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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">The influence of employment social support for risk and prognosis in nonspecific back pain: a systematic review and critical synthesis</title><author><name sortKey="Campbell, Paul" sort="Campbell, Paul" uniqKey="Campbell P" first="Paul" last="Campbell">Paul Campbell</name><affiliation><nlm:aff id="Aff1">Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Keele, Staffordshire, ST5 5BG UK</nlm:aff></affiliation></author><author><name sortKey="Wynne Jones, Gwenllian" sort="Wynne Jones, Gwenllian" uniqKey="Wynne Jones G" first="Gwenllian" last="Wynne-Jones">Gwenllian Wynne-Jones</name><affiliation><nlm:aff id="Aff1">Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Keele, Staffordshire, ST5 5BG UK</nlm:aff></affiliation></author><author><name sortKey="Muller, Sara" sort="Muller, Sara" uniqKey="Muller S" first="Sara" last="Muller">Sara Muller</name><affiliation><nlm:aff id="Aff1">Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Keele, Staffordshire, ST5 5BG UK</nlm:aff></affiliation></author><author><name sortKey="Dunn, Kate M" sort="Dunn, Kate M" uniqKey="Dunn K" first="Kate M." last="Dunn">Kate M. Dunn</name><affiliation><nlm:aff id="Aff1">Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Keele, Staffordshire, ST5 5BG UK</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">22875173</idno><idno type="pmc">3555241</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3555241</idno><idno type="RBID">PMC:3555241</idno><idno type="doi">10.1007/s00420-012-0804-2</idno><date when="2012">2012</date><idno type="wicri:Area/Pmc/Corpus">000203</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">The influence of employment social support for risk and prognosis in nonspecific back pain: a systematic review and critical synthesis</title><author><name sortKey="Campbell, Paul" sort="Campbell, Paul" uniqKey="Campbell P" first="Paul" last="Campbell">Paul Campbell</name><affiliation><nlm:aff id="Aff1">Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Keele, Staffordshire, ST5 5BG UK</nlm:aff></affiliation></author><author><name sortKey="Wynne Jones, Gwenllian" sort="Wynne Jones, Gwenllian" uniqKey="Wynne Jones G" first="Gwenllian" last="Wynne-Jones">Gwenllian Wynne-Jones</name><affiliation><nlm:aff id="Aff1">Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Keele, Staffordshire, ST5 5BG UK</nlm:aff></affiliation></author><author><name sortKey="Muller, Sara" sort="Muller, Sara" uniqKey="Muller S" first="Sara" last="Muller">Sara Muller</name><affiliation><nlm:aff id="Aff1">Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Keele, Staffordshire, ST5 5BG UK</nlm:aff></affiliation></author><author><name sortKey="Dunn, Kate M" sort="Dunn, Kate M" uniqKey="Dunn K" first="Kate M." last="Dunn">Kate M. Dunn</name><affiliation><nlm:aff id="Aff1">Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Keele, Staffordshire, ST5 5BG UK</nlm:aff></affiliation></author></analytic><series><title level="j">International Archives of Occupational and Environmental Health</title><idno type="ISSN">0340-0131</idno><idno type="eISSN">1432-1246</idno><imprint><date when="2012">2012</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>Purpose</title><p>To examine the influence of employment social support type (e.g. co-worker, supervisor, general support) on risk of occurrence of low back pain, and prognosis (e.g. recovery, return to work status) for those who have low back pain.</p></sec><sec><title>Methods</title><p>Systematic search of seven databases (MEDLINE, Embase, PsychINFO, CINAHL, IBSS, AMED and BNI) for prospective or case–control studies reporting findings on employment social support in populations with nonspecific back pain. Data extraction and quality assessment were carried out on included studies. A systematic critical synthesis was carried out on extracted data.</p></sec><sec><title>Results</title><p>Thirty-two articles were included that describe 46 findings on the effect of employment social support on risk of and prognosis of back pain. Findings show that there is no effect of co-worker, supervisor or general work support on risk of new onset back pain. Weak effects of employment support were found for recovery and return to work outcomes; greater levels of co-worker support and general work support were found to be associated with less time to recovery or return to work.</p></sec><sec><title>Conclusions</title><p>The evidence suggests that the association between employment support and prognosis may be subject to influence from wider concepts related to the employment context. 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<front><journal-meta><journal-id journal-id-type="nlm-ta">Int Arch Occup Environ Health</journal-id><journal-id journal-id-type="iso-abbrev">Int Arch Occup Environ Health</journal-id><journal-title-group><journal-title>International Archives of Occupational and Environmental Health</journal-title></journal-title-group><issn pub-type="ppub">0340-0131</issn><issn pub-type="epub">1432-1246</issn><publisher><publisher-name>Springer-Verlag</publisher-name><publisher-loc>Berlin/Heidelberg</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">22875173</article-id><article-id pub-id-type="pmc">3555241</article-id><article-id pub-id-type="publisher-id">804</article-id><article-id pub-id-type="doi">10.1007/s00420-012-0804-2</article-id><article-categories><subj-group subj-group-type="heading"><subject>Review Article</subject></subj-group></article-categories><title-group><article-title>The influence of employment social support for risk and prognosis in nonspecific back pain: a systematic review and critical synthesis</article-title></title-group><contrib-group><contrib contrib-type="author" corresp="yes"><name><surname>Campbell</surname><given-names>Paul</given-names></name><address><phone>+44-1782-734828</phone><fax>+1-44-1782-733911</fax><email>p.campbell@cphc.keele.ac.uk</email></address><xref ref-type="aff" rid="Aff1"></xref></contrib><contrib contrib-type="author"><name><surname>Wynne-Jones</surname><given-names>Gwenllian</given-names></name><xref ref-type="aff" rid="Aff1"></xref></contrib><contrib contrib-type="author"><name><surname>Muller</surname><given-names>Sara</given-names></name><xref ref-type="aff" rid="Aff1"></xref></contrib><contrib contrib-type="author"><name><surname>Dunn</surname><given-names>Kate M.</given-names></name><xref ref-type="aff" rid="Aff1"></xref></contrib><aff id="Aff1">Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Keele, Staffordshire, ST5 5BG UK</aff></contrib-group><pub-date pub-type="epub"><day>9</day><month>8</month><year>2012</year></pub-date><pub-date pub-type="pmc-release"><day>9</day><month>8</month><year>2012</year></pub-date><pub-date pub-type="ppub"><month>2</month><year>2013</year></pub-date><volume>86</volume><issue>2</issue><fpage>119</fpage><lpage>137</lpage><history><date date-type="received"><day>8</day><month>2</month><year>2012</year></date><date date-type="accepted"><day>24</day><month>7</month><year>2012</year></date></history><permissions><copyright-statement>© The Author(s) 2012</copyright-statement></permissions><abstract id="Abs1"><sec><title>Purpose</title><p>To examine the influence of employment social support type (e.g. co-worker, supervisor, general support) on risk of occurrence of low back pain, and prognosis (e.g. recovery, return to work status) for those who have low back pain.</p></sec><sec><title>Methods</title><p>Systematic search of seven databases (MEDLINE, Embase, PsychINFO, CINAHL, IBSS, AMED and BNI) for prospective or case–control studies reporting findings on employment social support in populations with nonspecific back pain. Data extraction and quality assessment were carried out on included studies. A systematic critical synthesis was carried out on extracted data.</p></sec><sec><title>Results</title><p>Thirty-two articles were included that describe 46 findings on the effect of employment social support on risk of and prognosis of back pain. Findings show that there is no effect of co-worker, supervisor or general work support on risk of new onset back pain. Weak effects of employment support were found for recovery and return to work outcomes; greater levels of co-worker support and general work support were found to be associated with less time to recovery or return to work.</p></sec><sec><title>Conclusions</title><p>The evidence suggests that the association between employment support and prognosis may be subject to influence from wider concepts related to the employment context. This review discusses these wider issues and offers directions for future research.