Invasive Treatments for Low Back Disorders.

OBJECTIVE: This abbreviated version of the American College of Occupational and Environmental Medicine's Low Back Disorders guideline reviews the evidence and recommendations developed for invasive treatments used to manage low back disorders. METHODS: Comprehensive systematic literature reviews were accomplished with article abstraction, critiquing, grading, evidence table compilation, and guideline finalization by a multidisciplinary expert panel and extensive peer-review to develop evidence-based guidance. Consensus recommendations were formulated when evidence was lacking and often relied on analogy to other disorders for which evidence exists. A total of 47 high-quality and 321 moderate-quality trials were identified for invasive management of low back disorders. RESULTS: Guidance has been developed for the invasive management of acute, subacute, and chronic low back disorders and rehabilitation. This includes 49 specific recommendations. CONCLUSION: Quality evidence should guide invasive treatment for all phases of managing low back disorders.

Workers' Compensation Elements in Different Jurisdictions in the United States.

: Over the decades, the workers' compensation system has provided many injured workers with a significant guarantee of both medical and financial support when they have been injured on the job. To be effective, workers' compensation systems at a minimum should include principles that require the addressing of medical causation, determination of an individual's functional ability both pre- and post-injury to include activity restrictions, return-to-work capability and disability, meeting jurisdiction-specific reporting requirements of the workers' compensation reporting requirements, and having knowledge of other perspectives of the various authorities and jurisdictions present in the United States. ACOEM lays out a description of various aspects of workers' compensations systems in the United States, with recommendations for minimal standards and best practices. This paper limits itself to the discussion of jurisdictions within the United States and ACOEM strongly recommends that providers consult directly with the states in which they are working as there are state variations in workers' compensation.

Non-Invasive and Minimally Invasive Management of Low Back Disorders.

OBJECTIVE: This abbreviated version of the American College of Occupational and Environmental Medicine's (ACOEM) Low Back Disorders Guideline reviews the evidence and recommendations developed for non-invasive and minimally invasive management of low back disorders. METHODS: Systematic literature reviews were accomplished with article abstraction, critiquing, grading, evidence table compilation, and guideline finalization by a multidisciplinary expert panel and extensive peer-review to develop evidence-based guidance. Consensus recommendations were formulated when evidence was lacking. A total of 70 high-quality and 564 moderate-quality trials were identified for non-invasive low back disorders. Detailed algorithms were developed. RESULTS: Guidance has been developed for the management of acute, subacute, and chronic low back disorders and rehabilitation. This includes 121 specific recommendations. CONCLUSION: Quality evidence should guide treatment for all phases of managing low back disorders.

Diagnostic Tests for Low Back Disorders.

OBJECTIVE: The aim of this study was to summarize evidence-based diagnostic guidelines for low back disorders. METHODS: A comprehensive literature review was conducted. A total of 101 articles of high or moderate quality addressing low back disorders diagnostic evaluation met the inclusion criteria. Evidence-based recommendations were developed and graded from (A) to (C) in favor and against the specific diagnostic test, with (A) level having the highest quality body of literature. Expert consensus was employed for insufficient evidence (I) to develop consensus guidance. RESULTS: Recommendations are given for these diagnostic tests: functional capacity evaluations, roentgenograms (x-rays), magnetic resonance imaging (MRI), computerized tomography, myelography, bone scans, single proton emission computed tomography, electromyography, surface electromyography, ultrasound, thermography, fluoroscopy, videofluoroscopy, lumbar discography, MRI discography, and myeloscopy. CONCLUSION: Diagnostic testing is not indicated for the majority of patients with low back pain.

Research Review: Language problems in children with Attention-Deficit Hyperactivity Disorder - a systematic meta-analytic review.

