Treatment of the chronic sequela that persist after a mild traumatic brain injury has been challenging with limited efficacy. The aim of this work was to report outcomes obtained from persons who met the criteria of persisting post-concussive symptoms (PPCS), utilizing a novel combination of modalities in a structured neurorehabilitation program. This work was designed as a retrospective, pre-post chart review of objective and subjective measures collected from 62 outpatients with PPCS a mean of 2.2 years post-injury, before and after a multi-modal 5-day treatment protocol. The subjective outcome measure was the 27-item modified Graded Symptom Checklist (mGSC). Objective outcome measures were motor speed/reaction time, coordination, cognitive processing, visual acuity, and vestibular function. Interventions included non-invasive neuromodulation, neuromuscular re-education exercises, gaze stabilization exercises, orthoptic exercises, cognitive training, therapeutic exercises, and single/multi-axis rotation therapy. Pre-post differences in measures were analyzed using the Wilcoxon signed-rank test, with effect size determined by the rank-biserial correlation coefficient. Pre-post treatment comparisons for the subjective mGSC overall, combined symptom measures, individual components of the mGSC, and cluster scores significantly improved for all items. Moderate strength relationships were observed for the mGSC composite score, number of symptoms, average symptom score, feeling in a "fog," "don't feel right," irritability, and physical, cognitive, and affective cluster scores. Objective symptom assessment significantly improved for trail making, processing speed, reaction time, visual acuity, and Standardized Assessment of Concussion. Patients suffering from PPCS ∼2 years after injury may have significant benefits with some moderate effect sizes from an intensive, multi-modal neurorehabilitation program.

Objective To present the evaluation of 12 rehabilitation cases as a case series in sports-related concussion. Background Sport-related concussion is a common injury in the NHL. While most athletes recover within few weeks of sustaining a mild head injury, some still experience persistent symptoms for months or years after following recommended recovery and return to play guidelines. Design/Methods Twelve male NHL athletes (6/6 active/retired; mean age/height/weight/symptom duration/#concussions [SD]: 33.4 years [7.9]: 185.8 cm [5.1]: 94.8 kg [14.6]; 121 wks: [156]; 4.3 [2.3]) with persistent but mild post-concussion symptoms were treated for 10 sessions at an outpatient neurorehabilitation center specializing in functional neurology. The athletes were evaluated before- and after treatment utilizing the C3 Logix platform. The interventions included joint manipulation, neuromuscular re-education, vestibular rehabilitation in a whole-body off-axis rotational device, orthoptic exercises, and cognitive training. Graded Symptoms Checklist (0-162), Digit-Symbol Coding, Simple- and Choice Reaction Time, and Trail Making Test A/B were analyzed in Graphpad PRISM. 9.1.0 by multiple paired t-tests with Holm-Sidak corrections. Results are reported as differences-of-means pre- to post-treatment (SE) with Cohen's d effect sizes [ES] (0.2, 0.5, 0.8 represents small, medium, and large effect sizes, respectively). p-values <0.05 were considered significant. Results Graded Symptom Checklist score (p < 0.001): -25.1 (4.0) [1.83]; Digit-Symbol Matching speed (#symbols) (p = 0.03): 6.2 (1.9) [0.92]; Simple reaction time (ms) (p = 0.03): -74.7 (22.9) [0.94]; Choice reaction time (ms) (p = 0.009): -106.1 (26.0) [1.18]; Trails A (s) (p = 0.04) [0.80]: -2.6 (0.9); and Trails B (s) (p = 0.04): -6.0 (2.2) [0.79]. Conclusions The present case series shows that a functional neurology approach of multimodal short duration intensive therapies can produce clinically meaningful improvements with large and very large effect sizes, in both the concussion symptoms and neurocognitive performance, of 12 professional NHL players experiencing symptom stagnation.