</p></sec></abstract><kwd-group xml:lang="en"><title>Keywords</title><kwd>Work social support</kwd><kwd>Social network</kwd><kwd>Back pain</kwd><kwd>Systematic review</kwd><kwd>Employment</kwd></kwd-group><custom-meta-group><custom-meta><meta-name>issue-copyright-statement</meta-name><meta-value>© Springer-Verlag Berlin Heidelberg 2013</meta-value></custom-meta></custom-meta-group></article-meta></front><body><sec id="Sec1" sec-type="introduction"><title>Introduction</title><p>Nonspecific low back pain (LBP) is very common. Two large population studies (Papageorgiou et al. <xref ref-type="bibr" rid="CR42">1995</xref>; Cote et al. <xref ref-type="bibr" rid="CR8">1998</xref>) place a lifetime prevalence of back pain at 60–80 %. This high prevalence has considerable impact within the employment sector. For example, in a study of back pain consulters from a UK primary care sample (Wynne-Jones et al. <xref ref-type="bibr" rid="CR55">2008</xref>), 37 % of those unemployed attributed this to their back pain, 22 % of those currently employed were on sickness absence and a further 11 % were on reduced duties at work due to their back pain. A recent report by the European Work Foundation ‘<italic>Fit for work</italic>’ (Bevan et al. <xref ref-type="bibr" rid="CR2">2009</xref>) reports that 25 % of workers in Europe suffer from back pain and estimate the total cost of musculoskeletal illness on employment productivity in Europe at €12 billion. This is further compounded by evidence that the longer a person is out of work due to back pain, the more difficult it is to re-engage into employment, and that recurrence rates are high (Waddell and Burton <xref ref-type="bibr" rid="CR53">2001</xref>).</p><p>In the light of the impact of back pain on employment, there has been a steady growth in interest in what employment factors impact on both risk for back pain and related outcomes such as sickness absence, recovery and return to work (Hartvigsen et al. <xref ref-type="bibr" rid="CR17">2004</xref>; Steenstra et al. <xref ref-type="bibr" rid="CR47">2005</xref>). One influential theoretical model, utilised within employment and illness research, is Karasek’s Demand Control Model (Karasek et al. <xref ref-type="bibr" rid="CR28">1998</xref>). According to the model having a job with high demands (e.g. high paced physical work), with no or little control over the decisions affecting work (e.g. fixed schedules, having a subordinate position), leads to an increase in stress and subsequent illness (Landsbergis et al. <xref ref-type="bibr" rid="CR34">2001</xref>). It is proposed that these outcomes can be modified if the person receives social support within the employment context (Johnson and Hall <xref ref-type="bibr" rid="CR25">1988</xref>; Theorell and Karasek <xref ref-type="bibr" rid="CR49">1996</xref>). This and similar theoretical models have been investigated within musculoskeletal research (Bongers et al. <xref ref-type="bibr" rid="CR4">2006</xref>) and have led to clinical guidelines on the consideration of work psychosocial factors (Costa-Black et al. <xref ref-type="bibr" rid="CR7">2010</xref>).</p><p>However, the evidence within systematic reviews on the impact of employment social support on back pain has been conflicting. The reasons given for inconsistency include difficulties synthesising evidence, due to variation in the measurement of work social support (Bongers et al. <xref ref-type="bibr" rid="CR4">2006</xref>; Hartvigsen et al. <xref ref-type="bibr" rid="CR17">2004</xref>; Steenstra et al. <xref ref-type="bibr" rid="CR47">2005</xref>; Woods <xref ref-type="bibr" rid="CR54">2005</xref>), and a lack of research focus specifically on work social support; for example, of the eight recent reviews (Bongers et al. <xref ref-type="bibr" rid="CR4">2006</xref>; Hartvigsen et al. <xref ref-type="bibr" rid="CR17">2004</xref>; Steenstra et al. <xref ref-type="bibr" rid="CR47">2005</xref>; Woods <xref ref-type="bibr" rid="CR54">2005</xref>; Waddell and Burton <xref ref-type="bibr" rid="CR53">2001</xref>; Hoogendoorn et al. <xref ref-type="bibr" rid="CR21">2000</xref>; Kuijer et al. <xref ref-type="bibr" rid="CR32">2006</xref>; Lakke et al. <xref ref-type="bibr" rid="CR33">2009</xref>), only one review (Woods <xref ref-type="bibr" rid="CR54">2005</xref>) solely considered work support issues using qualitative methodology.</p><p>The objective of this systematic review is to describe the evidence of employment-related social support on the risk of occurrence of a new episode of back pain and on the influence of employment-related support on prognosis once someone has back pain (e.g. recovery, return to work status). Furthermore, by way of a critical evidence synthesis, this review will address some current difficulties reported by previous reviews. This will be done by (1) stratification of evidence by study outcome (e.g. risk or prognosis), (2) stratification by type of support (e.g. co-worker, supervisor, general support), (3) critical assessment of the evidence based on the adequacy of the measure of employment social support and other key components of the included studies (e.g. response rate, attrition rate, geographic location, type of employment, sample size, sophistication of the analysis, length of follow up time, assessment of LBP).</p></sec><sec id="Sec2" sec-type="materials|methods"><title>Methods</title><p>This review uses a systematic approach to identify and synthesise research on employment social support (e.g. general level of support at work, level of supervisor support, level of co-worker support) within back pain populations.</p><sec id="Sec3"><title>Search strategy</title><p>The following computerised databases were searched from their respective inception dates up to 18 November 2011: MEDLINE, Embase, PsychINFO, CINAHL, IBSS, AMED and BNI. Reference lists of the studies and current relevant reviews were checked for additional study citations. Validated measures of social support were also citation checked using the ISI Web of Science citation mapping system, and databases of local experts were consulted for information on additional research studies.</p></sec><sec id="Sec4"><title>Inclusion criteria</title><p>Articles were included if they had a focus on LBP populations (e.g. search term keywords: Back Pain, Low Back Pain), measured employment social support (e.g. search term keywords: Social Support, Social Interaction, Occupational Health Services, Employment Support, Employment Based Support), and provided data for the role of employment social support on risk of occurrence of LBP or prognosis with LBP outcomes such as pain intensity, disability or associated prognostic factors (search term keywords: Risk factors, Prospective, Epidemiologic Studies, Cohort studies, Case–Control Studies). The search terms (<xref rid="Sec27" ref-type="sec">“Appendix 1”</xref>) were used as key words and also exploded to include all lower level headings (e.g. Mesh terms within MEDLINE).</p></sec><sec id="Sec5"><title>Exclusion criteria</title><p>Studies were excluded that focused exclusively on family support or informal social support or included populations with other specific health problems (e.g. cancer, diabetes), studies solely on pregnant women, studies of surgical cohorts (e.g. lumbar fusion patients), studies of back pain patients who have a specific diagnosis (e.g. lumbar stenosis, spondylolithesis, spinal cord diseases, red flags). Cross-sectional findings were also excluded due to the inability to distinguish cause and effect, as were small case series studies due to being underpowered (e.g. studies of <30 people).</p></sec><sec id="Sec6"><title>Procedure</title><p>Study abstracts were screened for clearly irrelevant studies, and for any study that was suitable, full text papers were obtained. Final selection of research papers was conducted by two reviewers (PC and KMD) using the inclusion and exclusion criteria.</p></sec><sec id="Sec7"><title>Assessment of study biases</title><p>All included articles were subject to quality assessment of study methodology for bias; the studies’ focus on employment social support, the measurement of social support, study population, analysis undertaken, and the quality of reporting. Further assessments were carried out relating to the study design type, such as the attrition rate and follow-up period as additional criteria for cohort studies or screening of controls within a case–control study designs. It was not possible to use a pre-existing quality assessment tool due to the inclusion of differing study designs (e.g. cohort, case control) and inclusion of specific assessments (i.e. social support, back pain) so the quality assessment measure (“<xref rid="Sec28" ref-type="sec">Appendix 2</xref>”) was based on the combination of assessments of a number of recent review articles and guidance on quality assessment within systematic reviews on the area of back pain (Woods <xref ref-type="bibr" rid="CR54">2005</xref>; Kuijer et al. <xref ref-type="bibr" rid="CR32">2006</xref>; Mallen et al. <xref ref-type="bibr" rid="CR38">2007</xref>; Hayden et al. <xref ref-type="bibr" rid="CR18">2009</xref>).</p><p>Articles were assessed using the quality assessment criteria checklist by two reviewers (PC, GWJ). Thereafter, all disagreements were discussed at a consensus meeting, and if disagreements were not resolved, a third reviewer (KMD) provided the final judgement.</p></sec><sec id="Sec8"><title>Data extraction and synthesis</title><p>Study information on author, country, study population, sample size, response rate, follow-up period (cohort designs only), study design, focus, assessment of back pain, assessment of employment social support, analysis, outcome in relation to employment social support, findings and strength of reported effect were extracted from the studies. Full data extraction tables can be found in “<xref rid="Sec29" ref-type="sec">Appendix 3</xref>”.