BACKGROUND: Children with Attention-Deficit Hyperactivity Disorder (ADHD) appear to have a higher risk of language problems compared with typically developing children, although the types of language problems experienced are less clear. This review aims to establish the types of language problems experienced by children with ADHD according to systematically reviewed literature and determine the empirical evidence for language problems in children with ADHD compared with non-ADHD controls. METHODS: A standardized search protocol was used on databases: CINAHL, Medline, and PsychINFO. We identified studies with the following inclusion criteria: (a) confirmed ADHD status at the time of the study, (b) inclusion of a non-ADHD control group, (c) use of a validated language measure, and (d) age ≤ 18. t-Tests, Pearson's r, and Hedges g effect sizes (ES) were calculated using summary statistics. Random effects meta-analyses were conducted for the language domain suitable for analysis. Publication bias was investigated using both the trim and fill and p-curve techniques. RESULTS: Twenty-one studies were included in the systematic review (ADHD = 1,209; Control = 1,101), within which 60 of 68 separate analyses found significant differences between the ADHD and control group on the language measures (p < .05). Follow-up meta-analyses found evidence for large deficits in the ADHD groups overall (10/11 studies met p < .05; weighted mean ES [WMES]: 1.04); expressive (10/10 met p < .05; WMES: 1.23); receptive (12/14 met p < .05; WMES: 0.97), and pragmatic language (4/4 studies met p < .05; WMES: 0.98) compared with controls. CONCLUSIONS: This study demonstrates that children with ADHD have poorer performance on measures of overall, expressive, receptive, and pragmatic language compared with controls. A screening of language functioning may be a valuable addition to the assessment of ADHD.

Common Genetic Variants in FOXP2 Are Not Associated with Individual Differences in Language Development.

Much of our current knowledge regarding the association of FOXP2 with speech and language development comes from singleton and small family studies where a small number of rare variants have been identified. However, neither genome-wide nor gene-specific studies have provided evidence that common polymorphisms in the gene contribute to individual differences in language development in the general population. One explanation for this inconsistency is that previous studies have been limited to relatively small samples of individuals with low language abilities, using low density gene coverage. The current study examined the association between common variants in FOXP2 and a quantitative measure of language ability in a population-based cohort of European decent (n = 812). No significant associations were found for a panel of 13 SNPs that covered the coding region of FOXP2 and extended into the promoter region. Power analyses indicated we should have been able to detect a QTL variance of 0.02 for an associated allele with MAF of 0.2 or greater with 80% power. This suggests that, if a common variant associated with language ability in this gene does exist, it is likely of small effect. Our findings lead us to conclude that while genetic variants in FOXP2 may be significant for rare forms of language impairment, they do not contribute appreciably to individual variation in the normal range as found in the general population.

Examining Procedural Learning and Corticostriatal Pathways for Individual Differences in Language: Testing Endophenotypes of DRD2/ANKK1.

The aim of the study was to explore whether genetic variation in the dopaminergic system is associated with procedural learning and the corticostriatal pathways in individuals with developmental language impairment (DLI). We viewed these two systems as endophenotypes and hypothesized that they would be more sensitive indicators of genetic effects than the language phenotype itself. Thus, we genotyped two SNPs in the DRD2/ANKK1 gene complex, and tested for their associations to the phenotype of DLI and the two endophenotypes. Results showed that individuals with DLI revealed poor procedural learning abilities and abnormal structures of the basal ganglia. Genetic variation in DRD2/ANKK1 was associated with procedural learning abilities and with microstructural differences of the caudate nucleus. The association of the language phenotype with these DRD2/ANKK1 polymorphisms was not significant, but the phenotype was significantly associated with the two endophenotypes. We suggest that procedural learning and the corticostriatal pathways could be used as effective endophenotypes to aid molecular genetic studies searching for genes predisposing to DLI.

Marijuana in the Workplace: Guidance for Occupational Health Professionals and Employers: Joint Guidance Statement of the American Association of Occupational Health Nurses and the American College of Occupational and Environmental Medicine.

