- Email: [email protected]
Musculoskeletal disorders and work disability
Ò
PAIN 154 (2013) 1904–1905
www.elsevier.com/locate/pain
Commentary
Musculoskeletal disorders and work disability From work we gain social contact, income, stability, purpose, and opportunities to demonstrate our skills and achievements. However, all over the world a large number of people are unable to work because of disability arising from musculoskeletal disorders (MSD) such as back pain, neck pain, and osteoarthritis. These conditions are the most common causes of medically diagnosed sick leave and health-related early retirement in Europe [2]. We now know that MSD start early in life [11,12], and those persons who have experienced pain during childhood and adolescence have an increased risk of pain and disability later in life [8,12]. In this issue of PAIN, Ropponen et al. present data supporting that one-time reporting of MSD in the form of pain in the back, shoulders, or neck that interferes with the ability to carry out normal duties predicts increased risk of work disability and award of disability pension for MSD, osteoarthritis, and back pain up to 23 years later [15]. The article adds to the growing body of evidence indicating that an episode of musculoskeletal pain is associated not only with future episodes of annoying pain and trouble [6], but also with severe social consequences such as inability to work. Primary prevention of MSD should therefore have a high priority everywhere, but unfortunately there is little evidence for the effectiveness of most prevention initiatives. For instance, programs in the workplace involving instructions in manual materials handling [19] or use of ergonomic aids, training in the use of these aids, and implementation of breaks [10] have shown little if any effect in preventing back and neck pain and upper limb disorders in workers. Burton et al. found that overall there was no evidence and little scope for primary prevention of back pain and recommended that prevention efforts should be directed at minimizing its consequences [4]. Injuries in sports also contribute substantially to lower limb musculoskeletal pain and osteoarthritis [12], and primary prevention of some injuries may be feasible through rigorous implementation of neuromuscular warm-up exercises, but this has not been tested on a large scale [7]. Intuitively one would then advocate aggressive early treatment for the first and perhaps inevitable episodes of MSD to avoid unfortunate long-term consequences and chronicity, but paradoxically, current best practice evolves around a ‘‘less is more’’ approach discouraging early aggressive treatment [18]. This is because commonly used therapies such as pain medication, manual treatment, and structured exercise programs may relieve and shorten an episode of pain, but there is little evidence that they significantly alter the natural long-term course of MSD [1]. Also for patients with early signs of osteoarthritis, simple interventions such as patient education, exercise, and weight loss are recommended as first-line treatment, reserving therapist-delivered passive interventions and surgery to fewer patients at later stages of the disease [14]. q
DOI of original article: http://dx.doi.org/10.1016/j.pain.2013.05.029
Prevention of work disability in persons with MSD is a complex problem that goes beyond the conventional biomedical paradigm and treatment for episodes of pain. Evidence suggests that we need to adopt a broader disability paradigm that takes into account the complex interaction of biological, psychological, and social factors, as well as interplays between several stakeholders (employer, insurer, and the health care providers) who interact with the patient during the disability process [13]. Primary prevention of work disability involves helping patients stay at work in spite of having a MSD, and secondary work disability prevention involves helping patients return to work. Evidence suggests that strategies and interventions involving all stakeholders including the workplace may be cost effective [3]. Finally, it has become apparent that one size does not fit all when it comes to treatment for MSD and prevention of disability. Recent advances include stratifying patients for care through screening for known biopsychosocial risk factors using reliable and valid tools, and then applying interventions designed to target their specific problems and risk profile [9]. The challenge is to develop appropriately validated instruments that stratify patients into streams of care matching their risk profile so their chance of a good outcome is optimized [16]. In addition, beliefs and behaviors at the population level may be influenced through mass media campaigns, if these are delivered efficiently [5]. In the Scandinavian countries, we have exceptional opportunities to perform registry-based research because of the unique personal identification number assigned to all persons with permanent residence. This number facilitates the linkage of registries with participant-reported information (such as twin registries) and public administrative registries (such as pension or hospital registries) for research purposes. Registry linkage is supported by legislation, and the population base of these registries allows sophisticated analyses using advanced multivariate statistical techniques due to their large sample sizes. Particularly useful methodologies can be applied in population-based twin registries where, such as in the study by Ropponen et al., effects of familial and genetic confounding can be controlled for [17]. Of course registry-based research also has its drawbacks. For example, detailed descriptions including objective measures of health and detailed measures of exposures are not always included. In the case of most MSD, however, self-report is the gold standard, making them ideally suited for research using population-based registries. Through registry-based research, we have long known that MSD are very prevalent; we now also know that they have profound impact on quality of life for individuals and on disability affecting employers and societies worldwide [20]. It is high time to intensify research efforts using all available resources and methodologies in order to determine just how these conditions and their effects can be prevented, or once present, treated or managed effectively.