</p></sec><sec id="Sec9"><title>Analysis</title><p>Studies were grouped together corresponding to their respective study design, occurrence (e.g. risk of back pain) and prognosis (e.g. disability, return to work, sickness absence, recovery). Studies were also grouped to reflect the type of employment social support reported within the research papers (e.g. co-worker support, supervisor support, unspecified work support). Studies that did not describe the specific type of support (i.e. unspecified work support) are described as ‘General Work Support’ (GWS) within this review. In addition, some studies had multiple outcomes within the analysis (e.g. a prospective cohort study reports on incident risk and follows up on disability or a study that report’s findings both on co-worker support and supervisor support) and were included within the findings more than once.</p><p>Studies were then stratified dependent on whether or not they reported a significant association of employment support on risk outcome (i.e. risk of LBP) or prognosis (i.e. sickness absence, return to work status). The analysis centred on comparisons between studies that reported an association or not using key aspects of extracted data, measurement of social support (studies that used a measure that included multiple items to assess support type were judged as adequate, studies that used a single item or did not specify were judged as poor), geographic location (countries where studies were carried out), worker sample (e.g. industrial workers, office workers, general workers), analysis type (e.g. univariate, multivariate), assessment of back pain (e.g. pain intensity, disability, mechanical assessment, medical codes, prevalence and duration), factors of study bias (sample size, baseline response, attrition, length of follow-up).</p><p>Assessment of strength of association was carried out following criteria guidelines (Hartvigsen et al. <xref ref-type="bibr" rid="CR17">2004</xref>; Iles et al. <xref ref-type="bibr" rid="CR24">2008</xref>); individual study results are described as: none (e.g. non-significant result), weak (e.g. OR/RR 1.01–1.49), moderate (e.g. OR/RR 1.50–1.99) or strong (e.g. OR/RR ≥ 2.0) in the support of an association between employment social support and back pain outcomes.</p></sec></sec><sec id="Sec10" sec-type="results"><title>Results</title><p>Systematic searching identified 375 publications (see Fig. <xref rid="Fig1" ref-type="fig">1</xref>). An additional 72 articles were included via alternative search strategies (hand search, expert consultation, and citation search). 378 articles were excluded following abstract screening (e.g. not nonspecific LBP population, duplicates) with a further 37 articles excluded following full text screening. The reasons for exclusion at the full text screening stage were studies solely focusing on family support, cross-sectional studies, studies on specific spinal pain populations (e.g. spondylolithesis, lumbar stenosis, spinal injury), or populations that focused on chronic pain patients outside of this study’s inclusion criteria (e.g. migraines, fibromyalgia, chronic widespread pain). This resulted in 32 suitable articles included within the review.<fig id="Fig1"><label>Fig. 1</label><caption><p>Flow diagram of review procedure</p></caption><graphic xlink:href="420_2012_804_Fig1_HTML" id="MO1"></graphic></fig></p><sec id="Sec11"><title>Quality assessment analysis</title><p>Taken together, all studies offered a clear research objective, 91 % described their recruitment procedure adequately, 69 % described the demographics of their study populations and 56 % reached a quality target criteria of a 70 % participation rate (see “<xref rid="Sec28" ref-type="sec">Appendix 2</xref>” for quality assessment scores for each study). Most (81 %) of the studies employed a citable measure of employment social support. For cohort designs, only 48 % of studies reported their attrition rates or reported comparisons of responders and non-responders and over half of the cohort studies reported a higher than 20 % attrition rate. Table <xref rid="Tab1" ref-type="table">1</xref> outlines the findings of employment social support for risk and prognosis for the included studies.<table-wrap id="Tab1"><label>Table 1</label><caption><p>Outcomes of low levels of employment social support on risk and prognosis for back pain</p></caption><table frame="hsides" rules="groups"><thead><tr><th align="left">Outcome</th><th align="left">Study</th><th align="left">Study quality (%)</th><th align="left">Strong support</th><th align="left">Moderate support</th><th align="left">Weak support</th><th align="left">No support</th></tr></thead><tbody><tr><td align="left" rowspan="20">Risk of occurrence for back pain</td><td align="left">Andersen et al.</td><td char="." align="char">100</td><td align="left"></td><td align="left"></td><td align="left"></td><td align="left">× (SS, CWS)</td></tr><tr><td align="left">Clays et al.</td><td char="." align="char">79</td><td align="left"></td><td align="left"></td><td align="left">+ (GWS males)</td><td align="left">× (GWS females)</td></tr><tr><td align="left">Elfering et al.</td><td char="." align="char">64</td><td align="left"></td><td align="left"></td><td align="left"></td><td align="left">× (GWS)</td></tr><tr><td align="left">Feuerstein et al.</td><td char="." align="char">85</td><td align="left"></td><td align="left"></td><td align="left">+ (SS)</td><td align="left"></td></tr><tr><td align="left">Fransen et al.</td><td char="." align="char">50</td><td align="left"></td><td align="left"></td><td align="left"></td><td align="left">× (GWS)</td></tr><tr><td align="left">Ghaffari et al.</td><td char="." align="char">64</td><td align="left"></td><td align="left"></td><td align="left"></td><td align="left">× (GWS)</td></tr><tr><td align="left">Gheldof et al.</td><td char="." align="char">86</td><td align="left"></td><td align="left"></td><td align="left"></td><td align="left">× (GWS)</td></tr><tr><td align="left">Gonge et al.</td><td char="." align="char">79</td><td align="left"></td><td align="left"></td><td align="left"></td><td align="left">× (GWS)</td></tr><tr><td align="left">Harkness et al.</td><td char="." align="char">64</td><td align="left"></td><td align="left"></td><td align="left"></td><td align="left">× (GWS)</td></tr><tr><td align="left">Hoogendoorn et al.</td><td char="." align="char">71</td><td align="left"></td><td align="left"></td><td align="left"></td><td align="left">× (CWS, SS)</td></tr><tr><td align="left">Ijzelenberg and Burdorf</td><td char="." align="char">79</td><td align="left">+ (SS)</td><td align="left"></td><td align="left"></td><td align="left">× (CWS)</td></tr><tr><td align="left">Josephson and Vingard</td><td char="." align="char">78</td><td align="left"></td><td align="left"></td><td align="left"></td><td align="left">× (GWS)</td></tr><tr><td align="left">Kaila-Kangas et al.</td><td char="." align="char">64</td><td align="left">+ (SS)</td><td align="left"></td><td align="left"></td><td align="left">× (CWS)</td></tr><tr><td align="left">Kerr et al.</td><td char="." align="char">92</td><td align="left"></td><td align="left">− (CWS)</td><td align="left"></td><td align="left"></td></tr><tr><td align="left">Krause et al.</td><td char="." align="char">86</td><td align="left"></td><td align="left"></td><td align="left"></td><td align="left">× (CWS, SS)</td></tr><tr><td align="left">Larsman and Hanse</td><td char="." align="char">64</td><td align="left"></td><td align="left"></td><td align="left"></td><td align="left">× (GWS)</td></tr><tr><td align="left">Leino and Hanninen</td><td char="." align="char">71</td><td align="left"></td><td align="left">+ (GWS)</td><td align="left"></td><td align="left"></td></tr><tr><td align="left">Rugulies and Krause</td><td char="." align="char">93</td><td align="left"></td><td align="left"></td><td align="left"></td><td align="left">× (CWS, SS)</td></tr><tr><td align="left">Shannon et al.</td><td char="." align="char">79</td><td align="left"></td><td align="left"></td><td align="left"></td><td align="left">× (GWS)</td></tr><tr><td align="left">Stevenson et al.</td><td char="." align="char">50</td><td align="left">+ (CWS)</td><td align="left"></td><td align="left"></td><td align="left"></td></tr><tr><td align="left" rowspan="13">Return to work/recovery</td><td align="left">Dionne et al.</td><td char="." align="char">93</td><td align="left"></td><td align="left"></td><td align="left"></td><td align="left">× (GWS)</td></tr><tr><td align="left">Gheldof et al.</td><td char="." align="char">86</td><td align="left"></td><td align="left"></td><td align="left"></td><td align="left">× (GWS)</td></tr><tr><td align="left">Helmhout et al.</td><td char="." align="char">79</td><td align="left"></td><td align="left"></td><td align="left"></td><td align="left">× (CWS, SS)</td></tr><tr><td align="left">Heymans et al.</td><td char="." align="char">86</td><td align="left"></td><td align="left"></td><td align="left">+ (GWS)</td><td align="left"></td></tr><tr><td align="left">Karlsson et al.</td><td char="." align="char">79</td><td align="left"></td><td align="left"></td><td align="left"></td><td align="left">× (GWS)</td></tr><tr><td align="left">Lotters and Burdorf</td><td char="." align="char">71</td><td align="left"></td><td align="left"></td><td align="left"></td><td align="left">× (GWS)</td></tr><tr><td align="left">Mielenz et al.</td><td char="." align="char">78</td><td align="left"></td><td align="left">+ (CWS)</td><td align="left"></td><td align="left">× (SS)</td></tr><tr><td align="left">Morken et al.</td><td char="." align="char">78</td><td align="left"></td><td align="left"></td><td align="left">+ (GWS short term absence)</td><td align="left">× (GWS long term absence)</td></tr><tr><td align="left">Schultz et al.