S TUDY III

Study III revealed ten challenges that arise when implementing EBP frameworks in a return to work process. Table 7 presents an overview of these challenges, including descriptions and possible solutions.

Table 7. Descriptions and possible solutions of the ten challenges that were revealed

Abbreviations: RCT = randomized controlled trial; ICF = International Classification of Functioning, Disability, and Health [102]. *The Cochrane Library, OTseeker, and PEDRO are databases containing RCTs and systematic reviews.

# Challenge Description Possible solutions

1

Sorting and subsuming into predefined categories

The patients in the studies often had simpler diagnoses that those seen in real life, which makes it difficult to use the evidence.

Allow multi-level interventions that target more than one diagnosis in RTCs and systematic reviews, since this reflects real situations in complex practices.

2

Degree of intervention flexibility

The interventions described in the RCTs are too rigid to be adapted to other persons.

Promote ―frame-type‖ interventions with flexible elements that enable tailored interventions (such as supported employment).

3

Possibility of re-using

interventions in new situations

Interventions in RCTs were not described thoroughly and are therefore hard to reproduce.

Provide descriptions of intervention programmes given in RCTs, in the Cochrane Library*, OTseeker*, and Pedro*.

4

Interventions available in the literature

The interventions used in practice are not that same as those in focus in the scientific literature.

Strengthen collaborative efforts towards practice to increase the adequacy and relevance of interventions that are tested in RCTs.

5

Translating average group results to individuals

It is difficult to apply the mean results to individuals.

Provide more information in published RTC-reports on characteristics of who did benefited from treatment and who did not.

6 Relevance of the outcome

In systematic reviews and RCTs, many interventions are considered and described as ineffective, but relevant outcomes are not assessed.

Based on ICF terminology, develop consensus regarding outcomes that should be used to report effectiveness of

interventions.

7 Role of the scientific evidence

The role of scientific evidence seems to differ regarding whether it inspires, challenges, enlightens, informs, or determines the intervention decision.

Apply a wider understanding of the role of each type of evidence, deciding whether it should determine, inform, enlighten, challenge or inspire the decision making.

8 Aim of the interventions

The interventions seem to differ when the aim varies between rehabilitation, cure, and prevention.

Discuss further whether intervention decisions concerning preventive, curative, or rehabilitative aims do differ, and provide scientific knowledge about this.

9 Complexity of the interventions

The interventions in the studies were on a continuum from simple to complex, which could challenge the intervention decision in different ways.

Differentiate between simple and multi-level interventions, as the latter might challenge the translation process the most.

10 Potential to tailor interventions

The interventions in the studies seemed unequal, some being ―good-for-all‖ interventions and others more tailored to individual participants.

Separate ―good-for-all-interventions‖ from

―tailored-interventions‖ as evidence might be applied differently in these categories.

The evidence seemed to differ depending on whether it was from interventions with preventive, curative, or rehabilitative aims. Moreover, in some cases evidence appeared to originate from ―good-for-all‖ interventions and in others from ―tailored-type‖

interventions. Thus, it was revealed that there is a need to differentiate the role of the evidence in terms of whether it inspires, challenges, enlightens, informs, or determines the intervention decision.

In general, it seemed that the existing EBP steps and the PICO framework constructed a confined decision process. Therefore, revised EBP-steps, based upon results from this hypothetical case study were suggested (see study III).

In addition, one of the EBP steps (no. 3 Acquire) was to search for knowledge in the scientific literature. We searched The Cochrane Library to find articles about

interventions for low back pain, and thus Study III gave results regarding the content of

such interventions described in RCTs and systematic reviews included in the Cochrane

database. This search and analysis revealed few workplace interventions, but a high

diversity of clinical interventions. Table 8 shows the content of the identified

interventions for low back pain.

Table 8. Interventions for low-back pain used in published international studies of effectiveness

* The identified studies were sorted according to the WHO ICF [102]**Including randomized and clinical controlled trials (RCTs and CCTs).Note: The search was done on 22 July 2010 in the Cochrane Library database, including the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials (CENTRAL), using low back pain or back pain in the title as the search strategy.

