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Review of occupational exposures which may result in the development of a chronic low-back disease with pain

Against the background of recurrent discussions of the concrete exposures required for recognition of chronic low-back diseases with pain, Labour Market Insurance (Arbejdsmarkedets Erhvervssikring) and the Occupational Diseases Committee have found that there is a need for a review, in the form of a scientific reference document, which assesses the possible causal association between the development of chronic low-back diseases with pain and preceding occupational  exposures.

Chronic low-back diseases with pain (lumbago/sciatica, lumbar prolapsed disc, degenerative low-back disease) are already included on the list of occupational diseases (item B.1.) for exposures in the form of back-loading lifting work involving lifting/upward pulling of heavy objects and a total daily lifting quantity of many tonnes for a considerable number of years (B.1.(a)); back-loading lifting work with generally occurring, extremely heavy and awkward single lifts and a total daily lifting quantity of several tonnes for a considerable number of years (B.1.(b)); back-loading care work with many daily handlings of adults or older handicapped children for a considerable number of years  (B.1.(c)); and back-loading, daily exposure to whole-body vibrations from heavily vibrating vehicles for a considerable number of years (B.1.(d)).

Only chronic low-back disease with pain is comprised by item B.1. of the list. Other diseases or exposures not on the list will in special cases qualify for recognition after submission of the case to the Occupational Diseases Committee. The Occupational Diseases Committee has for a number of years recommended recognition of other harmful exposures, for instance:

  • Iron binding in a stooping position without simultaneous lifting work
  • Work in a fixed working position without simultaneous lifting work
  • Heavy lifting work

What is currently needed is an examination of the available research with a view to clarifying such occupational exposures as may result in chronic low-back disease with pain and the extent to which such exposures must have occurred in order to be able to cause the said disease.

Project framework:

Against the background of a primarily epidemiologically based examination of the most substantial Danish and international research results in the field, the scientific reference document will elucidate, summarise and assess knowledge of the causal association between exposure and stresses in the workplace and the risk of subsequent disease. The document will contain a description of the statistical correlation and an evidence assessment against the background of the nature and duration of the exposure (exposure criteria) and competitive factors. Particular emphasis should be placed on an assessment of dose-response correlations.

Particular focus must be on:

  • The significance of the length of the exposure period
  • The significance of the total daily lifting quantity and the size of single lifts, including very heavy single lifts.
  • Elucidation of exposure-response correlations, including where possible a description of the interaction between the length of the exposure period (duration) and the lifting quantity (intensity).
  • The significance of factors other than lifting work: whole-body vibrations, care work, pushing and pulling, sedentary work. For these factors it is also required, where possible, to make an elucidation of exposure-response correlations and to describe the interaction between duration and intensity.
  • The significance of gender, competitive diseases, and similar factors.
  • Where possible, it will also be elucidated whether or not there is a basis for cumulating several different exposure periods.

What is needed specifically is a comparison of surveys across various research designs, including longitudinal surveys, case control surveys and various types of exposure measurement.

In their application, applicants must give an account of how, in the review, they plan to take a position on all the questions raised. In the event that the applicant does not find it possible to answer in the required manner all the questions raised, the applicant is required instead to describe an alternative method to be applied in the review or, perhaps, in a subsequent survey (not comprised by the review).

For a possible work-related chronic low-back disease with pain, the following information is required:

About the disease

  • Diagnostic delimitation and specification of the disease in exposed groups
  • Information on how the diagnosis was made
  • An assessment of the validity of the study results
  • Information on the severity of the disease/symptoms
  • The prognosis for the diseases in question

About the exposure

  • The general nature of the exposures (types of work)
  • The more concrete nature of the exposures and their severity/scope, compared with an assessment of the size of the risk
  • The total duration over time of the exposures
  • A description of the nature and scope of the occupational exposures and their duration
  • Correlation between the nature, scope and duration of the exposure and the risk of developing chronic low-back disease

About the causal association

  • A summarising description and assessment of the dose-response and dose-effect correlations
  • Description and assessment of the onset time of the disease in relation to exposure
  • An assessment of the disease prognosis and the significance of the exposure for the prognosis

About competitive and pre-existing diseases and factors

  • Description of the significance of competitive and pre-existing diseases for the current disease development, including:

Previous lumbago or other symptoms from the low back, prior to onset of the chronic disease (also the significance of when these symptoms were present in relation to the development of the chronic low-back disease)

The significance of overweight / high BMI

The significance of other diseases or genetic dispositions

  • Description of the significance of non-occupational, including private, exposures (exposures in a person’s free time or in connection with sports activities, or exposures which are not work-related)
  • Descriptions of the significance of other, non-occupational factors (for instance heredity, gender, age, and previous traumas; genetics and other diseases)
  • If possible, a quantitative assessment of the role played by occupational exposures in the development of the disease in relation to non-occupational diseases/factors, cf. the above

Summary

  • Description and assessment of the reliability of the exposure and disease documentation in the individual article
  • A summarised and graduated assessment of the evidence (see special guidelines for reviews of occupational diseases)
  • The project report will include a summary in Danish, directed at lay persons

In the event that the available literature is found to be inadequate for the elucidation of the required causal associations, this should be stated, examined and specified. 