</td><td char="." align="char">86</td><td align="left"></td><td align="left">− (CWS)</td><td align="left"></td><td align="left"></td></tr><tr><td align="left">Soucy et al.</td><td char="." align="char">79</td><td align="left"></td><td align="left"></td><td align="left">+ (GWS)</td><td align="left"></td></tr><tr><td align="left">Tubach et al.</td><td char="." align="char">86</td><td align="left">+ (GWS, long term absence)</td><td align="left"></td><td align="left"></td><td align="left">× (GWS, short term absence)</td></tr><tr><td align="left">van der Giezen et al.</td><td char="." align="char">79</td><td align="left"></td><td align="left"></td><td align="left">+ (GWS)</td><td align="left"></td></tr><tr><td align="left">van den Heuvel et al.</td><td char="." align="char">79</td><td align="left">+ (CWS)</td><td align="left"></td><td align="left"></td><td align="left">× (SS)</td></tr></tbody></table><table-wrap-foot><p><italic>LBP</italic> Low back pain, <italic>SS</italic> supervisor support, <italic>CWS</italic> Co-worker support, <italic>GWS</italic> General work support, + positive association, − negative association, × (no association)</p></table-wrap-foot></table-wrap></p></sec><sec id="Sec12"><title>Employment social support and risk of occurrence of back pain</title><p>In total, 20 studies report on 27 findings on the association of employment social support and occurrence of back pain. Of those findings, 20 reported no significant associations, one reported a strong reverse effect (a greater level of employment support increased the risk of back pain) and six reported an effect whereby lower levels of employment support increased the risk of back pain (Table <xref rid="Tab1" ref-type="table">1</xref>). Of those six findings, three were judged as weak associations, one of moderate strength and two judged as strong effects.</p></sec><sec id="Sec13"><title>Co-worker support (CWS)</title><p>Seven studies were included within this analysis, six of those studies reporting no effect (Andersen et al. <xref ref-type="bibr" rid="CR1">2007</xref>; Hoogendoorn et al. <xref ref-type="bibr" rid="CR22">2001</xref>; Ijzelenberg and Burdorf <xref ref-type="bibr" rid="CR23">2005</xref>; Kaila-Kangas et al. <xref ref-type="bibr" rid="CR27">2004</xref>; Krause et al. <xref ref-type="bibr" rid="CR31">1998</xref>; Rugulies and Krause <xref ref-type="bibr" rid="CR43">2005</xref>) and one study reporting a reverse effect of higher CWS increasing the risk of LBP (Kerr et al. <xref ref-type="bibr" rid="CR30">2001</xref>). Examination of the studies revealed that six utilised an adequate measure of employment support with one study using a measure judged as poor (Ijzelenberg and Burdorf <xref ref-type="bibr" rid="CR23">2005</xref>). Included studies covered a range of geographical areas, had a broad selection of employment type, and a broad range of assessments for back pain. All studies used multivariate statistical testing, report an average level of response to follow-up at 77 %, had a mean follow-up period of 7.6 years, and all included samples of 500 participants or over.</p></sec><sec id="Sec14"><title>Supervisor support (SS)</title><p>Six studies were included within this analysis. Four studies reported no effect of SS on risk of LBP (Andersen et al. <xref ref-type="bibr" rid="CR1">2007</xref>; Hoogendoorn et al. <xref ref-type="bibr" rid="CR22">2001</xref>; Krause et al. <xref ref-type="bibr" rid="CR31">1998</xref>; Rugulies and Krause <xref ref-type="bibr" rid="CR43">2005</xref>) with two studies reporting a strong effect of lower levels of SS increasing the risk of LBP (Ijzelenberg and Burdorf <xref ref-type="bibr" rid="CR23">2005</xref>; Kaila-Kangas et al. <xref ref-type="bibr" rid="CR27">2004</xref>). Comparing studies that report no effect with those that do report an effect, all those reporting no effect were judged as having an adequate measure of SS, whereas one study reporting an effect (Ijzelenberg and Burdorf <xref ref-type="bibr" rid="CR23">2005</xref>) was judged as poor, using only a single question to assess support. Assessment of back pain was similar across all studies. Studies were also relatively similar on their geographic populations. All of the studies had sample sizes above 500. Average baseline response rates for studies reporting no effect was 75 % compared to 86 % for the Ijzelenberg and Burdorf (<xref ref-type="bibr" rid="CR23">2005</xref>) study (Kaila-Kangas et al. <xref ref-type="bibr" rid="CR27">2004</xref>, failed to report a baseline response). Average attrition rates at follow-up for studies reporting no effect were 88 % compared to 57 % for the two studies that report an effect. However, this value of 57 % was markedly reduced by the Kaila-Kangas et al. (<xref ref-type="bibr" rid="CR27">2004</xref>) study who report loss to follow-up at 33 % with the Ijzelenberg and Burdorf (<xref ref-type="bibr" rid="CR23">2005</xref>) study reporting 86 %. The average follow-up time for studies that report no effect was 4.4 years in comparison with the studies that reported an effect were highly variable, with Ijzelenberg and Burdorf (<xref ref-type="bibr" rid="CR23">2005</xref>) at 6 months and Kaila-Kangas et al. (<xref ref-type="bibr" rid="CR27">2004</xref>) at 28 years.</p></sec><sec id="Sec15"><title>General work support (GWS)</title><p>In total, 13 studies report on 14 findings for risk of back pain and GWS. Overall, 10 studies (Clays et al. <xref ref-type="bibr" rid="CR6">2007</xref>; Elfering et al. <xref ref-type="bibr" rid="CR10">2002</xref>; Fransen et al. <xref ref-type="bibr" rid="CR12">2002</xref>; Ghaffari et al. <xref ref-type="bibr" rid="CR13">2008</xref>; Gheldof et al. <xref ref-type="bibr" rid="CR14">2006</xref>; Gonge et al. <xref ref-type="bibr" rid="CR15">2002</xref>; Harkness et al. <xref ref-type="bibr" rid="CR16">2003</xref>; Josephson and Vingard <xref ref-type="bibr" rid="CR26">1998</xref>; Larsman and Hanse <xref ref-type="bibr" rid="CR35">2009</xref>; Shannon et al. <xref ref-type="bibr" rid="CR45">2001</xref>) report no effect and 4 show an effect, of those 3 show a weak effect (Clays et al. <xref ref-type="bibr" rid="CR6">2007</xref>; Feuerstein et al. <xref ref-type="bibr" rid="CR11">2001</xref>; Leino and Hanninen <xref ref-type="bibr" rid="CR36">1995</xref>) and 1 reports a moderate effect (Stevenson et al. <xref ref-type="bibr" rid="CR48">2001</xref>). Studies reporting no effect all included an adequate assessment of GWS, whereas two studies reporting an effect (Feuerstein et al., Stevenson et al.) were judged to have poor assessments. Assessment of pain was variable in studies that did not report an effect with measurements of back pain measured via compensation claim records, current pain, pain in the previous week, or pain in the previous 12 months. The assessment was less variable for studies reporting effects, all of them assessing pain within the previous 6–12 months. Geographic locations are similar for studies. Employment type was similar between studies reporting an effect and those who did not. Average sample sizes were found to be similar. There are differences in the average baseline response with an average of 67 % for studies reporting no effect compared to 44 % for those reporting an effect but average attrition rates are similar. All studies employed multivariable analysis. The average follow-up time was 2.3 years (3 months to 6 years) for studies reporting no effect compared to 6 years (2–10 years) for studies that do report an effect.</p></sec><sec id="Sec16"><title>Employment social support and recovery from back pain</title><p>In total, 13 studies report 19 findings on the association between work support and return to work (RTW) for those with back pain. Overall, 11 findings report no association, 7 findings report associations whereby lower levels of work support delay RTW or recovery status and 1 study reports a weak reverse effect (Table <xref rid="Tab1" ref-type="table">1</xref>). Of the findings of effect supporting an association between low work support and delays in RTW, 4 were judged as weak, 1 as moderate and 2 of strong effect.</p></sec><sec id="Sec17"><title>Co-worker support (CWS)</title><p>In total, 4 studies report effects, 2 finding an association that lower levels of CWS delay RTW status (Mielenz et al. <xref ref-type="bibr" rid="CR40">2008</xref>; van den Heuvel et al. <xref ref-type="bibr" rid="CR51">2004</xref>), 1 reporting a reverse effect (Schultz et al. <xref ref-type="bibr" rid="CR44">2004</xref>) and 1 reporting no association (Helmhout et al. <xref ref-type="bibr" rid="CR19">2010</xref>). All studies were judged to have used an adequate measure of CWS. The assessment of LBP varied between studies: the study finding no association (Helmhout et al. <xref ref-type="bibr" rid="CR19">2010</xref>) using recurring LBP in the previous 4 weeks, the study reporting a reverse effect (Schultz et al.) measuring pain and disability in the previous 6 months, and the 2 studies reporting a positive association using biomechanical assessment (Mielenz et al. <xref ref-type="bibr" rid="CR40">2008</xref>) and presence of LBP in the previous 12 months (van den Heuvel et al. <xref ref-type="bibr" rid="CR51">2004</xref>). Geographic locations were similar for all studies. The 2 studies that report an association drew their samples from general workers, whereas the study reporting no association used a military sample, and the study reporting a reverse effect recruited general workers on current compensation for their LBP. Average sample size was larger for the studies reporting an association (1,042 vs. 190), and they also report a greater average response rate (88 vs. 32 %). Average follow-up response rates were lower for the 2 studies reporting an association (69 %) compared to 85 % for the Schultz et al. (<xref ref-type="bibr" rid="CR44">2004</xref>) study; Helmhout et al. (<xref ref-type="bibr" rid="CR19">2010</xref>) failed to report on attrition. Multivariable statistical testing was used by studies reporting an association, the study who reported no association and the study who found a reverse effect both used univariable analysis. Follow-up time was variable with the studies reporting a positive effect having the largest difference (8 weeks and 3 years), the study reporting no association at 6 months and the study reporting the reverse effect at 3 months.