BACKGROUNDWhile the psychosocial work environment within the hospital sector is a topic of great debate, surveys assessing stress often do not differentiate between stress related to work- and private life. Identifying risk factors associated with these domains of daily life would help improve policies as well as target relevant treatment options. Therefore, the aim of this study was to evaluate associations between stress during to work- and private time with Cohen's Perceived Stress Scale (CPSS).METHODSPerceived stress was assessed by the full version of CPSS (scores 0-40) as well as by two single-item questions related to stress related to work- and private life, respectively. Associations between these single-items and CPSS were modelled using general linear models controlling for lifestyle factors.RESULTSOverall, stress due to both work- and private time was strongly associated with CPSS scores. In the full population (n = 3,600), "never experiencing stress" during both work- and private time was associated with low stress scores (6.0, 95%CI 5.1-6.9). "Never experiencing" work-related stress but experiencing private time stress "very often" was associated with high stress scores (22.4, CI 19.8-25.1). Likewise, experiencing work-related stress "very often" but "never experiencing" private time stress was also associated with high stress scores (22.2, CI 20.3-24.2). Lastly, Spearman's r between the full CPSS and the two single-item questions about work- and private time stress were 0.62 (p <  0.0001) and 0.52 (p <  0.0001), respectively, while the two items were only weakly correlated (r = 0.32).CONCLUSIONThe present study shows that perceived stress due to both work and private time is strongly associated with Cohen's Perceived Stress Scale scores. The results illustrate the feasibility of using single-item questions related to work- and private time in identifying domain-specific risk factors for psychosocial stress.

The present study aims to evaluate symptom changes in a heterogeneous cohort 798 patients with complex CNS disorders.

The present study showed a significant, albeit weak, relationship between quality of life and GSC score. Short questions that provide meaningful insight into the wellbeing of the patient allow for long distance progress monitoring and follow-up consultations. More studies are needed to establish exactly what questions provide the best possible information as the present study is limited by its retrospective design using chart review data.

The results of the present case-series study suggest clinically relevant improvements in neurocognitive measures and subjective symptoms in individuals with PCS following a multi-modal 5-day rehabilitation program.

The incidence of occupational back injury in the healthcare sector remains high despite decades of efforts to reduce such injuries. This prospective cohort study investigated the risk factors for back injury during patient transfer. Healthcare workers (n = 2080) from 314 departments at 17 hospitals in Denmark replied to repeated questionnaires sent every 14 days for one year. Using repeated-measures binomial logistic regression, controlling for education, work, lifestyle, and health, the odds for back injury (i.e., sudden onset episodes) were modeled. On the basis of 482 back injury events, a higher number of patient transfers was an important risk factor, with odds ratio (OR) 3.58 (95% confidence interval (CI) 2.51–5.10) for 1–4 transfers per day, OR 7.60 (5.14–11.22) for 5–8 transfers per day, and OR 8.03 (5.26–12.27) for 9 or more transfers per day (reference: less than 1 per day). The lack of necessary assistive devices was a common phenomenon during back injury events, with the top four lacking devices being sliding sheets (30%), intelligent beds (19%), walking aids (18%), and ceiling lifts (13%). For the psychosocial factors, poor collaboration between and support from colleagues increased the risk for back injury, with OR 3.16 (1.85–5.39). In conclusion, reducing the physical burden in terms of number of daily patient transfers, providing the necessary assistive devices, and cultivating good collaboration between colleagues are important factors in preventing occupational back injuries among healthcare workers.

Background: While acute stress and pain are part of our inherent survival mechanisms, persistent stress and pain can negatively impact health and well-being. This may also lead to poor sleep and thus a lack of recovery. This study investigated the influence of stress and musculoskeletal pain on sleep quality. Methods: A total of 3,593 Danish hospital workers replied to a questionnaire about work and health. Pain intensity was evaluated using subjective values as an average of 9 body parts. Stress was assessed using the full version of Cohen's Perceived Stress scale. Sleep quality was rated using 3 questions on sleep characteristics. Associations between stress and pain (mutually adjusted predictors) and sleep (outcome) were modeled using binary logistic regression controlling for gender, age, education, BMI and smoking. Results: The risk ratio of moderate stress (compared to no/low stress) on poor sleep was 1.27 (CI 1.26-1.29), whereas the risk ratio of high stress on poor sleep was 1.87 (CI 1.83-1.91). Similarly, for pain, the risk ratio of moderate pain (compared to no/low pain) on poor sleep was 1.18 (95% CI 1.16-1.19), whereas the risk ratio of a high pain score on poor sleep was 1.48 (95% CI 1.44-1.52). Conclusion: This study demonstrates that both stress and musculoskeletal pain are associated with poor sleep among hospital workers. Hospital management should consider implementing strategies for preventing stress and musculoskeletal pain to improve the overall health and workability among hospital workers.