0304-3959/$36.00 Ó 2013 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.pain.2013.06.036
Ò
Commentary / PAIN 154 (2013) 1904–1905
References [1] Artus M, van der Windt DA, Jordan KP, Hay EM. Low back pain symptoms show a similar pattern of improvement following a wide range of primary care treatments: a systematic review of randomized clinical trials. Rheumatology 2010;49:2346–56. [2] Bevan S, Quadrello T, McGee R, Mahdon M, Vavrovsky A, Barham L. Fit for work? Musculoskeletal disorders in the European workforce: fit for work Europe. The Work Foundation; 2009. [3] Bultmann U, Sherson D, Olsen J, Hansen CL, Lund T, Kilsgaard J. Coordinated and tailored work rehabilitation: a randomized controlled trial with economic evaluation undertaken with workers on sick leave due to musculoskeletal disorders. J Occup Rehabil 2009;19:81–93. [4] Burton AK, Balague F, Cardon G, Eriksen HR, Henrotin Y, Lahad A, Leclerc A, Muller G, van der Beek AJ. European guidelines for prevention in low back pain. Eur Spine J 2006;15:S136–168. [5] Gross DP, Deshpande S, Werner EL, Reneman MF, Miciak MA, Buchbinder R. Fostering change in back pain beliefs and behaviors: when public education is not enough. Spine J 2012;12:979–88. [6] Henschke N, Maher CG, Refshauge KM, Herbert RD, Cumming RG, Bleasel J, York J, Das A, McAuley JH. Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study. BMJ 2008;337:a171. [7] Herman K, Barton C, Malliaras P, Morrissey D. The effectiveness of neuromuscular warm-up strategies, that require no additional equipment, for preventing lower limb injuries during sports participation: a systematic review. BMC Med 2012;10:75. [8] Hestbaek L, Leboeuf-Yde C, Kyvik KO, Manniche C. The course of low back pain from adolescence to adulthood: eight-year follow-up of 9600 twins. Spine 2006;31:468–72. [9] Hill JC, Whitehurst DG, Lewis M, Bryan S, Dunn KM, Foster NE, Konstantinou K, Main CJ, Mason E, Somerville S, Sowden G, Vohora K, Hay EM. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet 2011;378: 1560–71. [10] Hoe VC, Urquhart DM, Kelsall HL, Sim MR. Ergonomic design and training for preventing work-related musculoskeletal disorders of the upper limb and neck in adults. Cochrane Database Syst Rev 2012;8:CD008570. [11] Leboeuf-Yde C, Kyvik KO. At what age does low back pain become a common problem? A study of 29,424 individuals aged 12–41 years. Spine 1998;23:228–34. [12] Murphy L, Schwartz TA, Helmick CG, Renner JB, Tudor G, Koch G, Dragomir A, Kalsbeek WD, Luta G, Jordan JM. Lifetime risk of symptomatic knee osteoarthritis. Arthritis Rheum 2008;59:1207–13. [13] Pransky GS, Loisel P, Anema JR. Work disability prevention research: current and future prospects. J Occup Rehabil 2011;21:287–92. [14] Roos EM, Juhl CB. Osteoarthritis 2012 year in review: rehabilitation and outcomes. Osteoarthritis Cartilage 2012;20:1477–83. [15] Ropponen A, Svedberg P, Kalso E, Koskenvuo M, Silventoinen K, Kaprio J. A prospective twin cohort study of disability pensions due to musculoskeletal diagnoses in relation to stability and change in pain. PAINÒ 2013;154: 1966–72. [16] Shaw WS, Reme SE, Pransky G, Woiszwillo MJ, Steenstra IA, Linton SJ. The Pain Recovery Inventory of Concerns and Expectations Questionnaire. A psychosocial screening instrument to identify intervention needs among patients at elevated risk of back disability. J Occup Environ Med 2013. In press. [17] Skytthe A, Christiansen L, Kyvik KO, Bodker FL, Hvidberg L, Petersen I, Nielsen MM, Bingley P, Hjelmborg J, Tan Q, Holm NV, Vaupel JW, McGue M, Christensen K. The Danish Twin Registry: linking surveys, national registers, and biological information. Twin Res Hum Genet 2013;16:104–11. [18] Srinivas SV, Deyo RA, Berger ZD. Application of ‘‘less is more’’ to low back pain. Arch Int Med 2012;172:1016–20. [19] Verbeek J, Martimo KP, Karppinen J, Kuijer PP, Takala EP, Viikari-Juntura E. Manual material handling advice and assistive devices for preventing and treating back pain in workers: a Cochrane Systematic Review. Occup Environ Med 2012;69:79–80. [20] Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, Shibuya K, Salomon JA, Abdalla S, Aboyans V, Abraham J, Ackerman I, Aggarwal R, Ahn SY,