</p></sec><sec id="Sec18"><title>Supervisor support (SS)</title><p>In total, 3 studies were included within this category. All studies reported no association between the level of SS and RTW status. All studies were judged to have adequate measures of SS, included a broad assessment of LBP, and covered a broad geographical area (Europe and USA). Multivariable testing was used by 2 studies (Mielenz et al. <xref ref-type="bibr" rid="CR40">2008</xref>; van den Heuvel et al. <xref ref-type="bibr" rid="CR51">2004</xref>). Length of follow-up was variable between studies with an average baseline response of 65 % and an average 68 % follow-up rate.</p></sec><sec id="Sec19"><title>General work support (GWS)</title><p>For the effects of GWS on RTW status, 9 studies (Dionne et al. <xref ref-type="bibr" rid="CR9">2007</xref>; Gheldof et al. <xref ref-type="bibr" rid="CR14">2006</xref>; Heymans et al. <xref ref-type="bibr" rid="CR20">2006</xref>; Karlsson et al. <xref ref-type="bibr" rid="CR29">2010</xref>; Lotters and Burdorf <xref ref-type="bibr" rid="CR37">2006</xref>; Morken et al. <xref ref-type="bibr" rid="CR41">2003</xref>; Soucy et al. <xref ref-type="bibr" rid="CR46">2006</xref>; Tubach et al. <xref ref-type="bibr" rid="CR50">2002</xref>; van der Giezen et al. <xref ref-type="bibr" rid="CR52">2000</xref>) report on 12 findings. Of those findings, 5 are of an association between lower levels of GWS and delays in RTW status (4 of weak effect and 1 strong) and 7 findings of no association. All but one study that report no association (Lotters and Burdorf <xref ref-type="bibr" rid="CR37">2006</xref>), and all but one study that report an association (van der Giezen et al. <xref ref-type="bibr" rid="CR52">2000</xref>) included measures of GWS judged to be adequate. Assessment of LBP is variable within studies that report an association and those that do not, including current pain at time of assessment to pain within the previous 5 years, consultations and ICD coding. Geographic locations are generally similar between studies. Recruitment samples for studies that report associations are from general and industry workers, and also those involved in compensation claims; for studies reporting no association, there is recruitment from industrial workers but also those who have indicated working status from a random population sample, and health care consulters where work type was not recorded. Average sample sizes, baseline response rates, follow-up rates and follow-up time were similar for studies reporting no association and those reporting associations. All studies, except van der Giezen et al. (<xref ref-type="bibr" rid="CR52">2000</xref>) who reported an association, used multivariable analysis.</p></sec></sec><sec id="Sec20" sec-type="discussion"><title>Discussion</title><p>This review has carried out a systematic search for articles that reported on the effects of work social support on back pain from risk of occurrence and prognosis (recovery and return to work) studies. Overall, the evidence suggests no effect of work support as a risk factor for back pain; however, by examining the different types of support some distinctions occur. A similar picture emerges on the data and evidence for recovery and return to work with some evidence of CWS influencing outcome and mixed findings for GWS. The results suggest that employment-related support is less likely a factor on why someone gets back pain but could be an important factor on recovery and return to work once back pain is experienced.</p><sec id="Sec21"><title>Risk of occurrence of back pain</title><p>The evidence suggests that the level of support perceived from co-workers is not a factor in risk of back pain. For CWS, the included studies, all showing no or a reverse effect, incorporated an adequate range of measures on CWS, a broad range of employment types and a broad assessment of back pain. The results for the effects of SS do show some effect is present. However, the studies reporting effects had less adequate assessments of SS and highly variable follow-up periods (6 months and 28 years) and so the effect, although strong in both studies, has to be tempered with these differences. More research is needed to investigate whether SS is a risk factor for back pain. The results on risk and GWS show a similar pattern with no or little effect and no discernible differences on the key extracted data between studies that reported an effect and those that did not. One exception to this is the lesser variability on the assessment of pain in studies reporting an effect (presence of back pain in the previous 6–12 months). This may have led to an inflated incidence rate compared to perhaps more stringent assessments of compensation claims or current pain used in some of the studies reporting no effect. However, notably three studies that reported no effect (Gheldof et al. <xref ref-type="bibr" rid="CR14">2006</xref>; Josephson and Vingard <xref ref-type="bibr" rid="CR26">1998</xref>; Larsman and Hanse <xref ref-type="bibr" rid="CR35">2009</xref>) could be considered as non-significant trends and so more information is needed before conclusions can be drawn.</p></sec><sec id="Sec22"><title>Prognosis for back pain</title><p>Overall, the evidence for prognosis is less clear with mixed findings for both CWS and GWS. The results for CWS, considering the key elements of study bias, suggest that the findings of an effect (less CWS delays recovery and return to work status) are more robust than those reporting no effect or a reverse effect. It may be that a supportive co-worker environment is important for those who have back pain, and this study’s finding supports the finding of a previous review (Steenstra et al. <xref ref-type="bibr" rid="CR47">2005</xref>), who showed a small pooled effect of CWS and work-related prognostic outcomes for those with back pain. The results for SS show no effect for all the included studies. This suggests that the perception of support directly from supervisors is not a factor in recovery. However, due to only three included studies, more research is needed. Findings are mixed for evidence of an effect of GWS on recovery and return to work with no apparent differences in key areas of bias between studies reporting and not reporting an effect. A reason for the stronger presence of an effect for GWS compared to SS could be that the measure of GWS is more than just a measure of support <italic>per se</italic>. For example, many of the studies that have measured general work support have included within their support measures aspects such as: perceived satisfaction of support (Leino and Hanninen <xref ref-type="bibr" rid="CR36">1995</xref>; Fransen et al. <xref ref-type="bibr" rid="CR12">2002</xref>), emotional aspects of support (Elfering et al. <xref ref-type="bibr" rid="CR10">2002</xref>), questions on work output (Fransen et al. <xref ref-type="bibr" rid="CR12">2002</xref>), conflict within the employment context (Larsman and Hanse <xref ref-type="bibr" rid="CR35">2009</xref>) or have used generic unspecified measures of support (Gonge et al. <xref ref-type="bibr" rid="CR15">2002</xref>; Ghaffari et al. <xref ref-type="bibr" rid="CR13">2008</xref>; Shannon et al. <xref ref-type="bibr" rid="CR45">2001</xref>;Morken et al. <xref ref-type="bibr" rid="CR41">2003</xref>; van der Giezen et al. <xref ref-type="bibr" rid="CR52">2000</xref>; Heymans et al. <xref ref-type="bibr" rid="CR20">2006</xref>). These aspects could be seen as support items but also as part of a larger concept of the workers’ general evaluation of their job. According to Karasek et al. (<xref ref-type="bibr" rid="CR28">1998</xref>), aspects such as satisfaction with work, level of demands on the worker, the level of control the worker has, level of conflict at work are all important in their own right. It may be that the measures of general work support have been influenced by some of these factors. This therefore suggests that aspects involved in the supportive context for workers are important as prognostic factors for back pain; however, due to the variation in measurements used by studies in this review, the exact constructs relating to this are indistinct.