Background: Evidence-based occupational health guidelines recommend that some form of case-management approach, involving getting ‘all players onside’, should be implemented for control of absence due to back pain; this approach has not been formally tested in the UK.

Methods/Results: A quasi-experimental controlled trial was conducted at selected sites of a large pharmaceutical company in the UK. The experimental intervention, delivered by occupational health nurses working to a guidelines-based protocol, was implemented at two manufacturing sites (n=1,435). Three matched sites acted as controls, delivering management as usual (n=1,483). Absence data were collected for both experimental and control sites for the two years prior to, and the two years during, the intervention period.

The intended early contact (within first week) of workers absent with musculoskeletal disorders only occurred at one experimental site; the control sites had no procedure for early contact. Absence rates improved over the four years at the intervention sites compared with the control sites: a decrease of 2.0 v an increase of 0.9 days/1000 working hours. The median return-to-work time for early intervention compared with controls was 4 days v 5 days (P=NS). Considering return-to-work time irrespective of whether the intervention was delivered early or late, the median durations were also 4 days v 5 days (P< 0.05). When looking at work retention over 12 months, the median duration of subsequent absence for early intervention was 5 days compared with 11 days for controls (P=NS). For the larger number of workers receiving a late intervention, the median duration of subsequent absence was median 4 days v 11 days for controls (P< 0.05).

Conclusion: The data consistently favoured a reduction in absence at the experimental sites, but organisational obstacles (black flags) precluded statistically significant results for early intervention. Implementation of certain guidelines principles (a supportive network with ‘all players onside’) can be effective for reducing absence.

Purpose of study and background: It is generally accepted that a biopsychosocial model is required to explain the complex phenomenon of whiplash associated disorders, particularly in the development of chronic pain and disability. Because the factors leading to chronicity are present early in the course of the disorder, clinical guidelines and recommendations have stressed the need for appropriate information and advice for patients. Following the success of patient educational material, in the form of an evidence-based booklet, in the management of low back pain, a similar booklet has been produced for whiplash patients. The messages for the booklet were synthesised from a comprehensive review of the available scientific evidence; the resultant text was intended to challenge unhelpful beliefs about whiplash, promote positive attitudes, and stimulate an active approach to recovery.

Methods and results: Using samples of patients and non-patients, the booklet was evaluated for its ability to create a positive shift in beliefs, and for its ability to impart its intended messages about active management. The results showed that the booklet is considered easy to read, understandable, believable, and conveys its intended messages. Furthermore, it created a substantial and highly statistically significant positive shift in attitudes and beliefs about whiplash associated disorders, suggesting its suitability as patient educational material.

Conclusion: This booklet changes beliefs about whiplash, however only a randomised clinical trials will determine whether such a booklet can have an effect on clinical outcomes.

Background: The influence of psychosocial factors on absence rates is incompletely understood; much research has been cross-sectional, involving a limited range of psychosocial variables. This paper reports a large prospective study of the relationship between psychosocial factors and absence rates due to low back pain across a multi-site UK pharmaceutical company.

Methods/Results: Baseline data were collected from 4,637 workers, and absence data over the ensuing 15 months were obtained from company records. In addition to demographic and historical variables, a wide range of psychosocial variables was included with a focus on occupational psychosocial factors, termed ‘blue flags’. Validated questionnaires were used to quantify job satisfaction, social support, attribution of cause, control over work, and organisation of work, with psychological distress as a ’yellow flag’. 176 workers took absence due to back pain during follow-up.

Previously defined cut-off scores were used to categorise hypothesised risk; scores beyond the cut-off point were considered detrimental, and the ‘flag’ was considered to be ‘flying’. Odds ratios (OR) were calculated to explore the association between the flags and taking sick leave; a statistically significant association was found with ORs between 1.5 and 2.9. The cut-off scores were then used to compare the length of absence between workers who had zero flags flying and those who had one or more flags flying. Absence over the ensuing 15 months was significantly longer for those people who had one or more flags flying (mean 10.6 days compared with 6.1 days, P< 0.05). There was a trend for longer absence with more flags flying.

Conclusion: This prospective study confirms the influence of blue, as well as yellow, psychosocial flags on both the taking of sick leave and the subsequent length of absence. This supports their hypothesised role as obstacles to recovery that might be suitable targets for occupational health interventions.

Objective: To implement an early occupational intervention which tackles the psychosocial factors (yellow and blue flags) that influence recovery from occupational back pain.

Design: An early, psychosocial, occupational health nurse-led intervention using a basic ‘counselling’ technique that reinforces evidence-based messages and advice, along with availability of modified work.

Subjects: 206 workers from a sample of Glaxosmithkline sites who took absence due to back pain.

Outcome measures: Duration of presenting absence.

Results: The target for contacting the worker was achieved at Site 1 (mean 3 days), but not Site 2 (mean 12 days). Results showed that late contact of absent workers (> 1 week) was significantly associated with both longer presenting absence and fewer recipients of the psychosocial intervention, compared with early contact. Preliminary results show that the psychosocial intervention (irrespective of early or late contact) reduces the length of presenting absence by half.

Conclusions: The lack of early contact at Site 2 was due to local sickness absence management differences. This study reveals a third class of obstacles to recovery – organisational policies (black flags) – that can negate the effect of occupational rehabilitation programs.

Objective: A review of scientific literature on whiplash associated disorders was conducted to inform appropriate messages for an evidenced-based patient educational booklet – The Whiplash Book. The booklet has been developed for use as both a clinical tool and general health intervention.

Design and Results: A systematic literature search was conducted, using MEDLINE and psychINFO, together with hand searches, reference tracking, and the Internet. The Quebec Task Force report and the British Columbia Whiplash Initiative were taken as the starting point. The new evidence covered the period May 1994 through March 2001 (163 articles). All relevant articles were included, with a particular focus on management and treatment of whiplash associated disorders. The quantity, consistency and relevance of all retrieved articles was evaluated, and rated as:

*** consistent findings in multiple reports

** consensus based on balance of various findings

* limited information (single report)

Conclusions: The main messages from the literature suggest: serious physical injury is rare, reassurance about good prognosis is important, over-medication is detrimental, fastest recovery occurs with early return to normal pre-accident activities; self-exercise/manual therapy and positive attitudes/beliefs are helpful to regain activity levels; collars/rest and negative attitudes/beliefs delay recovery and contribute to chronicity.