and curtail "dependency" between patient and providers; and co-location of providers to strengthen existing interprofessional communication and relationships. Key informants called for patient care that is collaborative, integrated and patient-centered, rather than "patient-driven" care; civilian providers understanding and respecting military culture rather than assuming transferability of patient management processes from the public civilian sector; standardization of communication protocols and measures to evaluate outcomes of care; and the need to move slowly and respectfully within the current CAF health care system if planning the on-base implementation of chiropractic services. CONCLUSION: This study illuminated many opportunities and barriers, in complex and diverse domains, related to introducing collaborative chiropractic services in the CFHS. The findings are relevant to increasing understanding and strengthening interprofessional collaborative care within the unique CAF health care delivery system.

Applying theories to better understand socio-political challenges in implementing evidence-based work disability prevention strategies.

PURPOSE: This article explores and applies theories for analyzing socio-political aspects of implementation of work disability prevention (WDP) strategies. METHOD: For the analysis, theories from political science are explained and discussed in relation to case examples from three jurisdictions (Sweden, Brazil and Québec). RESULTS: Implementation of WDP strategies may be studied through a conceptual framework that targets: (1) the institutional system in which policy-makers and other stakeholders reside; (2) the ambiguity and conflicts regarding what to do and how to do it; (3) the bounded rationality, path dependency and social systems of different stakeholders; and (4) coalitions formed by different stakeholders and power relations between them. In the case examples, the design of social insurance systems, the access to and infrastructure of healthcare systems, labor market policies, employers' level of responsibility, the regulatory environment, and the general knowledge of WDP issues among stakeholders played different roles in the implementation of policies based on scientific evidence. CONCLUSIONS: Future research may involve participatory approaches focusing on building coalitions and communities of practice with policy-makers and stakeholders, in order to build trust, facilitate cooperation, and to better promote evidence utilization. Implications for Rehabilitation Implementation of work disability prevention policies are subject to contextual influences from the socio-political setting and from relationships between stakeholders Stakeholders involved in implementing strategies are bound to act based on their interests and previous courses of action To promote research uptake on the policy level, stakeholders and researchers need to engage in collaboration and translational activities Political stakeholders at the government and community levels need to be more directly involved as partners in the production and utilization of evidence.

Supervisors' perceptions of organizational policies are associated with their likelihood to accommodate back-injured workers.

Background Low back pain (LBP) is a major concern among North American workplaces and little is known regarding a supervisor's decision to support job accommodation for workers with LBP. The extent to which supervisors are included in a company's effort to institute disability management policies and practices and workplace safety climate are two factors that may influence a supervisor's decision to accommodate workers with LBP. Objective Determine the association between supervisors' perceptions of disability management policies, corporate safety culture and their likelihood of supporting job accommodations for workers with LBP. Methods We conducted a cross-sectional study of supervisors (N=796) recruited from a non-random, convenience sample of 19 Canadian and US employers. The outcome was supervisors' likeliness to support job accommodation and the exposure was global work safety culture and disability management policies and practices. A multivariable generalized linear modelling strategy was used and final models for each exposure were obtained after assessing potential effect modifiers and confounders. Results In the study, 796 eligible supervisors from 19 employers participated. Disability management policies and practices were positively associated with supervisors' likeliness to accommodate (ß=0.19; 95% CI: 0.13; 0.24) while no significant association was found between corporate safety culture (ß= -0.084; 95% CI: -0.19; 0.027) and supervisors' likeliness to accommodate. Conclusions Employers should ensure that proactive disability management policies and practices are clearly communicated to supervisors in order to improve job modification and return to work efforts. Implications for Rehabilitation Low back pain (LBP) is a major workplace concern and little is known regarding what factors are associated with a supervisor's likelihood to support job accommodation for workers with LBP. The objective of this article was to determine the association between supervisors' perceptions of disability management policies and practices, corporate safety culture and their likelihood of support job accommodations for workers with LBP. Results suggest that disability management policies and practices are positively associated with supervisors' likelihood to accommodate while corporate safety culture is not. These results are important for employers as it suggests that employers should ensure that their disability management policies and practices are clearly communicated to supervisors in order to improve job accommodation and return to work efforts.