BACKGROUND AND OBJECTIVE:Musculoskeletal pain is common in the population. Negative beliefs about musculoskeletal pain and physical activity may lead to avoidance behavior resulting in absence from work. The present study investigates the influence of fear avoidance beliefs on long-term sickness absence.METHODS:Workers of the general working population with musculoskeletal pain (low back, neck/shoulder, and/or arm/hand pain; n = 8319) from the Danish Work Environment Cohort Study were included. Long-term sickness absence data were obtained from the Danish Register for Evaluation and Marginalization (DREAM). Time-to-event analyses (cox regression) controlled for various confounders estimated the association between fear avoidance beliefs (very low, low, moderate [reference category], high, and very high) at baseline and long-term sickness absence (LTSA; ≥6 consecutive weeks) during a 2-year follow-up.RESULTS:During the 2-year follow-up, 10.2% of the workers experienced long-term sickness absence. In the fully adjusted model, very high-level fear avoidance increased the risk of LTSA with hazard ratio (HR) of 1.48 (95% CI 1.15-1.90). Similar results were seen analyses stratified for occupational physical activity, i.e., sedentary workers (HR 1.72 (95% CI 1.04-2.83)) and physically active workers (HR 1.48 (95% CI 1.10-2.01)).CONCLUSION:A very high level of fear avoidance is a risk factor for long-term sickness absence among workers with musculoskeletal pain regardless of the level of occupational physical activity. Future interventions should target fear avoidance beliefs through information and campaigns about the benefits of staying active when having musculoskeletal pain.

BACKGROUND AND AIMS:The association between different types of physical activity and fear-avoidance beliefs remains unclear. This study investigates the association between work-related and leisure-time physical activity with fear-avoidance beliefs in the general working population. METHODS:Currently employed wage earners (n=10,427) from the 2010 round of the Danish Work Environment Cohort Study replied to questions about work, lifestyle and health. General linear models controlling for lifestyle, psychosocial work factors, education, pain, medication-use and chronic diseases tested associations of work-related and leisure-time physical activity (explanatory variables) with fear-avoidance beliefs (outcome variable, scale 0-100). RESULTS:The level of fear-avoidance was 41.7 (SD 27.3), 38.0 (SD 26.9) and 54.3 (SD 27.7) among the general working population, a subgroup of pain-free individuals, and a subgroup with back disease, respectively. In the general working population, the level of fear-avoidance among those with low, moderate and high physical activity during leisure were 47 [95% confidence intervals (CI) 45-49], 44 (95% CI 42-46) and 43 (95% CI 41-45), and physical activity at work were 40 (95% CI 39-42), 44 (95% CI 42-46) and 49 (95% CI 48-51), respectively. Individuals with back disease and a high level of physical activity at work showed the overall highest level of fear-avoidance whereas pain-free individuals with a low level of physical activity at work showed the overall lowest level of fear-avoidance. CONCLUSIONS:Physical activity during work and leisure shows contrasting associations with fear-avoidance beliefs. While high physical activity during leisure is associated with lower levels, high physical activity at work is associated with higher levels of fear-avoidance. IMPLICATIONS:The present results may reflect some deeply rooted negative beliefs about pain and work in the population. On the societal level, campaigns may be a possible way forward as these have shown to improve beliefs about musculoskeletal pain and work.