</p><p>Taken together, the results for risk and prognosis show a weak effect of employment-related support for those with back pain. Less clear are the mechanisms that explain this association and this may be partly due to the ambiguity on what is meant by ‘support’ in an employment context. For example, a recent review by Woods (<xref ref-type="bibr" rid="CR54">2005</xref>) included aspects of support such as satisfaction with employment, emotional support, conflict in the workplace, policy on occupational health, level of communication, health and safety policy, sickness absence policy, whereas other reviews such as Hartvigsen et al. (<xref ref-type="bibr" rid="CR17">2004</xref>) have only reported on effects of direct co-worker support and supervisor support; Steenstra et al. (<xref ref-type="bibr" rid="CR47">2005</xref>) and Hoogendoorn et al. (<xref ref-type="bibr" rid="CR22">2001</xref>) have both included measures of problematic relations with other workers, whereas Kuijer et al. (<xref ref-type="bibr" rid="CR32">2006</xref>) did not clearly specify what they meant by employment social support. This then broadens the scope of the concept of ‘support’ and this variation in definition may have contributed to the level of inconsistency described in previous reviews. Interestingly, this review could be construed as spanning this inconsistency, with no or very weak evidence of an effect for specific measures of CWS and SS (e.g. similar to Harvigsen et al.) but an increase in association for the generic GWS concept (e.g. similar to Woods). Many of the studies within the review who report GWS have combined measures of CWS and SS, and it is suggestive that some effect is there but it appears greater than the sum of its parts. Future research needs to consider the inherent complexity in the conceptualisation of employment social support (for a fuller explanation see “<xref rid="Sec30" ref-type="sec">Appendix 4</xref>”). Furthermore, as mentioned in the introduction, the concept of employment co-worker and supervisor support forms only part of a larger model proposed by Karasek et al. (<xref ref-type="bibr" rid="CR28">1998</xref>). There is a need to consider the component influence of employment social support as a moderator by using more sophisticated statistical modelling (e.g. path analysis, structural equation modelling) if we are to understand the role of employment social support, and in what context, on outcomes of spinal pain. Added to this is the evidence of the heterogeneity in the measurement of the outcome of back pain within this review. Studies differed in their assessment (patient rated, biomechanical testing, compensation status, different time scales for assessment) which makes comparisons all the more complex; future reviews should consider this issue.</p></sec><sec id="Sec23"><title>Comparison with other reviews</title><p>This review has concentrated on the effects of employment social support, whereas most other reviews have considered this as part of a wider search of employment psychosocial factors. This has led other reviews to include only a small number of studies on which to base their conclusions, for example, Steenstra et al. (<xref ref-type="bibr" rid="CR47">2005</xref>) based theirs on four studies, Hoogendoorn et al. (<xref ref-type="bibr" rid="CR21">2000</xref>) on six studies and Hartvigsen et al. (<xref ref-type="bibr" rid="CR17">2004</xref>) on nine studies. The greater number of studies included in this review (thirty-two) has enabled a more specified focus on employment support type and outcome (risk and prognosis), which we believe has overcome some of the issues of heterogeneity and inconsistency described by previous reviews.</p></sec><sec id="Sec24"><title>Strengths and limitations</title><p>While this review has a comprehensive systematic search strategy, it did not include studies in languages other than English and so may have missed important findings; however, we did include studies from a range of countries worldwide. In addition, no review is completely immune from publication bias, and it may be the case that there are other findings (<underline>grey literature</underline>) we have not accessed. Strengths of the study are: the use of a systematic critical synthesis of the evidence which has enabled a closer inspection of the term employment social support and a better assessment of the types of support combined with an examination of individual study bias on the associations.</p></sec><sec id="Sec25"><title>Further research</title><p>This review has highlighted a need for consensus on what is meant by the term ‘employment social support’. As mentioned previously, there are a number of differing conceptualisations and future research needs to report on those concepts to facilitate easier comparisons for future reviews but also, more importantly, to understand what factors of employment social support associate with outcomes. Secondly, and related to the first point, there is a need for research to consider the role of theoretical models within their research. Many studies (over 50 % in this review) employed the Karasek Job Content Questionnaire, or a derivative, as their measure of employment social support. However, studies did not perform the appropriate analysis techniques to ascertain whether employment social support is a moderator component as prescribed by the Karasek model.</p></sec></sec><sec id="Sec26" sec-type="conclusion"><title>Conclusion</title><p>This review has shown that employment-related support has little to no effect on risk of occurrence but a more notable effect on prognosis for those with back pain. The overall effect is weak for these findings; however, a greater understanding of the construct of ‘support’ in an employment context, and what factors interact with support, may lead to important pathways to reduce risk and reduce sickness absence, which could then be implemented by employers and occupational health practitioners.</p></sec></body><back><ack><p>Systematic review advice from Jo Jordan and Danielle van der Windt both from the Arthritis Research UK Primary Care Centre, Keele University. 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rules="groups"><thead><tr><th align="left">Term</th><th align="left">Major heading</th><th align="left">Keywords</th><th align="left">Search text</th></tr></thead><tbody><tr><td align="left" colspan="4">Medline</td></tr><tr><td align="left"> Back pain</td><td align="left">Back pain (exploded)<break></break>Low back pain (exploded)<break></break>Sciatica (exploded)</td><td align="left">Back pain, backache, low back pain</td><td align="left">(“Back pain”[Mesh] OR “Low back pain”[Mesh] OR “Back pain”[Text Word] OR “Backache”[Text Word]</td></tr><tr><td align="left"> Social support</td><td align="left">Social support (exploded)<break></break>Social isolation (exploded)</td><td align="left">Interpersonal relations, interpersonal relation, social interaction, interaction social, social interactions, interactions social, employee health services, occupational health services, employment support, employment based support</td><td align="left">(“Social support”[Mesh] OR “Social Isolation”[Mesh]] OR “Interpersonal relations”[Text Word] OR “Social interaction”[Text Word] OR “Social interactions”[Text Word] OR “interaction social”[Text Word] OR “interactions social”[Text Word] OR “employee health services”[Text Word] OR “occupational health services”[Text Word] OR “employment support”[Text Word] OR “employment based support”[Text Word])</td></tr><tr><td align="left"> Study setting</td><td align="left">Cohort studies (exploded)<break></break>Epidemiologic studies (exploded)<break></break>Follow up studies (exploded)<break></break>Prospective studies (exploded)<break></break>Longitudinal studies (exploded)<break></break>Cross-sectional studies (exploded)<break></break>Health surveys (exploded)</td><td align="left"></td><td align="left">(“Cohort studies”[Mesh] OR “Epidemiologic studies”[Mesh] OR “Follow up studies”[Mesh] OR “Prospective studies”[Mesh] OR “Longitudinal studies”[Mesh] OR “Cross sectional studies”[Mesh] OR “Health surveys”[Mesh])</td></tr><tr><td align="left" colspan="4">AMED, IBSS and the British nursing index</td></tr><tr><td align="left"> Back pain</td><td align="left"></td><td align="left"></td><td align="left">DE “Back pain” or KW “Low back pain” or AB “Back pain” or AB “Low back pain” or AB “Lower back pain” or AB “Lumbago” or AB “Backache” or AB “Back ache” or AB “Lower back ache”</td></tr><tr><td align="left"> Social support</td><td align="left"></td><td align="left"></td><td align="left">DE “Social support” or DE “Social networks” or DE “Friendship” or DE “Social interaction” or KW “Social support” or KW “Social networks” or AB “Social support” or AB “Social networks” or DE “Employment” OR DE “Employment support”</td></tr><tr><td align="left"> Study setting</td><td align="left"></td><td align="left"></td><td align="left">(DE “Between groups Design” or DE “Cohort analysis” or DE “Followup studies” or DE “Longitudinal studies” or DE “Repeated measures” or DE “Quantitative methods” or DE “Mail surveys” or DE “Telephone surveys”) or (TX “Between groups design” or TX “Cohort analysis” or TX “Followup studies” or TX “Longitudinal studies” or TX “Repeated measures” or TX “Quantitative methods” or TX “Mail surveys” or TX “Telephone surveys”)</td></tr><tr><td align="left" colspan="4">PsychINFO</td></tr><tr><td align="left"> Back pain</td><td align="left">Back pain (exploded)</td><td align="left">Low back pain, backache, lumbago, back ache, lower back pains, low back ache</td><td align="left">DE “Back pain” or KW “Low back pain” or AB “Back pain” or AB “Low back pain” or