1905
Ali MK, Alvarado M, Anderson HR, Anderson LM, Andrews KG, Atkinson C, Baddour LM, Bahalim AN, Barker-Collo S, Barrero LH, Bartels DH, Basanez MG, Baxter A, Bell ML, Benjamin EJ, Bennett D, Bernabe E, Bhalla K, Bhandari B, Bikbov B, Bin Abdulhak A, Birbeck G, Black JA, Blencowe H, Blore JD, Blyth F, Bolliger I, Bonaventure A, Boufous S, Bourne R, Boussinesq M, Braithwaite T, Brayne C, Bridgett L, Brooker S, Brooks P, Brugha TS, Bryan-Hancock C, Bucello C, Buchbinder R, Buckle G, Budke CM, Burch M, Burney P, Burstein R, Calabria B, Campbell B, Canter CE, Carabin H, Carapetis J, Carmona L, Cella C, Charlson F, Chen H, Cheng AT, Chou D, Chugh SS, Coffeng LE, Colan SD, Colquhoun S, Colson KE, Condon J, Connor MD, Cooper LT, Corriere M, Cortinovis M, de Vaccaro KC, Couser W, Cowie BC, Criqui MH, Cross M, Dabhadkar KC, Dahiya M, Dahodwala N, Damsere-Derry J, Danaei G, Davis A, De Leo D, Degenhardt L, Dellavalle R, Delossantos A, Denenberg J, Derrett S, Des Jarlais DC, Dharmaratne SD, Dherani M, Diaz-Torne C, Dolk H, Dorsey ER, Driscoll T, Duber H, Ebel B, Edmond K, Elbaz A, Ali SE, Erskine H, Erwin PJ, Espindola P, Ewoigbokhan SE, Farzadfar F, Feigin V, Felson DT, Ferrari A, Ferri CP, Fevre EM, Finucane MM, Flaxman S, Flood L, Foreman K, Forouzanfar MH, Fowkes FG, Franklin R, Fransen M, Freeman MK, Gabbe BJ, Gabriel SE, Gakidou E, Ganatra HA, Garcia B, Gaspari F, Gillum RF, Gmel G, Gosselin R, Grainger R, Groeger J, Guillemin F, Gunnell D, Gupta R, Haagsma J, Hagan H, Halasa YA, Hall W, Haring D, Haro JM, Harrison JE, Havmoeller R, Hay RJ, Higashi H, Hill C, Hoen B, Hoffman H, Hotez PJ, Hoy D, Huang JJ, Ibeanusi SE, Jacobsen KH, James SL, Jarvis D, Jasrasaria R, Jayaraman S, Johns N, Jonas JB, Karthikeyan G, Kassebaum N, Kawakami N, Keren A, Khoo JP, King CH, Knowlton LM, Kobusingye O, Koranteng A, Krishnamurthi R, Lalloo R, Laslett LL, Lathlean T, Leasher JL, Lee YY, Leigh J, Lim SS, Limb E, Lin JK, Lipnick M, Lipshultz SE, Liu W, Loane M, Ohno SL, Lyons R, Ma J, Mabweijano J, MacIntyre MF, Malekzadeh R, Mallinger L, Manivannan S, Marcenes W, March L, Margolis DJ, Marks GB, Marks R, Matsumori A, Matzopoulos R, Mayosi BM, McAnulty JH, McDermott MM, McGill N, McGrath J, Medina-Mora ME, Meltzer M, Mensah GA, Merriman TR, Meyer AC, Miglioli V, Miller M, Miller TR, Mitchell PB, Mocumbi AO, Moffitt TE, Mokdad AA, Monasta L, Montico M, Moradi-Lakeh M, Moran A, Morawska L, Mori R, Murdoch ME, Mwaniki MK, Naidoo K, Nair MN, Naldi L, Narayan KM, Nelson PK, Nelson RG, Nevitt MC, Newton CR, Nolte S, Norman P, Norman R, O’Donnell M, O’Hanlon S, Olives C, Omer SB, Ortblad K, Osborne R, Ozgediz D, Page A, Pahari B, Pandian JD, Rivero AP, Patten SB, Pearce N, Padilla RP, PerezRuiz F, Perico N, Pesudovs K, Phillips D, Phillips MR, Pierce K, Pion S, Polanczyk GV, Polinder S, Pope 3rd CA, Popova S, Porrini E, Pourmalek F, Prince M, Pullan RL, Ramaiah KD, Ranganathan D, Razavi H, Regan M, Rehm JT, Rein DB, Remuzzi G, Richardson K, Rivara FP, Roberts T, Robinson C, De Leon FR, Ronfani L, Room R, Rosenfeld LC, Rushton L, Sacco RL, Saha S, Sampson U, SanchezRiera L, Sanman E, Schwebel DC, Scott JG, Segui-Gomez M, Shahraz S, Shepard DS, Shin H, Shivakoti R, Singh