Work-related musculoskeletal pain and stress are both highly prevalent in the working environment and relate well to the biopsychosocial model. While the onset of musculoskeletal pain is often dependent on the biological element of the biopsychosocial model, chronic pain is often influenced by psychological and social factors. Similarly, stress is also influenced by biological, psychological, and social factors. This study investigates the possibility of social capital being a buffer for stress and musculoskeletal pain in a group of female laboratory technicians. Female laboratory technicians (n = 500) replied to questions about stress (Cohens Perceived Stress Scale-10), musculoskeletal pain (0-10 visual analog scale), and social capital at the workplace (bonding [in teams], bridging [between teams], and linking [between teams and leaders]). Outcome variables were stress and musculoskeletal pain and the predictor variable was social capital. General linear models tested the association of the 3 types of social capital (predictor variables) with stress and pain (mutually adjusted outcome variables). Analyses were controlled for age, lifestyle (body mass index, smoking), seniority, and working hours per week. For stress as outcome, moderate and high bonding social capital were different from low social capital with -2.04 (95% confidence interval [CI] -3.33 to -0.76) and -4.56 (95% CI -5.84 to -3.28) points on the Perceived Stress Scale of 0 to 42, respectively. Similarly, moderate and high bridging social capital were different from low social capital with -1.50 (95% CI -2.76 to -0.24) and -4.39 (95% CI -5.75 to -3.03), respectively. For linking, only high social was significantly different from low with -2.94 (95% CI -4.28 to -1.60). None of the 3 types of social capital was associated with musculoskeletal pain. Higher levels of social capital at the workplace appear to buffer against stress, but not against musculoskeletal pain. Intervention studies should investigate whether improving bonding, bridging, and linking social capital at the workplace may be a viable strategy to prevent or reduce work-related stress.

BACKGROUND:More than one third of nurses experience musculoskeletal pain several times during a normal work week. Consistent use of assistive devices during patient transfers is associated with a lower risk of occupational back injuries and low back pain (LBP). While uncertainties exist regarding which type of assistive devices most efficiently prevent LBP, exposure assessments using technological advancements allow for quantification of muscle load and body positions during common work tasks.OBJECTIVE:The main objectives of this study are (1) to quantify low back and neck/shoulder muscle load in Danish nurses during patient transfers performed with different types of assistive devices, and (2) to combine the exposure profile for each type of assistive device with fortnightly questionnaires to identify the importance of muscle load (intensity and frequency of transfers) and body position (degree of back inclination and frequency) on LBP intensity and risk of back injury during a patient transfer.METHODS:A combination of technical measurements (n=50) and a prospective study design (n=2000) will be applied on a cohort of female nurses in Danish hospitals. The technical measurements will be comprised of surface electromyography and accelerometers, with the aim of quantifying muscle load and body positions during various patient transfers, including different types of assistive devices throughout a workday. The study will thereby gather measurements during real-life working conditions. The prospective cohort study will consist of questionnaires at baseline and 1-year follow-up, as well as follow-up via email every other week for one year on questions regarding the frequency of patient transfers, use of assistive devices, intensity of LBP, and back injuries related to patient transfers. The objective measurements on muscle load and body positions during patient handlings will be applied to the fortnightly replies regarding frequency of patient transfer and use of different assistive devices, in order to identify risk factors for back injuries related to patient transfers and intensity of LBP.RESULTS:Data collection is scheduled to commence during the winter of 2017.CONCLUSIONS:The design of this study is novel in its combination of technical measurements applied on a prospective cohort, and the results will provide important information about which assistive devices are associated with intensity of LBP and risk of back injury related to patient transfers. Furthermore, this study will shed light on the dose-response relationship between intensity, duration, and frequency of patient transfers and the intensity of LPB in Danish nurses, and will thereby help to guide and improve electronic health practices among this population.

Objectives . The present study investigates the effect of workplace- versus home-based physical exercise on muscle reflex response to sudden trunk perturbation among healthcare workers. Methods . Two hundred female healthcare workers (age: 42 [SD 11], BMI: 24 [SD 4], and pain intensity: 3.1 [SD 2.2] on a scale of 0–10) from 18 departments at three hospitals were randomized at the cluster level to 10 weeks of (1) workplace physical exercise (WORK) performed in groups during working hours for 5 × 10 minutes per week and up to 5 group-based coaching sessions on motivation for regular physical exercise, or (2) home-based physical exercise (HOME) performed during leisure time for 5 × 10 minutes per week. Mechanical and neuromuscular (EMG) response to randomly assigned unloading and loading trunk perturbations and questions of fear avoidance were assessed at baseline and 10-week follow-up. Results . No group by time interaction for the mechanical trunk response and EMG latency time was seen following the ten weeks ( 𝑃 = 0.17–0.75). However, both groups demonstrated within-group changes ( 𝑃 < 0.05 ) in stopping time during the loading and unloading perturbation and in stopping distance during the loading perturbation. Furthermore, EMG preactivation of the erector spinae and fear avoidance were reduced more following WORK than HOME (95% CI − 2.7– − 0.7 ( 𝑃 < 0.05 ) and − 0.14 ( − 0.30 to 0.02) ( 𝑃 = 0.09 )), respectively. WORK and HOME performed 2.2 (SD: 1.1) and 1.0 (SD: 1.2) training sessions per week, respectively. Conclusions . Although training adherence was higher following WORK compared to HOME this additional training volume did not lead to significant between-group differences in the responses to sudden trunk perturbations. However, WORK led to reduced fear avoidance and reduced muscle preactivity prior to the perturbation onset, compared with HOME. This trial is registered with Clinicaltrials.gov (NCT01921764).