If, in this connection, it is found that additional research should be initiated, the relevant efforts and goals for further research should be pointed out, substantiated and included in the overall conclusion of the project.

Special guidelines

The preparation of the review must follow the special guidelines for preparation and quality approval of reviews in the form of reference documents in the field of occupational diseases. The current edition of the guidelines is found below.

Special guidelines for preparation and quality approval of reviews in the form of reference documents in the field of occupational diseases

 November 2012

(1st July 2016: The National Board of Industrial Injuries (Arbejdsskadestyrelsen) changed name to Labour Market Insurance (Arbejdsmarkedets Erhvervssikring/AES))


The objective of preparing a reference document in the field of occupational diseases is to provide the best evidence-based answers to questions regarding possible causalities between various types of work-related exposures and the development of various types of diseases/complaints.

Therefore, with a view to ensuring the highest possible targeted quality of the required scientific literature examination, the following special guidelines have been set up for preparation and quality approval of a reference document in the field of occupational diseases.

1. In connection with carrying out the project, the applicant will point to three or four external experts in the research area in question as relevant and competent reviewers. The Working Environment Research Fund (Arbejdsmiljøforskningsfonden) quality approves all reviewers and finally appoints two of those reviewers for the further process. All costs deriving from the work of the two reviewers will form part of the overall financial budget of the project, cf. the guide to application for subsidies from the Working Environment Research Fund. Budgets must be kept within an overall frame of DKK 50,000 for the reviewers’ work. Once the reviewers have been finally appointed by the Fund, a detailed budget for the project will be determined and approved by the Fund.

2. The reference document must be prepared according to the requirement specifications of the notice and will also, in addition to the budget, include a detailed plan for time consumption and deadlines for each phase of the project, including for the reviewing phase.

3. Within one month after receiving the applicant’s first final draft, the two reviewers will prepare and deliver to the applicant their written comments on the document.

4. The subsidy recipient will write the final conclusion of the manuscript, in accordance with the comments received, and the revised work will be forwarded to the reviewers for any new comments. If needed, there may be one or more rounds of changes and comments in this conclusive part of the process. If it is not possible to reach a final agreement on the evidence basis and conclusions in connection with the conclusive evaluation of the work, such disagreement, and the specific origin of it, will appear explicitly from the final document. Any disagreement will be set out separately in the document.

5. The final document with incorporated contributions from reviewers will be delivered to the Fund within the agreed time limit for conclusion of the project.

6. The reference document will be delivered in an English version, including an exhaustive Danish summary. The summary will focus in particular on answering the most substantial, overall questions of the notice, including in particular a summary of conclusions regarding causalities between exposures and disease(s) and the respective evidence levels.

7. In connection with the assessment of the evidence, the subsidy recipient will apply the recognised evidence model seen below – Guidelines for establishing a reference document on the causal relation between an occupational exposure and a disease outcome. In the event of the exceptional application of any other evidence model, such a model is required to give a presentation of evidence which is just as clear and transparent, based on equivalent principles.

8. The subsidy recipient will be under an obligation to personally present the results of the project, including the main conclusions of the reference document and the work method applied, to the Occupational Diseases Committee. Arrangements will be made with the National Board of Industrial Injuries. The presentation will in principle be made not later than two months after conclusion of the project.

9. As soon as the National Board of Industrial Injuries and the Occupational Diseases Committee have finalised their negotiations on the review, the National Board of Industrial Injuries, in connection with publishing the results of the negotiations, will also publish the reference document on their website www.ask.dk. This will also appear from any press release.

10. The subsidy recipient must hold back his/her own publication of the reference document and its results, including part results, until the National Board of Industrial Injuries has reported back to the subsidy recipient that negotiations have been concluded and that the document may be released for own publication. The time of publication/release of the document and its results, including part results, cannot be determined in detail, this depending on the course of the negotiations.

11. In connection with any own publication of the reference document and its results after release by the National Board of Industrial Injuries, the subsidy recipient must state that the document was written on the initiative of the National Board of Industrial Injuries and the Occupational Diseases Committee and that the reference document can also be found on the website of the National Board of Industrial Injuries www.ask.dk.

12. In the event of an own publication of the reference document and its results after release by the National Board of Industrial Injuries, the Board will receive a copy of the subsidy recipient’s own published versions of the review and its results.

13. The subsidy recipient and reviewers must not be members of the Occupational Diseases Committee or employees of wage-earner or employer organisations or the National Board of Industrial Injuries.

Further reference is made to the current standard terms for subsidies from the Working Environment Research Fund. These standard terms also apply to the preparation of reference documents.
 

Guidelines for establishing a reference document on the causal association between an occupational exposure and a disease outcome (The Working Environment Research Fund)

Guidelines for manuscripts of reference documents

The aim of establishing a reference document is to provide the best evidence-based answers to questions on the causal relations between an occupational exposure and a disease outcome.