Employers are often put in a difficult position trying to accommodate state laws that allow the use of marijuana for medical purposes while enforcing federal rules or company drug-use policies based on federal law. To ensure workplace safety as well as compliance with state and federal legislation, employers should review state laws on discrimination against marijuana users and ensure that policies enacted are consistent with the state's antidiscrimination statutes. Although it appears that in most states that allow medical marijuana use, employers can continue enforcing policies banning or restricting the use of marijuana, this approach may change on the basis of future court decisions. The Joint Task Force recommends that marijuana use be closely monitored for all employees in safety-sensitive positions, whether or not covered by federal drug-testing regulations. Best practice would support employers prohibiting marijuana use at work. Employers, in compliance with applicable state laws, may choose to simply prohibit their employees from working while using or impaired by marijuana. In some states, employers may choose to prohibit marijuana use by all members of their workforce whether on or off duty. Nevertheless, in all cases, a clear policy to guide decisions on when marijuana use is allowed and how to evaluate for impairment must be widely distributed and carefully explained to all workers. Legal consultation during policy development and continual review is imperative to ensure compliance with federal, state, and case law. Drug-use and drug-testing policies should clearly delineate expectations regarding on-the-job impairment and marijuana use outside of work hours. Specific criteria for use by supervisors and HR personnel when referring employees suspected of impairment for an evaluation by a qualified occupational health professional are critical. Detailed actions based on the medical evaluation results must also be clearly delineated for HRs, supervisors, and workers. The Joint Task Force recommends that employers review the following points when developing workplace policies that address marijuana use in the workplace: 1. For employees covered by federal drug testing regulations (eg, DOT and other workers under federal contract), marijuana use, both on or off the job, is prohibited. Thus, employers may use urine drug screening in this population. 2. Employees in safety-sensitive positions must not be impaired at work by any substance, whether it be illicit, legally prescribed, or available over-the-counter. Employers may consider prohibiting on the job marijuana use for all employees in safety-sensitive positions, even when not covered by federal drug testing regulations. Nevertheless, legal review of the employer's policy in the context of state statutes is strongly encouraged. When employers allow medical marijuana use by employees, consultation with a qualified occupational health professional is recommended. 3. Employers residing in or near states that allow the use of recreational marijuana must establish a policy regarding off-work use of marijuana. In many states, the employer may choose to prohibit employees from simply working while using or under the influence of marijuana or may choose to prohibit marijuana use both on and off the job. Urine drug testing above traditional cutoff levels, or serum testing at any level, would be reasonable criteria for the employer wishing to ban both on- and off-the-job use. To detect impairment, a limit of 5 ng/mL of THC measured in serum or plasma as THC (or possibly the sum of THC plus THC-OH for employers who choose to evaluate both psychoactive components) would meet the goal of identifying individuals most likely to be impaired. Nevertheless, employers using the 5 ng/ml level need to understand the limitations of using a single number to fit all cases; therefore, a medical examination focused on identifying impairment is always recommended. Legal consultation is strongly recommended. 4. Although it appears that in most states that allow the use of medical marijuana, employers may be able to continue policies banning or restricting the use of marijuana as previously discussed, this practice may change on the basis of future case law. Currently the ADA does not apply in these situations because marijuana is illegal under federal law. Legal consultation is again strongly recommended. 5. Most workers' compensation statutes allow reduced benefits when a worker is under the influence of alcohol or illegal drugs. Two samples should usually be obtained as a second confirmatory test may be needed. Proof of use and/or impairment is usually required for these cases, and a positive urine drug test (for the inactive metabolite) does not prove acute impairment. The serum level of less than 5 ng/mL could be used for presumptive evidence of impairment in these situations. An MRO is most helpful in helping determine these types of cases because legal testimony may be required. 6. All employers should have clear policies and procedures for supervisors to follow regarding the criteria for identifying potential impairment and the process for referring an employee suspected of impairment for an occupational medical evaluation. Policies should include action required by HR personnel based on the results of the examination. 7. Employee education is vital to ensure compliance with company expectations. Education is needed at hire and again at regular intervals. Workers must know the company's chemical substance policy and management's expectations for adherence. The employer's commitment to a drug-free workplace and existing company policy will influence the education program's content. At a minimum, employees should learn how chemical substances affect their health, safety, personal behavior, and job performance. Supervisors and employees should also be educated about how to recognize behaviors indicative of impairment, whether the source is medical marijuana, prescription medications, illegal drugs, alcohol, over-the-counter medications, fatigue, or any combination thereof. 8. In states where marijuana use is permitted, employers should provide educational resources regarding the detrimental effects of marijuana use, including caution regarding dose and delayed effects of edible products. This information may be obtained from SAMHSA and state governmental agencies. The safety of workers and the public must be central to all workplace policies and employers must clearly articulate that legalization of marijuana for recreational or medical use does not negate workplace policies for safe job performance. The evolving legal situation on medical and recreational marijuana requires employers to consult with legal experts to craft company policy and clarify implications of impaired on-duty workers. This changing environment surrounding marijuana use requires close collaboration between employers, occupational health professionals, and legal experts to ensure that workplace safety is not compromised.