Objective: To investigate whether bodyweight exercises can induce comparable levels of muscle activity as conventional machine exercises in chronic stroke patients.Methods: Eighteen patients performed three repetitions of bilateral- and unilateral machine leg press and the bodyweight exercises chair rise and hip thrust. Surface electromyography (EMG) was recorded from 10 lower extremity muscles and normalized to maximal EMG (nEMG) of the non-paretic leg.Results: For the paretic leg, the bodyweight exercises showed comparable levels of nEMG in 6 out of 10 muscles compared with the bilateral leg press. Vastus lateralis nEMG was higher during bilateral leg press compared with hip thrust (38% [95% CI 33-42] vs. 10% [95% CI 6-15], p < 0.0001) and chair rise (38% [95% CI 33-42] vs. 27% [95% CI 22-32], p < 0.0001). Vastus medialis nEMG was higher during bilateral leg press compared with hip thrust (34% [95% CI 27-40] vs. 8% [95% CI 2-15], p < 0.0001). Unilateral leg press showed higher nEMG compared with bilateral leg press in biceps femoris (28% [95% CI 23-34] vs. 19% [95% CI 13-24], p = 0.0009), gluteus maximus (32% [95% CI 23-41] vs. 25% [95% CI 16-34], p < 0.05), and vastus medialis (42% [95% CI 36-48] vs. 34% [95% CI 27-40], p = 0.0013).Discussion: In patients with chronic stroke, bodyweight exercises activate the majority of the lower limb muscles to comparable levels as bilateral leg press performed in machine. In addition, unilateral leg press was superior to the bilateral leg press and both bodyweight exercises.

Background Knowledge of factors associated with chronic pain is necessary for preventive strategies. The present study investigates biopsychosocial differences, with specific focus on rate of force development (RFD) and work ability, between workers with and without chronic upper limb pain. Methods Eighty-two male slaughterhouse workers, 49 with chronic upper limb pain and 33 pain-free controls participated in the study. Maximal muscle strength, RFD, and muscle activity was determined from fast and forceful maximal voluntary contractions for the shoulder and hand. Participants filled out a questionnaire on work ability (work ability index), work disability (Work module of DASH questionnaire), fear avoidance, and self-rated health. Additionally, pressure pain threshold (PPT) was measured in muscles of the arm, shoulder and lower leg. Results Muscle strength and RFD (determined within time intervals of 30, 50, 100, and 200 ms relative to onset of contraction) was 28 % and 58–78 % lower, respectively, in workers with chronic pain compared with pain-free controls, and paralleled by reduced muscle activity (all p < 0.001). Workers with chronic pain had lower PPT of the arm, shoulder and lower leg ( p < 0.01), and reported impaired work ability index score and general health along with higher work disability and fear avoidance compared with controls (all p < 0.0001). No differences were observed between the groups in regard to age, BMI, physical activity level, job position and duration of slaughterhouse work (all p > 0.4). Conclusions Chronic upper limb pain was paralleled by reduced neuromuscular function of the shoulder and hand along with impaired work ability, work disability and general health. Future studies on chronic pain management at the workplace should carefully consider the biopsychosocial nature of pain when designing and implementing preventive strategies.