Development of the Return-to-Work Obstacles and Self-Efficacy Scale (ROSES) and Validation with Workers Suffering from a Common Mental Disorder or Musculoskeletal Disorder.

Introduction Common mental disorders (CMDs) and musculoskeletal disorders (MSDs) lead the list of causes for work absence in several countries. Current research is starting to look at workers on sick leave as a single population, regardless of the nature of the disease or accident. The purpose of this study is to report the validation of the Return to Work Obstacles and Self-Efficacy Scale (ROSES) for people with MSDs and CMDs, based on the disability paradigm. Methods From a prospective design, the ROSES' reliability and validity were investigated in a Canadian sample of workers on sick leave due to MSDs (n = 206) and CMDs (n = 157). Results Exploratory and confirmatory factor analyses revealed that 46 items spread out on 10 conceptual dimensions (e.g., Fears of a relapse, Job demands, Difficult relation with the immediate supervisor), with satisfactory alpha coefficients and test-retest reliability for all subscales. Finally, several dimensions of ROSES also predict the participant's RTW within 6 months for MSDs (e.g., job demands), and CMDs (e.g., difficult relation with the immediate supervisor), even when adjusted by several variables (e.g., age, severity of symptoms). Apart from the job demands dimension, when the ROSES dimension is more external to the individual, only the perception of obstacles remains significant to predict RTW whereas it is the opposite result when the dimension is more internal (e.g., fears of a relapse). Conclusion The ROSES demonstrated satisfactory results regarding its validity and reliability with people having MSDs or CMDs, at the time of the return-to-work process.

Supervisor and Organizational Factors Associated with Supervisor Support of Job Accommodations for Low Back Injured Workers.

Purpose Temporary job accommodations contribute to the prevention of chronic work disability due to low back pain (LBP) through the facilitation of early return to work; yet, workplace dimensions of job accommodation are poorly understood. The objective of this study was to determine supervisor and organizational factors associated with supervisors' support for temporary job accommodations for LBP injured workers. Methods Supervisors were recruited from 19 workplaces in the USA and Canada and completed an online survey regarding job accommodation practices and potential associated factors with respect to a case vignette of a worker with LBP. Multivariable linear regression was used to identify the most parsimonious set of factors associated with supervisors' support for accommodations. Results A total of 804 supervisors participated with 796 eligible for inclusion in the analysis. The final set of factors explained 21 % of the variance in supervisors' support for temporary job accommodations. Considerate leadership style (ß = 0.261; 95 % CI 0.212, 0.310), workplace disability management policies and practices (ß = 0.243; 95 % CI 0.188, 0.298), and supervisor autonomy for designing and providing workplace accommodations (ß = 0.156; 95 % CI 0.071, 0.241) had the largest effect on supervisor support for accommodations. Conclusion Factors predicting supervisors' likelihood to accommodate LBP injured workers include use of considerate leadership style, workplace disability management policies and practices, and supervisor autonomy. Workplace interventions targeting these factors should be developed and evaluated for their ability to improve work disability prevention outcomes.

Management of neck pain and associated disorders: A clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.