Target*

(ICF)

Interventions listed according to type of study

Cochrane Reviews/Protocols Single studies: Clinical trials**

Body structure and body function (incl. psychological functions)

Acupuncture, Antidepressants, Back schools, Behavioural treatment, Botulinum toxin, Chiropractic interventions, Disk replacement (total), Electrical nerve stimulation, Exercise, therapy, Herbal medicine, Injection therapy, Insoles, Laser therapy, Lumbar support, Manual therapy, Massage, Muscle relaxants,

Neuroreflexotherapy, Non-steroidal anti-inflammatory drugs, Opioids, Patient education, Prolotherapy injections, Physical examination for lumbar radiculopathy,

Radiofrequency denervation, Spinal manipulative therapy, Superficial heat or cold, Traction

Acupuncture, Aerobic training, Anterior discectomy, Anti-inflammatory drugs, ATEAM, Attentional strategi (pain fear), Auriculotherapy, Avinza, Baklosan, Balneogherapy, Biofreeze, Botulinum toxins, Calcitoin, Celecoxib, Chiropractic, Cognitive behavioural treatment, Comprehensive group training, Conservative treatment, Cyclobenzaprine, Depo-Medrol, Dexketoprofen, Diclofenack, Dorsal ramus block, Drug therapy, Duloxetine, Dynamic-strength exercise, Education on return to work status (fear avoidance), Electrotherapy, Eperisone hydrochloride, Ergometric training program, Etanercept, Exercise (individual-group), Extensor strengthening program, Feldenkrais therapy, Fluoroscopic caudal injections, Functional restoration, Function-centred rehab, Fusion surgery, Graded exercise, Graded in vivo exposure, Heat therapy, Information booklet on pain persistence, Informative approach, Injection, Integrative medicine, Kuesu point, Laser, Leg lock brace, Lornoexicam, Lumbar fixation, Lumbar fusion, Lumbar support/belt, Lumbar stimulation belt, Magnetotherapy, Massage, Manipulation, Manual therapy, Meditation, McKenzie therapy, Mensendieck exercise, Microcurrent therapy, Mind-body program, Mobilization program, Motivation for self-care, Motor control learning, Movement training, Muscle relaxant, Muscle training, Naprapathic manual therapy, Neuropathic care, Neuroreflexotherapy, Nimesulide, Non-surgical treatment, Opioid therapy, Oscillating blade, Osteopathic manipulation, Oxygen-ozone therapy, Oxymorphone, Ozone therapy, Pain management, Physical strength treatments, Pilates, Piroxicam-beta-cyclodextrin, Pregabalin, Problem-solving training,

Psychological intervention, Psychosocial education, Radiofrequency, Radiography, Reflexology, Roptrotherapy, Sagittal spinal alignment, Sensory discrimination training, Spinal cord stimulation, Spinal manipulation, Spinal nerve root infiltration, Stabilization techniques, Stress management program, Stretching, Steroid injections, Surgery, Sustained-release morphine, Tai Chi, Tapentadol, Thiocolchicoside, Traction technique, Tramadol, Transdermal fentanyl, TENS, TTM-based motivational counselling, Yoga, Valdecoxib, Water gymnastics, Wet-cupping

Activity Bed rest, Manual material handling advices, Physical conditioning programmes for improving work outcomes, Staying active

Active treatment, Bed rest, Dual-tasking, Function-centred (vs. pain-centred) rehabilitation, Functioning restoration, Graded activity, Lifting instructions, Normal activity, Transfer technique instructions, Participatory ergonomics

Partici-pation

Active sick leave

Environ -ment

Workplace interventions, Assistive devices

Workplace interventions, Worksite visit, Chair interventions, Contextualized educational package

Combin ations/

others

Multidisciplinary bio-psychosocial rehabilitation, General interventions for pregnant with back pain

Problem-solving therapy, Back schools, Behavioural rehabilitation programs, Biopsychosocial intervention, Classification-based physical therapy, Client centred therapy, Collaboration, Integrated care, Guidelines, Mini-intervention, Modern rehabilitation, Multidisciplinary rehab. Programs, Multistage RTW program, Occupational rehabilitation, Patient education, Physiotherapy, Rehabilitation programs, Therapy based on clinical guidelines, Treatment-based classification system, Innovative work related multidisciplinary program