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Schaafsma FG, Whelan K, van der Beek AJ, et.al. Physical conditioning as part of a return to work strategy to reduce sickness absence for workers with back pain. Cochrane Database of Systematic Reviews 2013; Issue 8: CD001822.
Background
Back pain is the leading cause of years lived with disability worldwide,1 and related work absenteeism contributes to the substantial economic burden of this health condition.2 Identification of effective treatments is important to reduce this burden. Physical conditioning programmes are an option for improving health-related outcomes including work absenteeism, but the effectiveness of these programmes on work absenteeism related to back pain is unclear.
Aim
The aim of this Cochrane review was to investigate the effectiveness of physical conditioning on work absenteeism related to back pain.3
Searches and inclusion criteria
Searches for randomised controlled trials (RCTs) were conducted on CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO and PEDro up to May 2013. RCTs were eligible if they included adults (>16 years) with work disability related to back pain who took part in physical conditioning programmes. The work disability criterion required that participants were on sick leave, partial sick leave or had limited work performance due to back pain.
Interventions
Physical conditioning programmes that met the following criteria were included: (1) exercises and/or advice specifically designed to improve individuals’ systemic, neurological, musculoskeletal and/or cardiopulmonary function; (2) the intervention aimed to improve work status and (3) the intervention-targeted functional job demands.
Main outcome measure
The review only included published trials that reported measures of work absenteeism.
Synthesis methods
Effects were described separately for patients with acute (duration of symptoms <6 weeks), subacute (>6 to <12 weeks) and chronic (>12 weeks) symptoms, and for light (≤5 sessions) or intense (>5 sessions) programmes. When possible, meta-analyses were conducted using fixed-effects (I 2 ≤50%) or random-effects models (I 2 >50%). Pooled effects were reported as ORs or standardised mean differences (SMDs) with 95% CIs. ORs of 0.65 and SMDs of −0.24 were considered as the smallest clinically worthwhile effect. The quality of evidence was assessed using the GRADE approach.3
Results
Twenty-five RCTs including a total of 4272 participants with acute (n=3 RCTs), subacute (n=8) and chronic (n=14) back pain were identified. Twenty-one trials investigated intense physical conditioning programmes. Seventeen programmes were delivered by a multidisciplinary group. Nine out of the 25 trials were classified as having high risk of bias. Interventions commonly included: ergonomic advice, an operant conditioning approach (eg, cognitive behavioural therapy), return to work advice and occupational training.
For acute and subacute back pain, there was low-quality evidence that physical conditioning programmes are not effective on work absenteeism when compared with usual care, this was the case regardless of intervention intensity. For instance, analyses of individual trials with 190 and 59 participants found SMDs of −0.02 (95% CI −0.30 to 0.27) and −0.10 (−0.61 to 0.41) at intermediate-term (18 weeks) and long-term (12 months) follow-ups, for light and intense programmes, respectively. Intense programmes combined with usual care (three trials with 283 participants), executed at the workplace or including a workplace visit, for subacute back pain, suggested long-term effects, when compared with usual care alone (SMD, −0.42 (−0.65 to −0.18)).
For chronic back pain, there was moderate quality evidence that intense physical conditioning programmes are effective on work absenteeism when compared with usual care at a 12-month follow-up (SMD, −0.23 (−0.42 to −0.03)). In addition, there was low-quality evidence from one trial that an intense programme combined with usual care is effective when compared with usual care alone at long-term follow-up (SMD, −4.42 (−5.06 to −3.79)), it is noted that the size of this effect may be unreliable due to the skewed distribution of work absence data in this trial.
Few trials compared physical conditioning programmes with exercise therapy or cognitive behavioural therapy. Substantial statistical and methodological heterogeneity across these small number of trials limited the capacity to draw firm conclusions. The findings are inconsistent when physical conditioning was compared with exercise therapy, and no difference was found between physical conditioning and cognitive behavioural therapy.
Limitations
Outcome data reported in the included studies were recalculated for pooling by the review authors and these recalculations sometimes resulted in different conclusions than those reported by included trials. Statistical heterogeneity among included trials was considerable, which may be explained by differences in intervention content. High risk of bias of the included trials may have impacted on estimated effects, and small numbers of participants in several comparisons means effect estimates are imprecise.
Clinical implications
The current review suggests that there may be clinically worthwhile effects of intense programmes for chronic back pain in the long term, particularly if they include a workplace component. However, there is considerable uncertainty regarding the size of the effects, and further high-quality trials may have an important impact on estimates. Moreover, whether studied interventions were actually intense programmes are still unclear because authors considered time spent on them only. There was no robust evidence that physical conditioning programmes are worthwhile for workers with acute and subacute pain.
Footnotes
Contributors GCJ, VCO and SJK: selected the systematic review, interpreted data and reviewed drafts.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.