PURPOSE: To develop an evidence-based guideline for the management of grades I-III neck pain and associated disorders (NAD). METHODS: This guideline is based on recent systematic reviews of high-quality studies. A multidisciplinary expert panel considered the evidence of effectiveness, safety, cost-effectiveness, societal and ethical values, and patient experiences (obtained from qualitative research) when formulating recommendations. Target audience includes clinicians; target population is adults with grades I-III NAD <6 months duration. RECOMMENDATION 1: Clinicians should rule out major structural or other pathologies as the cause of NAD. Once major pathology has been ruled out, clinicians should classify NAD as grade I, II, or III. RECOMMENDATION 2: Clinicians should assess prognostic factors for delayed recovery from NAD. RECOMMENDATION 3: Clinicians should educate and reassure patients about the benign and self-limited nature of the typical course of NAD grades I-III and the importance of maintaining activity and movement. Patients with worsening symptoms and those who develop new physical or psychological symptoms should be referred to a physician for further evaluation at any time during their care. RECOMMENDATION 4: For NAD grades I-II ≤3 months duration, clinicians may consider structured patient education in combination with: range of motion exercise, multimodal care (range of motion exercise with manipulation or mobilization), or muscle relaxants. In view of evidence of no effectiveness, clinicians should not offer structured patient education alone, strain-counterstrain therapy, relaxation massage, cervical collar, electroacupuncture, electrotherapy, or clinic-based heat. RECOMMENDATION 5: For NAD grades I-II >3 months duration, clinicians may consider structured patient education in combination with: range of motion and strengthening exercises, qigong, yoga, multimodal care (exercise with manipulation or mobilization), clinical massage, low-level laser therapy, or non-steroidal anti-inflammatory drugs. In view of evidence of no effectiveness, clinicians should not offer strengthening exercises alone, strain-counterstrain therapy, relaxation massage, relaxation therapy for pain or disability, electrotherapy, shortwave diathermy, clinic-based heat, electroacupuncture, or botulinum toxin injections. RECOMMENDATION 6: For NAD grade III ≤3 months duration, clinicians may consider supervised strengthening exercises in addition to structured patient education. In view of evidence of no effectiveness, clinicians should not offer structured patient education alone, cervical collar, low-level laser therapy, or traction. RECOMMENDATION 7: For NAD grade III >3 months duration, clinicians should not offer a cervical collar. Patients who continue to experience neurological signs and disability more than 3 months after injury should be referred to a physician for investigation and management. RECOMMENDATION 8: Clinicians should reassess the patient at every visit to determine if additional care is necessary, the condition is worsening, or the patient has recovered. Patients reporting significant recovery should be discharged.

Using Cartoons to Transfer Knowledge Concerning the Principles of Work Disability Prevention Among Stakeholders.

Purpose This study assesses how well two cartoons transfer knowledge of principles of work disability prevention among stakeholders, according to their level of experience. We also document stakeholders' perceptions of the usefulness of the cartoons. Method We performed a descriptive study. Two groups of stakeholders were recruited: (1) experienced (working for more than 2 years in work disability), (2) non-experienced (in training). A self-administered questionnaire with open-ended questions documented stakeholders' understanding of each cartoon box and their perception of the possible usefulness of the cartoons. We transformed qualitative responses into quantitative responses for descriptive purposes. We performed independent t tests to compare the groups' level of understanding, and content analysis for the perception of usefulness. Results Overall, 149 stakeholders (50 experienced and 99 non-experienced) participated and identified 79.4 and 61.4 % of all principles presented in each of the two cartoons respectively. Experienced stakeholders identified more principles compared to non-experienced stakeholders (p = 0.007). Both cartoons were perceived to be useful for knowledge transfer. Conclusions Principles were generally well identified in the cartoons by all participants. Cartoons can be used as an effective tool among stakeholders to achieve a common understanding in order to coordinate their actions.

Does the Upper-Limb Work Instability Scale Predict Transitions Out of Work Among Injured Workers?