AB “Lower back pain” or AB “Lumbago” or AB “Backache” or AB “Back ache” or AB “Lower back ache”</td></tr><tr><td align="left"> Social support</td><td align="left">Social support (exploded)<break></break>Social networks (exploded)<break></break>Social interaction (exploded)</td><td align="left">Social support, social networks, work, employment</td><td align="left">DE “Social support” or DE “Social networks” or DE “Social interaction” or KW “Social support” or KW “Social networks” or AB “Social support” or AB “Social networks” or DE “Job satisfaction” or DE “Employment status” or DE “Work attitudes toward”</td></tr><tr><td align="left"> Study setting</td><td align="left">Between groups design (exploded or text terms)<break></break>Cohort analysis (exploded or text terms)<break></break>Followup studies (exploded or text terms)<break></break>Mail surveys (exploded or text terms)<break></break>Telephone surveys (exploded or text terms)<break></break>Longitudinal studies (exploded or text terms)</td><td align="left"></td><td align="left">(DE “Between groups design” or DE “Cohort analysis” or DE “Followup studies” or DE “Longitudinal studies” or DE “Repeated measures” or DE “Quantitative methods” or DE “Mail surveys” or DE “Telephone surveys”) or (TX “Between groups design” or TX “Cohort analysis” or TX “Followup studies” or TX “Longitudinal studies” or TX “Repeated measures” or TX “Quantitative methods” or TX “Mail surveys” or TX “Telephone surveys”)</td></tr><tr><td align="left" colspan="4">EMBASE</td></tr><tr><td align="left"> Back pain</td><td align="left">Backache (exploded)</td><td align="left"></td><td align="left">(Back AND Pain OR Back AND Injuries OR Back AND Pain AND with AND Radiation OR Back AND Pain AND without AND Radiation OR Backache OR Low AND Back AND Pain OR Low AND Back AND Ache OR Low AND Backache OR Mechanical AND Low AND Back AND Pain OR Recurrent AND Low AND Back AND Pain OR Postural AND Low AND Back AND Pain OR Lumbago OR Lumbalgesia OR Lumbal AND Pain OR Lumbar AND Pain OR Lumbalgia OR Lumbosacral AND Pain).ti,ab OR (exp BACKACHE/)</td></tr><tr><td align="left"> Social support</td><td align="left">Social support (exploded)<break></break>Social network (exploded)<break></break>Social structure (exploded)<break></break>Social interaction (exploded)</td><td align="left"></td><td align="left">(exp *SOCIAL NETWORK/OR exp SOCIAL STRUCTURE/OR exp SOCIAL SUPPORT/OR exp SOCIAL INTERACTION/)</td></tr><tr><td align="left"> Study setting</td><td align="left">Longitudinal study (exploded)<break></break>Follow up study (exploded)<break></break>Case–control study (exploded)<break></break>Cross-sectional study (exploded)<break></break>Cohort analysis (exploded)<break></break>Epidemiology (exploded)<break></break>Prevalence (exploded)<break></break>Questionnaire (exploded)</td><td align="left"></td><td align="left">(exp LONGITUDINAL STUDY/OR exp FOLLOW UP/OR exp CASE CONTROL STUDY/OR exp CROSS-SECTIONAL STUDY/OR exp COHORT ANALYSIS/OR exp EPIDEMIOLOGY/OR exp PREVALENCE/OR exp QUESTIONNAIRE/)</td></tr><tr><td align="left" colspan="4">CINAHL</td></tr><tr><td align="left"> Back pain</td><td align="left">Back pain low back pain, sciatica</td><td align="left">Back pain, low back pain, backache, back ache, lumbago</td><td align="left">(MH “Back pain+”) or (MH “Lower back pain”) or (MH “Back”) or (“Lumbago”) or (“Lower back pain”) or (“Back pain”) or (“Neck pain”) or (“Backache”) or (“Back ache”)</td></tr><tr><td align="left"> Social support</td><td align="left">Social support<break></break>Norbeck social support questionnaire<break></break>Social support Iowa NOC<break></break>Social support index<break></break>Support, psychosocial (exploded)<break></break>Social networks</td><td align="left">Social support<break></break>Social networks</td><td align="left">(“Social support”) or (Work psychosocial factors) or (MH “Norbeck Social support Questionnaire”) or (MH “Social support (Iowa NOC)”) or (MH “Social support index”) or (MH “Support, Psychosocial+”) or (“Social networks”) or (MH “Social networks”)</td></tr><tr><td align="left"> Study setting</td><td align="left">Experimental studies<break></break>Nonexperimental studies<break></break>Concurrent prospective studies<break></break>Cross-sectional studies<break></break>Health policy studies</td><td align="left"></td><td align="left">(MH “Experimental studies”) or (MH “Nonexperimental studies”) or (MH “Concurrent prospective studies”) or (MH “Cross sectional studies”) or (MH “Health policy studies”)</td></tr></tbody></table></table-wrap></p></sec><sec id="Sec28"><title>Appendix 2</title><p>See Table <xref rid="Tab3" ref-type="table">3</xref>.<table-wrap id="Tab3"><label>Table 3</label><caption><p>Quality assessment</p></caption><table frame="hsides" rules="groups"><thead><tr><th align="left" rowspan="3">First author</th><th align="left" colspan="16">Scoring criteria for quality assessment</th></tr><tr><th align="left" colspan="11">All designs</th><th align="left" colspan="3">Cohort</th><th align="left" colspan="2">Case control</th></tr><tr><th align="left">1</th><th align="left">2</th><th align="left">3</th><th align="left">4</th><th align="left">5</th><th align="left">6</th><th align="left">7</th><th align="left">8</th><th align="left">9</th><th align="left">10</th><th align="left">11</th><th align="left">12</th><th align="left">13</th><th align="left">14</th><th align="left">15</th><th align="left">16</th></tr></thead><tbody><tr><td align="left">Andersen</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left"></td><td align="left"></td></tr><tr><td align="left">Clays</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N/R</td><td align="left">Y</td><td align="left">N</td><td align="left">Y</td><td align="left"></td><td align="left"></td></tr><tr><td align="left">Dionne</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">Y</td><td align="left">Y</td><td align="left"></td><td align="left"></td></tr><tr><td align="left">Elfering</td><td align="left">Y</td><td align="left">N/R</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left"></td><td align="left"></td></tr><tr><td align="left">Feuerstein</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">N/A</td><td align="left">N/A</td><td align="left">N/A</td><td align="left">Y</td><td align="left">Y</td></tr><tr><td align="left">Fransen</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">N/R</td><td align="left">N/R</td><td align="left">N</td><td align="left"></td><td align="left"></td></tr><tr><td align="left">Ghaffari</td><td align="left">Y</td><td align="left">N</td><td align="left">N</td><td align="left">Y</td><td align="left">N</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">Y</td><td align="left">N/R</td><td align="left">Y</td><td align="left">Y</td><td align="left"></td><td align="left"></td></tr><tr><td align="left">Gheldof</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">Y</td><td align="left">N</td><td align="left">Y</td><td align="left"></td><td align="left"></td></tr><tr><td align="left">Gonge</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">N</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">Y</td><td align="left">Y</td><td align="left"></td><td align="left"></td></tr><tr><td align="left">Harkness</td><td align="left">Y</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">Y</td><td align="left"></td><td align="left"></td></tr><tr><td align="left">Helmhout</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N/R</td><td align="left">N/R</td><td align="left">Y</td><td align="left">Y</td><td align="left"></td><td align="left"></td></tr><tr><td align="left">Heymans</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N/R</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left"></td><td align="left"></td></tr><tr><td align="left">Hoogendoorn</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">N</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">N</td><td align="left">Y</td><td align="left"></td><td align="left"></td></tr><tr><td align="left">Ijzelenberg</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">N</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left"></td><td align="left"></td></tr><tr><td align="left">Josephson</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">N</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">N/A</td><td align="left">N/A</td><td align="left">N/A</td><td align="left">Y</td><td align="left">Y</td></tr><tr><td align="left">Kaila-Kangas</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">Y</td><td align="left">N</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N/R</td><td align="left">N/R</td><td align="left">N/R</td><td align="left">Y</td><td align="left"></td><td align="left"></td></tr><tr><td align="left">Karlsson</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N/R</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N/R</td><td align="left">N</td><td align="left">Y</td><td align="left"></td><td align="left"></td></tr><tr><td align="left">Kerr</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">N/A</td><td align="left">N/A</td><td align="left">N/A</td><td align="left">Y</td><td align="left">Y</td></tr><tr><td align="left">Krause</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">Y</td><td align="left"></td><td align="left"></td></tr><tr><td align="left">Larsman</td><td align="left">Y</td><td align="left">Y</td><td align="left">N/R</td><td align="left">N</td><td