D, Singh GM, Singh JA, Singleton J, Sleet DA, Sliwa K, Smith E, Smith JL, Stapelberg NJ, Steer A, Steiner T, Stolk WA, Stovner LJ, Sudfeld C, Syed S, Tamburlini G, Tavakkoli M, Taylor HR, Taylor JA, Taylor WJ, Thomas B, Thomson WM, Thurston GD, Tleyjeh IM, Tonelli M, Towbin JA, Truelsen T, Tsilimbaris MK, Ubeda C, Undurraga EA, van der Werf MJ, van Os J, Vavilala MS, Venketasubramanian N, Wang M, Wang W, Watt K, Weatherall DJ, Weinstock MA, Weintraub R, Weisskopf MG, Weissman MM, White RA, Whiteford H, Wiersma ST, Wilkinson JD, Williams HC, Williams SR, Witt E, Wolfe F, Woolf AD, Wulf S, Yeh PH, Zaidi AK, Zheng ZJ, Zonies D, Lopez AD, Murray CJ, AlMazroa MA, Memish ZA. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012;380:2163–96.
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Jan Hartvigsen Institute of Sports Science and Clinical Biomechanics and Nordic Institute of Chiropractic and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark ⇑ Tel.: +45 65504522; fax: +45 6550 3480. E-mail address: [email protected]
PAIN 154 (2013) 1904–1905
www.elsevier.com/locate/pain
Commentary
Musculoskeletal disorders and work disability From work we gain social contact, income, stability, purpose, and opportunities to demonstrate our skills and achievements. However, all over the world a large number of people are unable to work because of disability arising from musculoskeletal disorders (MSD) such as back pain, neck pain, and osteoarthritis. These conditions are the most common causes of medically diagnosed sick leave and health-related early retirement in Europe [2]. We now know that MSD start early in life [11,12], and those persons who have experienced pain during childhood and adolescence have an increased risk of pain and disability later in life [8,12]. In this issue of PAIN, Ropponen et al. present data supporting that one-time reporting of MSD in the form of pain in the back, shoulders, or neck that interferes with the ability to carry out normal duties predicts increased risk of work disability and award of disability pension for MSD, osteoarthritis, and back pain up to 23 years later [15]. The article adds to the growing body of evidence indicating that an episode of musculoskeletal pain is associated not only with future episodes of annoying pain and trouble [6], but also with severe social consequences such as inability to work. Primary prevention of MSD should therefore have a high priority everywhere, but unfortunately there is little evidence for the effectiveness of most prevention initiatives. For instance, programs in the workplace involving instructions in manual materials handling [19] or use of ergonomic aids, training in the use of these aids, and implementation of breaks [10] have shown little if any effect in preventing back and neck pain and upper limb disorders in workers. Burton et al. found that overall there was no evidence and little scope for primary prevention of back pain and recommended that prevention efforts should be directed at minimizing its consequences [4]. Injuries in sports also contribute substantially to lower limb musculoskeletal pain and osteoarthritis [12], and primary prevention of some injuries may be feasible through rigorous implementation of neuromuscular warm-up exercises, but this has not been tested on a large scale [7]. Intuitively one would then advocate aggressive early treatment for the first and perhaps inevitable episodes of MSD to avoid unfortunate long-term consequences and chronicity, but paradoxically, current best practice evolves around a ‘‘less is more’’ approach discouraging early aggressive treatment [18]. This is because commonly used therapies such as pain medication, manual treatment, and structured exercise programs may relieve and shorten an episode of pain, but there is little evidence that they significantly alter the natural long-term course of MSD [1]. Also for patients with early signs of osteoarthritis, simple interventions such as patient education, exercise, and weight loss are recommended as first-line treatment, reserving therapist-delivered passive interventions and surgery to fewer patients at later stages of the disease [14]. q