OBJECTIVE: To investigate the predictive ability of the Upper-Limb Work Instability Scale (UL-WIS) for transitioning out of work among injured workers with chronic, work-related upper extremity disorders (WRUEDs). DESIGN: Secondary analysis of a 12-month cohort study with data collection at baseline and 3-, 6-, and 12-month follow-up. Survey questionnaires were used to collect data on an array of sociodemographic, health-related, and work-related variables. SETTING: Upper extremity specialty clinics. PARTICIPANTS: Injured workers (N=356) with WRUEDs who were working at the time of initial clinic attendance. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Transitioning out of work. RESULTS: Multivariable logistic regression that considered 9 potential confounders revealed baseline UL-WIS (range, 0-17) to be a statistically significant predictor of a subsequent transition out of work (adjusted odds ratio, 1.18; 95% confidence interval [CI], 1.07-1.31; P=.001). An assessment of predictive values across the UL-WIS score range identified cut-scores of <6 (negative predictive value, .81; 95% CI, .62-.94) and >15 (positive predictive value, .80; 95% CI, .52-.96), differentiating the scale into 3 bands representing low, moderate, and high risk of exiting work. CONCLUSIONS: The UL-WIS was shown to be an independent predictor of poor work sustainability among injured workers with chronic WRUEDs; however, when applied as a standalone tool in clinical settings, some limits to its predictive accuracy should also be recognized.

Results of a feasibility study: barriers and facilitators in implementing the Sherbrooke model in France.

OBJECTIVES: Return-to-work interventions associated with the workplace environment are often more effective than conventional care. The Sherbrooke model is an integrated intervention that has proved successful in preventing work disability due to low-back pain. Implementation, however, runs up against many obstacles, and failure has been reported in many countries. The present study sought to identify barriers to and facilitators of the implementation of the Sherbrooke model within the French health system. METHODS: A multiple case study with nested levels of analysis was performed in two regions of France. A conceptual framework was designed and refined to identify barriers and facilitators at the individual, organizational and contextual levels. Qualitative data were collected via semi-structured interview (N=22), focus groups (N=7), and observation and from the gray literature. Participants (N=61) belonged to three fields: healthcare, social insurance, and the workplace. RESULTS: Numerous barriers and facilitators were identified in each field and at each level, some specific and others common to workers in all fields. Individual and organizational barriers comprised lack of time and resources, discordant professional values, and perceived risk. Legal barriers comprised medical confidentiality, legal complexity, and priority given to primary prevention. Individual-level facilitators comprised needs and perceived benefits. Some organizations had concordant values and practices. Legal facilitators comprised possibilities of collaboration and gradual return to work. CONCLUSION: The present feasibility analysis of implementing the Sherbrooke model revealed numerous barriers and facilitators suggesting a new implementation strategy be drawn up if failure is to be avoided.

The Job Accommodation Scale (JAS): psychometric evaluation of a new measure of employer support for temporary job modifications.

INTRODUCTION: An employer offer of temporary job modification is a key strategy for facilitating return-to-work for musculoskeletal conditions, but there are no validated scales to assess the level of support for temporary job modifications across a range of job types and organizations. OBJECTIVE: To pilot test a new 21-item self-report measure [the Job Accommodation Scale (JAS)] to assess its applicability, internal consistency, factor structure, and relation to physical job demands. METHODS: Supervisors (N = 804, 72.8 % male, mean age = 46) were recruited from 19 employment settings in the USA and Canada and completed a 30-min online survey regarding job modification practices. As part of the survey, supervisors nominated and described a job position they supervised and completed the JAS for a hypothetical worker (in that position) with an episode of low back pain. Job characteristics were derived from the occupational informational network job classification database. RESULTS: The full response range (1-4) was utilized on all 21 items, with no ceiling or floor effects. Avoiding awkward postures was the most feasible accommodation and moving the employee to a different site or location was the least feasible. An exploratory factor analysis suggested five underlying factors (Modify physical workload; Modify work environment; Modify work schedule; Find alternate work; and Arrange for assistance), and there was an acceptable goodness-of-fit for the five parceled sub-factor scores as a single latent construct in a measurement model (structural equation model). Job accommodations were less feasible for more physical jobs and for heavier industries. CONCLUSIONS: The pilot administration of the JAS with respect to a hypothetical worker with low back pain showed initial support for its applicability, reliability, and validity when administered to supervisors. Future studies should assess its validity for use in actual disability cases, for a range of health conditions, and to assess different stakeholder opinions about the feasibility of job accommodation strategies.