ACOEM practice guidelines: opioids for treatment of acute, subacute, chronic, and postoperative pain.

DESCRIPTION: The American College of Occupational and Environmental Medicine's guidelines have been updated to develop more detailed guidance for treatment of acute, subacute, chronic, and postoperative pain with opioids. METHODS: Literature searches were performed using PubMed, EBSCO, Cochrane Review, and Google Scholar without publication date limits. Of 264,617 articles' titles screened and abstracts reviewed, 263 articles met inclusion criteria. Of these, a total of 157 were of high and moderate quality addressing pain treatment. Comprehensive literature reviews were accomplished with article abstraction, critiquing, grading, evidence table compilation, and guideline finalization by a multidisciplinary expert panel to develop evidence-based guidance. RECOMMENDATIONS: No quality evidence directly supports histories, physical examinations, and opioid treatment agreements, although they are thought to be important. No quality trials were identified showing superiority of opioids, compared with nonsteroidal anti-inflammatory and other medications for treatment of chronic, noncancer pain. The use of opioid-sparing treatments associated with lower doses of postoperative opioids is also associated with better long-term functional outcomes. Selective use of opioids is recommended for patients with acute and postoperative pain. Consensus recommendations also include consideration of carefully conducted trials of chronic opioid treatment for highly select patients with subacute and chronic pain and to maintenance opioid prescriptions only if documented objective functional gain(s) results. A strong and reproducible dose-response relationship identifies a recommended morphine equivalent dose limit of no more than 50 mg/day. Higher doses should be prescribed only with documented commensurately greater functional benefit(s), comprehensive monitoring for adverse effects, informed consent, and careful consideration of risk versus benefit of such treatment. Chronic opioid use should be accompanied by informed consent, a treatment agreement, tracking of functional benefits, drug screening, and attempts at tapering.

ACOEM practice guidelines: opioids and safety-sensitive work.

OBJECTIVE: ACOEM has updated the treatment guidelines concerning opioids. This report highlights the safety-sensitive work recommendation that has been developed. METHODS: Comprehensive literature reviews were accomplished with article abstraction, critiquing, grading, evidence table compilation, and guideline finalization by a multidisciplinary expert panel to develop evidence-based guidance. A total of 12 moderate-quality studies were identified to address motor vehicle crash risk, and none regarding other work among opioid-using patients. RESULTS: Acute or chronic opioid use is not recommended for patients who perform safety-sensitive jobs. These jobs include operating motor vehicles, other modes of transportation, forklift driving, overhead crane operation, heavy equipment operation and tasks involving high levels of cognitive function and judgment. CONCLUSION: Quality evidence consistently demonstrates increased risk of vehicle crashes and is recommended as the surrogate for other safety-sensitive work tasks.

Language problems in children with ADHD: a community-based study.