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People with chronic musculoskeletal pain often experience pain-related fear of movement and avoidance behavior. The FearAvoidance model proposes a possible mechanism at least partly explaining the development and maintenance of chronic pain. People who interpret pain during movement as being potentially harmful to the organism may initiate a vicious behavioral cycle by generating pain-related fear of movement accompanied by avoidance behavior and hyper-vigilance. This study investigates whether an individually adapted multifactorial approach comprised of biopsychosocial elements, with a focus on physical exercise, mindfulness, and education on pain and behavior, can decrease work-related fear-avoidance beliefs. As part of a large scale 10-week worksite randomized controlled intervention trial focusing on company initiatives to combat workrelated musculoskeletal pain and stress, we evaluated fear-avoidance behavior in 112 female laboratory technicians with chronic neck, shoulder, upper back, lower back, elbow, and hand/wrist pain using the Fear-Avoidance Beliefs Questionnaire at baseline, before group allocation, and again at the post intervention follow-up 10 weeks later. A significant group by time interaction was observed (P<0.05) for work-related fear-avoidance beliefs. The between-group difference at follow-up was –2.2 (–4.0 to –0.5), corresponding to a small to medium effect size (Cohen’s d=0.30). Our study shows that work-related, but not leisure time activity-related, fear-avoidance beliefs, as assessed by the Fear-avoidance Beliefs Questionnaire, can be significantly reduced by 10 weeks of physical-cognitive-mindfulness training in female laboratory technicians with chronic pain. Abbreviations: FAB = Fear-avoidance beliefs, FABQ = Fear-avoidance beliefs questionnaire, PCMT = hysical-cognitivemindfulness training, PRF = Pain-related fear, REF = Reference.

Background: Cognitive and physical performance can be negatively affected by chronic pain. This study evaluates the effect of combined physical-, cognitive-, and mindfulness training (PCMT) on cognitive and physical performance. Methods: From a large pharmaceutical company in Denmark we randomly allocated 112 female laboratory technicians with chronic upper limb pain to group-based PCMT at the worksite or a reference group for 10 weeks. Neurocognitive performance was measured by the computerized central nervous system vital signs neurocognitive assessment battery. Physical function was assessed in terms of shoulder external rotation strength and rate of force development in a custom-made dynamometer setup. Results: No between-group differences (least square means [95% confidence interval]) from baseline to follow-up could be detected in any of the neurocognitive domains as measured by the central nervous system vital signs neurocognitive assessment battery, for example, Psychomotoer Speed 1.9 (−1.0 to 4.7), Reaction Time −4.0 (−19.5 to 11.6), Complex Attention −0.3 (−1.9 to 1.4), and Executive Function −0.2 (−3.5 to 3.0). Similarly, we found no change in maximal voluntary isometric strength −0.63 (−4.8 to 3.6), or rate of force development 14.8 (−12.6 to 42.2) of the shoulder external rotators. Finally, test–retest reliability of maximal voluntary contraction and rate of force development shoulder external rotation showed high reliability at 0 to 30 ms, 0 to 50 ms, 0 to 100 ms, and 0 to 200 ms with ICCs at 0.95, 0.92, 0.93, 0.92, and 0.91, respectively. Conclusion: Ten weeks of PCMT did not improve neurocognitive or physical performance.

BACKGROUND We aimed to determine the association between work, health, and lifestyle with regular use of pain medication due to musculoskeletal disorders in the general working population. METHODS Currently employed wage earners (N = 10,024) replied to questions about health, work, and lifestyle. The odds for regularly using medication for musculoskeletal disorders were modeled using logistic regression controlled for various confounders. RESULTS Pain intensity increased the odds for using pain medication in a dose-response fashion. With seated work as reference, the odds for using pain medication were 1.26 (95%CI: 1.09-1.47) for workers engaged in standing or walking work that is not strenuous and 1.59 (95%CI: 1.39-1.82) for workers engaged in standing or walking work with lifting tasks or heavy and fast strenuous work. CONCLUSIONS Workers with higher levels of physical activity at work are more likely to use pain medication on a regular basis for musculoskeletal disorders, even when adjusting for pain intensity, lifestyle, and influence at work. Am. J. Ind. Med. 59:934-941, 2016. © 2016 Wiley Periodicals, Inc.