Are work disability prevention interventions effective for the management of neck pain or upper extremity disorders? A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration.

PURPOSE: We conducted a systematic review to critically appraise and synthesize literature on the effectiveness of work disability prevention (WDP) interventions in workers with neck pain, whiplash-associated disorders (WAD), or upper extremity disorders. METHODS: We searched electronic databases from 1990 to 2012. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. Scientifically admissible studies were summarized and synthesized following best-evidence synthesis methodology. RESULTS: Of the 6,359 articles retrieved, 16 randomized controlled trials were eligible for critical appraisal and five were admissible. We found that a return-to-work coordination program (including workplace-based work hardening) was superior to clinic-based work hardening for persistent rotator cuff tendinitis. Workplace high-intensity strength training and workplace advice had similar outcomes for neck and shoulder pain. Mensendieck/Cesar postural exercises and strength and fitness exercises had similar outcomes for non-specific work-related upper limb complaints. Adding a brief job stress education program to a workplace ergonomic intervention was not beneficial for persistent upper extremity symptoms. Adding computer-prompted work breaks to ergonomic adjustments and workplace education benefited workers' recovery from recent work-related neck and upper extremity complaints. CONCLUSIONS: At present, no firm conclusions can be drawn regarding the effectiveness of WDP interventions for managing neck pain, WAD, and upper extremity disorders. Our review suggests a return-to-work coordination program is more effective than clinic-based work hardening. Also, adding computer-prompted breaks to ergonomic and workplace interventions benefits workers' recovery. The current quality of evidence does not allow for a definitive evaluation of the effectiveness of ergonomic interventions.

Examination of the relationship between theory-driven policies and allowed lost-time back claims in workers' compensation: a system dynamics model.

OBJECTIVE: The purpose of this study was to develop a model that evaluates the impact of policy changes on the number of workers' compensation lost-time back claims in Ontario, Canada, over a 30-year timeframe. The model was used to test the hypothesis that a theory- and policy-driven model would be sufficient in reproducing historical claims data in a robust manner and that policy changes would have a major impact on modeled data. METHODS: The model was developed using system dynamics methods in the Vensim simulation program. The theoretical effects of policies for compensation benefit levels and experience rating fees were modeled. The model was built and validated using historical claims data from 1980 to 2009. Sensitivity analysis was used to evaluate the modeled data at extreme end points of variable input and timeframes. The degree of predictive value of the modeled data was measured by the coefficient of determination, root mean square error, and Theil's inequality coefficients. RESULTS: Correlation between modeled data and actual data was found to be meaningful (R(2) = 0.934), and the modeled data were stable at extreme end points. Among the effects explored, policy changes were found to be relatively minor drivers of back claims data, accounting for a 13% improvement in error. Simulation results suggested that unemployment, number of no-lost-time claims, number of injuries per worker, and recovery rate from back injuries outside of claims management to be sensitive drivers of back claims data. CONCLUSION: A robust systems-based model was developed and tested for use in future policy research in Ontario's workers' compensation. The study findings suggest that certain areas within and outside the workers' compensation system need to be considered when evaluating and changing policies around back claims.

Exploring the diversity of conceptualizations of work (dis)ability: a scoping review of published definitions.