OBJECTIVES: To examine the prevalence of language problems in children with attention-deficit/hyperactivity disorder (ADHD) versus non-ADHD controls, and the impact of language problems on the social and academic functioning of children with ADHD. METHODS: Children (6 to 8 years) with ADHD (n = 179) and controls (n = 212) were recruited through 43 Melbourne schools. ADHD was assessed by using the Conners 3 ADHD Index and the Diagnostic Interview Schedule for Children IV. Oral language was assessed by using the Clinical Evaluation of Language Fundamentals, fourth edition, screener. Academic functioning was measured via direct assessment (Wide Range Achievement Test 4) and teacher report (Social Skills Improvement System). Social functioning was measured via parent and teacher report (Strengths and Difficulties Questionnaire; Social Skills Improvement System). Logistic and linear regression models were adjusted for sociodemographic factors and child comorbidities. RESULTS: Children with ADHD had a higher prevalence of language problems than controls after adjustment for sociodemographic factors and comorbidities (odds ratio, 2.8; 95% confidence interval [CI], 1.5 to 5.1). Compared with children with ADHD alone, those with language problems had poorer word reading (mean difference [MD], -11.6; 95% CI, -16.4 to -6.9; effect size, -0.7), math computation (MD, -11.4; 95% CI, -15.0 to -7.7; effect size, -0.8), and academic competence (MD, -10.1; 95% CI, -14.0 to -6.1; effect size, -0.7). Language problems were not associated with poorer social functioning. CONCLUSIONS: Children with ADHD had a higher prevalence of language problems than controls, and language problems in children with ADHD contributed to markedly poorer academic functioning.

Characterization of the DYX2 locus on chromosome 6p22 with reading disability, language impairment, and IQ.

Reading disability (RD) and language impairment (LI) are common neurodevelopmental disorders with moderately strong genetic components and lifelong implications. RD and LI are marked by unexpected difficulty acquiring and processing written and verbal language, respectively, despite adequate opportunity and instruction. RD and LI-and their associated deficits-are complex, multifactorial, and often comorbid. Genetic studies have repeatedly implicated the DYX2 locus, specifically the genes DCDC2 and KIAA0319, in RD, with recent studies suggesting they also influence LI, verbal language, and cognition. Here, we characterize the relationship of the DYX2 locus with RD, LI, and IQ. To accomplish this, we developed a marker panel densely covering the 1.4 Mb DYX2 locus and assessed association with reading, language, and IQ measures in subjects from the Avon Longitudinal Study of Parents and Children. We then replicated associations in three independent, disorder-selected cohorts. As expected, there were associations with known RD risk genes KIAA0319 and DCDC2. In addition, we implicated markers in or near other DYX2 genes, including TDP2, ACOT13, C6orf62, FAM65B, and CMAHP. However, the LD structure of the locus suggests that associations within TDP2, ACOT13, and C6orf62 are capturing a previously reported risk variant in KIAA0319. Our results further substantiate the candidacy of KIAA0319 and DCDC2 as major effector genes in DYX2, while proposing FAM65B and CMAHP as new DYX2 candidate genes. Association of DYX2 with multiple neurobehavioral traits suggests risk variants have functional consequences affecting multiple neurological processes. Future studies should dissect these functional, possibly interactive relationships of DYX2 candidate genes.

Associations of prenatal nicotine exposure and the dopamine related genes ANKK1 and DRD2 to verbal language.

Language impairment (LI) and reading disability (RD) are common pediatric neurobehavioral disorders that frequently co-occur, suggesting they share etiological determinants. Recently, our group identified prenatal nicotine exposure as a factor for RD and poor reading performance. Using smoking questionnaire and language data from the Avon Longitudinal Study of Parents and Children, we first determined if this risk could be expanded to other communication disorders by evaluating whether prenatal nicotine exposure increases risk for LI and poor performance on language tasks. Prenatal nicotine exposure increased LI risk (OR = 1.60; p = 0.0305) in a dose-response fashion with low (OR = 1.25; p = 0.1202) and high (OR = 3.84; p = 0.0002) exposures. Next, hypothesizing that the effects of prenatal nicotine may also implicate genes that function in nicotine related pathways, we determined whether known nicotine dependence (ND) genes associate with performance on language tasks. We assessed the association of 33 variants previously implicated in ND with LI and language abilities, finding association between ANKK1/DRD2 and performance on language tasks (p≤0.0003). The associations of markers within ANKK1 were replicated in a separate LI case-control cohort (p<0.05). Our results show that smoking during pregnancy increases the risk for LI and poor performance on language tasks and that ANKK1/DRD2 contributes to language performance. More precisely, these findings suggest that prenatal environmental factors influence in utero development of neural circuits vital to language. Our association of ANKK1/DRD2 further implicates the role of nicotine-related pathways and dopamine signaling in language processing, particularly in comprehension and phonological memory.