DOI of original article: http://dx.doi.org/10.1016/j.pain.2013.05.029
Prevention of work disability in persons with MSD is a complex problem that goes beyond the conventional biomedical paradigm and treatment for episodes of pain. Evidence suggests that we need to adopt a broader disability paradigm that takes into account the complex interaction of biological, psychological, and social factors, as well as interplays between several stakeholders (employer, insurer, and the health care providers) who interact with the patient during the disability process [13]. Primary prevention of work disability involves helping patients stay at work in spite of having a MSD, and secondary work disability prevention involves helping patients return to work. Evidence suggests that strategies and interventions involving all stakeholders including the workplace may be cost effective [3]. Finally, it has become apparent that one size does not fit all when it comes to treatment for MSD and prevention of disability. Recent advances include stratifying patients for care through screening for known biopsychosocial risk factors using reliable and valid tools, and then applying interventions designed to target their specific problems and risk profile [9]. The challenge is to develop appropriately validated instruments that stratify patients into streams of care matching their risk profile so their chance of a good outcome is optimized [16]. In addition, beliefs and behaviors at the population level may be influenced through mass media campaigns, if these are delivered efficiently [5]. In the Scandinavian countries, we have exceptional opportunities to perform registry-based research because of the unique personal identification number assigned to all persons with permanent residence. This number facilitates the linkage of registries with participant-reported information (such as twin registries) and public administrative registries (such as pension or hospital registries) for research purposes. Registry linkage is supported by legislation, and the population base of these registries allows sophisticated analyses using advanced multivariate statistical techniques due to their large sample sizes. Particularly useful methodologies can be applied in population-based twin registries where, such as in the study by Ropponen et al., effects of familial and genetic confounding can be controlled for [17]. Of course registry-based research also has its drawbacks. For example, detailed descriptions including objective measures of health and detailed measures of exposures are not always included. In the case of most MSD, however, self-report is the gold standard, making them ideally suited for research using population-based registries. Through registry-based research, we have long known that MSD are very prevalent; we now also know that they have profound impact on quality of life for individuals and on disability affecting employers and societies worldwide [20]. It is high time to intensify research efforts using all available resources and methodologies in order to determine just how these conditions and their effects can be prevented, or once present, treated or managed effectively.