PURPOSE: Researchers are confronted to numerous definitions of work ability/disability, influenced by their context of emergence, discipline, purpose, underlying paradigm and relationship to time. This study provides an in-depth analysis of the concept through a systematic scoping review and the development of an integrative concept map of work (dis)ability. The research questions are: How has work (dis)ability been conceptualized from the perspectives of research, practice, policy and industry in the published scientific literature? How has the conceptualization of work (dis)ability evolved over time? METHODS: A search strategy was designed with a library scientist to retrieve scientific publications containing explicit definition(s) of work (dis)ability in leading-edge databases. The screening and the extraction of the definitions were achieved by duplicate assessment. The definitions were subject to a comparative analysis based on the grounded theory approach. RESULTS: In total, 423 abstracts were retrieved from the bibliographic databases. After removing duplicates, 280 unique records were screened for inclusion. A final set of 115 publications containing unique original conceptual definitions served as basis for analysis. CONCLUSIONS: The scientific literature does not reflect a shared, integrated vision of the exact nature and dimensions of work (dis)ability. However, except for a few definitions, there seems to be a consensus that work (dis)ability is a relational concept resulting from the interaction of multiple dimensions that influence each other through different ecological levels. The conceptualization of work (dis)ability also seems to have become more dynamic over time. The way work (dis)ability is defined has important implications for research, compensation and rehabilitation.

Twenty-five years with the biopsychosocial model of low back pain-is it time to celebrate? A report from the twelfth international forum for primary care research on low back pain.

STUDY DESIGN: An integrated review of current knowledge about the biopsychosocial model of back pain for understanding etiology, prognosis, and interventions, as presented at the plenary sessions of the XII International Forum on LBP Research in Primary Care (Denmark; October 17-19, 2012). OBJECTIVE: To evaluate the utility of the model in reference to rising rates of back pain-related disability, by identifying (a) the most promising avenues for future research in biological, psychological, and social approaches, (b) promising combinations of all 3 approaches, and (c) obstacles to effective implementation of biopsychosocial-based research and clinical practice. SUMMARY OF BACKGROUND DATA: The biopsychosocial model of back pain has become a dominant model in the conceptualization of the etiology and prognosis of back pain, and has led to the development and testing of many interventions. Despite this back pain remains a leading source of disability worldwide. METHODS: The review is a synthesis based on the plenary sessions and discussions at the XII International Forum on LBP Research in Primary Care. The presentations included evidence-based reviews of the current state of knowledge in each of the 3 areas (biological, psychological, and social), identification of obstacles to effective implementation and missed opportunities, and identification of the most promising paths for future research. RESULTS: Although there is good evidence for the role of biological, psychological, and social factors in the etiology and prognosis of back pain, synthesis of the 3 in research and clinical practice has been suboptimal. CONCLUSION: The utility of the biopsychosocial framework cannot be fully assessed until we truly adopt and apply it in research and clinical practice. LEVEL OF EVIDENCE: N/A.

Work reintegration for veterans with mental disorders: a systematic literature review to inform research.

BACKGROUND: Some veterans, and especially those with mental disorders, have difficulty reintegrating into the civilian workforce. PURPOSE: The objectives of this study were to describe the scope of the existing literature on mental disorders and unemployment and to identify factors potentially associated with reintegration of workers with mental disorders into the workforce. DATA SOURCES: The following databases were searched from their respective inception dates: MEDLINE, EMBASE, Cumulative Index Nursing Allied Health (CINAHL), and PsycINFO. STUDY SELECTION: In-scope studies had quantitative measures of employment and study populations with well-described mental disorders (eg, anxiety, depression, posttraumatic stress disorder, substance-use disorders). DATA EXTRACTION: A systematic and comprehensive search of the relevant published literature up to July 2009 was conducted that identified a total of 5,195 articles. From that list, 81 in-scope studies were identified. An update to July 2012 identified 1,267 new articles, resulting in an additional 16 in-scope articles. DATA SYNTHESIS: Three major categories emerged from the in-scope articles: return to work, supported employment, and reintegration. The literature on return to work and supported employment is well summarized by existing reviews. The reintegration literature included 32 in-scope articles; only 10 of these were conducted in populations of veterans. LIMITATIONS: Studies of reintegration to work were not similar enough to synthesize, and it was inappropriate to pool results for this category of literature. CONCLUSIONS: Comprehensive literature review found limited knowledge about how to integrate people with mental disorders into a new workplace after a prolonged absence (>1 year). Even more limited knowledge was found for veterans. The results informed the next steps for our research team to enhance successful reintegration of veterans with mental disorders into the civilian workplace.