The reference document should be written in English and should be supplied with an extended popular summary. The text part of this summary will be translated to Danish. The reference document, tables and appendices will not be translated. 

The reference document should be written in a form, which is suitable for publication in a peer-reviewed international journal. The word count of the main text should not exceed 8000 words.  If the requirements outlined below (e.g. text summaries of key studies) imply that the review becomes too long for such a publication, some of the detailed information may be put in an appendix and only summarized in the main text.

The manuscript should be organised as follows:

1. Background and delimitations of the task to specific diagnoses and exposures

2. The outcome under study

- Clinical diagnosis and proxy-measures used in epidemiological studies.

- Exclusions of certain conditions from the study.

 -Risk factors for the outcome (excluding the exposure under study).

- Descriptive epidemiology, incidences and prevalences of the outcome.

Preferably, literature references in this section should be to high quality reviews rather than original papers, since this introductory section is not based on a separate literature review by the authors.

This section should be oriented towards problems to be discussed in subsequent sections.

3. The exposure under study

- Definition of the exposure.

- Measurement of the exposure. 

- Distribution in the general population and occupational groups.

Preferably, literature references in this section should be to high quality reviews for the reasons given above.

This section should be oriented towards problems to be discussed in subsequent sections.

4. Literature search

- Description of search terms, databases searched, date of final search and number of references.

- Description of the procedure followed to arrive at the studies that are considered in the document (inclusion and exclusion criteria and the methods used to apply them).

- If the final set of references includes a large number of studies (e.g. more than 25-30 studies per outcome) it is recommended to include only the studies that are most informative with respect to the issue (key studies).  The procedure used to get to these studies must be described and documented.

- A flow-diagram of the literature selection should be included. 

5. Literature review

The final set of references from the literature search should be described in text and tables, study by study. The text should shortly present essential details of the study and provide the reader with a good impression of its distinguishing features, strengths and limitations, and should include evaluative comments by the authors of the reference document. More important studies are presented with more detail than less important ones. Critical comments on the individual study should be given [in square brackets] in this section.

If there are more than 25-30 references per outcome, only the key studies on which the conclusion is based need to be described in the text. The remaining articles should be described in an independent table corresponding to the table of the more informative studies. The purpose of this selection is to move quickly to the more important studies and not having the presentation mixed up with detailed descriptions and results from less informative studies.

6. Quality assessment of a specific study

In addition to systematic assessments of study quality using formal scoring systems, the quality of studies reviewers are encouraged to qualitatively assess the results of each study with respect to the likelihood that they may reflect chance, bias or confounding, and to assess the external validity of the study results. Quality should not be assessed only by a formal scoring system since there is no ‘gold standard’ for the true validity of a study. 

7. Other relevant data

Other relevant data from human or animal, observational or experimental studies should be referred to. The assessment of plausible disease mechanisms to support a cause-effect relation may typically rest on such contributing evidence. The description of contributing evidence may rely on good reviews rather than original studies.

8. Discussion

The discussion should consider the whole set of results from the studies included in the reference document, and especially consider the degree to which it may be assumed that bias or confounding could explain the overall results. The discussion should aim at clarifying the main arguments pertinent to the overall conclusion on causality based on the literature review. 

The discussion should deal with the diagnostic entities used in the epidemiological studies in the review compared to diagnostic criteria in clinical practice, the reliability and validity of the outcome measures used in different studies.

The discussion should further deal with problems of exposure assessment relevant to the problem, including reliability and validity. Inaccuracies in diagnosis or exposure assessment should be discussed with respect to the direction and magnitude of the resulting bias of the exposure-outcome relation. 

Furthermore, the discussion should consider the effects of potential confounding or effect modification which was not accounted for, and the degree to which the overall results may be influenced by such uncontrolled confounding or effect modification.

The different arguments relating to bias and confounding of the relation between outcome and exposure should be detailed and summed up in a manner that clearly explains and justifies the conclusion.

9. Conclusion

The conclusion should start by describing the premises on which it is made. It should be a natural extension of the discussion and shortly declare the degree of evidence for a causal association between the outcome and exposure under consideration. The degree of evidence is described with a view to the classification scheme on the last page of these guidelines, but must verbally reflect the opinions of the authors in sufficient detail. However, the conclusion should be short and to the point. If it is concluded that there is strong or moderate evidence of a causal exposure-effect relationship, the exposure-response pattern of this relationship should be described – and if possible translated to a practically useful exposure measure. If several outcomes or exposures are included in the review, there must be a conclusion for each specific relation.

10. Abstract

11. Extended popular summary

The extended summary must give an accurate account of the work and especially focus on an argued response to the questions raised in the task description. The language should be straight forward and technical terms should be avoided. The summary is aimed at informing the organisation that funded the work, decision makers and the public at large on the background, results and conclusions of the work. The extended popular summary will be translated to Danish.