0304-3959/$36.00 Ó 2013 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.pain.2013.06.036
Ò
Commentary / PAIN 154 (2013) 1904–1905
References [1] Artus M, van der Windt DA, Jordan KP, Hay EM. Low back pain symptoms show a similar pattern of improvement following a wide range of primary care treatments: a systematic review of randomized clinical trials. Rheumatology 2010;49:2346–56. [2] Bevan S, Quadrello T, McGee R, Mahdon M, Vavrovsky A, Barham L. Fit for work? Musculoskeletal disorders in the European workforce: fit for work Europe. The Work Foundation; 2009. [3] Bultmann U, Sherson D, Olsen J, Hansen CL, Lund T, Kilsgaard J. Coordinated and tailored work rehabilitation: a randomized controlled trial with economic evaluation undertaken with workers on sick leave due to musculoskeletal disorders. J Occup Rehabil 2009;19:81–93. [4] Burton AK, Balague F, Cardon G, Eriksen HR, Henrotin Y, Lahad A, Leclerc A, Muller G, van der Beek AJ. European guidelines for prevention in low back pain. Eur Spine J 2006;15:S136–168. [5] Gross DP, Deshpande S, Werner EL, Reneman MF, Miciak MA, Buchbinder R. Fostering change in back pain beliefs and behaviors: when public education is not enough. Spine J 2012;12:979–88. [6] Henschke N, Maher CG, Refshauge KM, Herbert RD, Cumming RG, Bleasel J, York J, Das A, McAuley JH. Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study. BMJ 2008;337:a171. [7] Herman K, Barton C, Malliaras P, Morrissey D. The effectiveness of neuromuscular warm-up strategies, that require no additional equipment, for preventing lower limb injuries during sports participation: a systematic review. BMC Med 2012;10:75. [8] Hestbaek L, Leboeuf-Yde C, Kyvik KO, Manniche C. The course of low back pain from adolescence to adulthood: eight-year follow-up of 9600 twins. Spine 2006;31:468–72. [9] Hill JC, Whitehurst DG, Lewis M, Bryan S, Dunn KM, Foster NE, Konstantinou K, Main CJ, Mason E, Somerville S, Sowden G, Vohora K, Hay EM. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet 2011;378: 1560–71. [10] Hoe VC, Urquhart DM, Kelsall HL, Sim MR. Ergonomic design and training for preventing work-related musculoskeletal disorders of the upper limb and neck in adults. Cochrane Database Syst Rev 2012;8:CD008570. [11] Leboeuf-Yde C, Kyvik KO. At what age does low back pain become a common problem? A study of 29,424 individuals aged 12–41 years. Spine 1998;23:228–34. [12] Murphy L, Schwartz TA, Helmick CG, Renner JB, Tudor G, Koch G, Dragomir A, Kalsbeek WD, Luta G, Jordan JM. Lifetime risk of symptomatic knee osteoarthritis. Arthritis Rheum 2008;59:1207–13. [13] Pransky GS, Loisel P, Anema JR. Work disability prevention research: current and future prospects. J Occup Rehabil 2011;21:287–92. [14] Roos EM, Juhl CB. Osteoarthritis 2012 year in review: rehabilitation and outcomes. Osteoarthritis Cartilage 2012;20:1477–83. [15] Ropponen A, Svedberg P, Kalso E, Koskenvuo M, Silventoinen K, Kaprio J. A prospective twin cohort study of disability pensions due to musculoskeletal diagnoses in relation to stability and change in pain. PAINÒ 2013;154: 1966–72. [16] Shaw WS, Reme SE, Pransky G, Woiszwillo MJ, Steenstra IA, Linton SJ. The Pain Recovery Inventory of Concerns and Expectations Questionnaire. A psychosocial screening instrument to identify intervention needs among patients at elevated risk of back disability. J Occup Environ Med 2013. In press. [17] Skytthe A, Christiansen L, Kyvik KO, Bodker FL, Hvidberg L, Petersen I, Nielsen MM, Bingley P, Hjelmborg J, Tan Q, Holm NV, Vaupel JW, McGue M, Christensen K. The Danish Twin Registry: linking surveys, national registers, and biological information. Twin Res Hum Genet 2013;16:104–11. [18] Srinivas SV, Deyo RA, Berger ZD. Application of ‘‘less is more’’ to low back pain. Arch Int Med 2012;172:1016–20. [19] Verbeek J, Martimo KP, Karppinen J, Kuijer PP, Takala EP, Viikari-Juntura E. Manual material handling advice and assistive devices for preventing and treating back pain in workers: a Cochrane Systematic Review. Occup Environ Med 2012;69:79–80. [20] Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, Shibuya K, Salomon JA, Abdalla S, Aboyans V, Abraham J, Ackerman I, Aggarwal R, Ahn SY,
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Jan Hartvigsen Institute of Sports Science and Clinical Biomechanics and Nordic Institute of Chiropractic and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark ⇑ Tel.: +45 65504522; fax: +45 6550 3480. E-mail address: [email protected]