Confirmatory factor analysis of the Work Limitations Questionnaire (WLQ-25) in Workers' Compensation Claimants with chronic upper-limb disorders.

PURPOSE: To examine the factorial validity of the Work Limitations Questionnaire (WLQ-25) among workers' compensation claimants with chronic upper-limb disorders. METHODS: Attendees of the WSIB Shoulder and Elbow Specialty clinic in Toronto, Ontario, Canada, completed a survey that includes the WLQ-25 [4 subscales: time-management (TM), physical demands (PD), mental-interpersonal (MI), and output demands (OD)]. Confirmatory factor analyses (n = 2262) were conducted to evaluate and compare alternative 4- and 5-factor WLQ-25 structures [MI subscale intact vs. separated into mental demands (MD) and interpersonal demands (IP) subscales]. Model fit indices, saliency of factor loadings, and convergent/divergent validity of latent factors (r = 0.4 - 0.85 expected) were concurrently assessed. RESULTS: The 4-factor WLQ-25 showed acceptable model fit after allowing the residuals of a pair of PD items to correlate (CFI = 0.924, TLI = 0.915, RMSEA = 0.057, SRMR = 0.054); however, significantly lower-than-expected correlations between the PD factor and all other factors (r = -0.11 - -0.03) were also observed. Model fit for the 5-factor WLQ-25 was even more optimal (CFI = 0.934, TLI = 0.925, RMSEA = 0.053, SRMR = 0.051), with MD and IP factors correlating at r = 0.83. CONCLUSIONS: Evidence of factorial validity was demonstrated by the WLQ-25; however, users should be attentive of an instrumentation issue that could be directly related to the psychometric performance of its PD subscale.

Cross-cultural adaptation of the Work Disability Diagnosis Interview (WoDDI) for the Brazilian context.

The Work Disability Diagnosis Interview (WoDDI) is a structured interview guide developed by the University of Sherbrooke, Canada to help clinicians detect the most important work-related disability predictors and to identify one or more causes of prolonged absenteeism. This methodological study aims for the cross-cultural adaptation of the WoDDI for the Brazilian context. The method followed international guidelines for studies of this kind, including the following steps: initial translation, synthesis of translations, back translation, evaluation by an expert committee and testing of the penultimate version. These steps allowed obtaining conceptual, semantic, idiomatic, experiential and operational equivalences, in addition to content validity. The results showed that the translated WoDDI is adapted to the Brazilian context and can be used after training.

Validation of the programme impact theory for a work rehabilitation programme.

OBJECTIVE: The Therapeutic Return to Work (TRW) is a comprehensive rehabilitation process that is centralised in the workplace and consists of a worker's progressive return to his or her regular work. A programme impact theory for the TRW and three mechanism hypotheses were developed [12]. The objective of this study was to validate the mechanism hypotheses. participants: Construction workers who received compensation for low back pain. METHODS: A multiple-case study was carried out. Data on the programme activities were collected on a repeated basis using validated measurement instruments and semi-structured interviews of the 20 participants and the clinicians responsible for them. Analyses were carried out using the pattern matching technique. RESULTS: The results supported two of the three hypotheses proposed in the impact theory, specifically, that the development of competent work behaviours is a key factor in promoting return to work and appears to be associated with a reduction in work environment constraints, an improvement in work capacities and the presence of concerted action. CONCLUSION: This study revealed that rehabilitation interventions carried out in the workplace and involving workers with low back pain are both complex and embedded in the social environment, and that the actions taken must be coordinated in collaboration with various stakeholders.