align="left">N</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N/R</td><td align="left">N</td><td align="left">Y</td><td align="left"></td><td align="left"></td></tr><tr><td align="left">Leino</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">N</td><td align="left">Y</td><td align="left">N</td><td align="left">Y</td><td align="left"></td><td align="left"></td></tr><tr><td align="left">Lotters</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">Y</td><td align="left">Y</td><td align="left"></td><td align="left"></td></tr><tr><td align="left">Mielenz</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">Y</td><td align="left">N</td><td align="left"></td><td align="left"></td></tr><tr><td align="left">Morken</td><td align="left">Y</td><td align="left">Y</td><td align="left">N/R</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N/R</td><td align="left">N</td><td align="left">Y</td><td align="left"></td><td align="left"></td></tr><tr><td align="left">Rugulies</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left"></td><td align="left"></td></tr><tr><td align="left">Schultz</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left"></td><td align="left"></td></tr><tr><td align="left">Shannon</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">Y</td><td align="left">N</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">Y</td><td align="left"></td><td align="left"></td></tr><tr><td align="left">Soucy</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">N</td><td align="left">N</td><td align="left">Y</td><td align="left"></td><td align="left"></td></tr><tr><td align="left">Stevenson</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">N/R</td><td align="left">N</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">N/R</td><td align="left">N/R</td><td align="left">N/R</td><td align="left">Y</td><td align="left"></td><td align="left"></td></tr><tr><td align="left">Tubach</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">Y</td><td align="left"></td><td align="left"></td></tr><tr><td align="left">van den Heuvel</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">N</td><td align="left">Y</td><td align="left"></td><td align="left"></td></tr><tr><td align="left">van der Giezen</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">Y</td><td align="left">N</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">Y</td><td align="left">N</td><td align="left">Y</td><td align="left"></td><td align="left"></td></tr><tr><td align="left">Overall total %</td><td align="left">100</td><td align="left">91</td><td align="left">69</td><td align="left">69</td><td align="left">60</td><td align="left">81</td><td align="left">100</td><td align="left">94</td><td align="left">97</td><td align="left">75</td><td align="left">56</td><td align="left">48</td><td align="left">41</td><td align="left">90</td><td align="left">100</td><td align="left">100</td></tr></tbody></table><table-wrap-foot><p><italic>Y</italic><italic>yes, N</italic><italic>no, N/R</italic><italic>not recorded, N/A</italic><italic>not applicable</italic></p><p>Quality assessment scoring key (<italic>CC</italic> Case control, <italic>CH</italic> Cohort)</p><p>1: Does the study have a clear defined research objective? CH/CC</p><p>2: Does the study clearly describe the recruitment procedure? CH/CC</p><p>3: Does the study adequately describe the inclusion/exclusion criteria? CH/CC</p><p>4: Does the study report on the population parameters and demographics? CH/CC</p><p>5: Does the study report participation rates and provide evidence of comparisons of responders and non-responders? CH/CC</p><p>6: Does the study include the sufficient assessment of social support? Criteria—Higher quality where measure is validated or measures at least two dimensions. CH/CC</p><p>7: Does the study adequately report on the strength of effect (e.g. ways of calculating effect size, reporting of confidence intervals)? CH/CC</p><p>8: Does the study use multivariate analysis? CH/CC</p><p>9: Is the study sample size appropriate for the analysis used? CH/CC</p><p>10: Do the authors report on the limitations of their study? CH/CC</p><p>11: Does the study report a participation rate at baseline >70 %?CH/CC</p><p>12: Does the study report attrition rates and provide evidence of comparisons of responders and non-responders? CH</p><p>13: Does the study report an attrition rate <20 %? CH</p><p>14: Does the study have a follow up time period >6 months? CH</p><p>15: Does the study use the same population for cases and controls? CC</p><p>16: Are the study controls adequately (e.g. no pain for >3 months) screened for symptoms compared to cases? CC</p></table-wrap-foot></table-wrap></p></sec><sec id="Sec29"><title>Appendix 3</title><p>See Table <xref rid="Tab4" ref-type="table">4</xref>.<table-wrap id="Tab4"><label>Table 4</label><caption><p>Data extraction tables for included studies</p></caption><table frame="hsides" rules="groups"><thead><tr><th align="left">Author (years)</th><th align="left">Country</th><th align="left">Study population</th><th align="left">Design</th><th align="left">Main study focus</th><th align="left">LBP assessment</th><th align="left">Work support assessment</th><th align="left">Findings</th><th align="left">Results</th></tr></thead><tbody><tr><td align="left">Andersen et al. (<xref ref-type="bibr" rid="CR1">2007</xref>)</td><td align="left">Denmark</td><td align="left">General workers sample</td><td align="left">Prospective cohort with a 2 year follow up</td><td align="left">Psychosocial risk factors for musculoskeletal symptoms within workers</td><td align="left">Presence of pain in previous 12 months + absence from work</td><td align="left">Danish National institute of Occupational health Questionnaire—CWS and SS</td><td align="left">Low SS not a risk for LBP<break></break>CWS as a non-significant risk factor for LBP</td><td align="left">HR 1.1 (0.8–1.6)<break></break>HR 1.1 (0.8–1.6)</td></tr><tr><td align="left">Clays et al. (<xref ref-type="bibr" rid="CR6">2007</xref>)</td><td align="left">Belgium</td><td align="left">General workers sample</td><td align="left">Prospective cohort over 6 years</td><td align="left">The impact of psychosocial factors on LBP</td><td align="left">Nordic questionnaire >8 days in previous 12 months</td><td align="left">Karasek Demand Control model—GWS</td><td align="left">Low GWS increased risk of LBP in men<break></break>No association between GWS and risk in women</td><td align="left">RR 1.2 (1.02–1.42)<break></break>RR 1.00 (0.8–1.24)</td></tr><tr><td align="left">Dionne et al. (<xref ref-type="bibr" rid="CR9">2007</xref>)</td><td align="left">Canada</td><td align="left">Consulters for LBP who have been absent from work for at least 1 day</td><td align="left">Prospective BL, 6 week, 12 week, 1 year and 2 year follow ups</td><td align="left">RTW for those with LBP</td><td align="left">RMDQ, pain levels, fear avoidance</td><td align="left">Work APGAR</td><td align="left">No significant role for GWS on RTW</td><td align="left">OR 4.76 (0.43, 52.13)</td></tr><tr><td align="left">Elfering et al. (<xref ref-type="bibr" rid="CR10">2002</xref>)</td><td align="left">Switzerland</td><td align="left">Workers (unspecified)</td><td align="left">Prospective cohort over 5 years</td><td align="left">Social support at work and risk of LBP</td><td align="left">Nordic questionnaire, pain frequency and intensity, RMDQ, McGill Questionnaire</td><td align="left">General questions on support in employment</td><td align="left">No significant association between low GWS and LBP</td><td align="left">N/S</td></tr><tr><td align="left">Feuerstein et al. (<xref ref-type="bibr" rid="CR11">2001</xref>)</td><td align="left">USA</td><td align="left">Military personnel</td><td align="left">Case control</td><td align="left">Workplace psychosocial factors associated with sickness absence due to LBP</td><td align="left">Self report LBP symptoms, NIOSH survey. One episode of LBP in past 12 months resulting in an episode of sickness absence</td><td align="left">Work environment scale (inclusive of one question on GWS)</td><td align="left">Participants with low GWS were at higher odds of getting LBP</td><td align="left">OR 1.22 (1.05, 1.36)</td></tr><tr><td align="left">Fransen et al. (<xref ref-type="bibr" rid="CR12">2002</xref>)</td><td align="left">New Zealand</td><td align="left">Workers claiming compensation</td><td align="left">Prospective cohort 3 months</td><td align="left">Risk factors associated with transition from acute to chronic LBP status</td><td align="left">Work-related back injury codes on claim files and the Owestry disability index</td><td align="left">Work APGAR—7 questions on perception of support at work (GWS)</td><td align="left">Perceived levels of GWS support at work did not predict transition from acute to chronic status and was not included in the final multivariable model</td><td align="left">N/S</td></tr><tr><td align="left">Ghaffari et al. (<xref ref-type="bibr" rid="CR13">2008</xref>)</td><td align="left">Iran</td><td align="left">Industrial workers</td><td align="left">Prospective 1 year study</td><td align="left">Psychosocial factors predictive of risk of LBP in workers</td><td align="left">MUSIC measure—assesses the presence of aches and pain in lower back</td><td align="left">GWS measure (unspecified)</td><td align="left">No significant associations found for GWS and LBP</td><td align="left">OR 0.5 (0.3, 1.0)</td></tr><tr><td align="left">Gheldof et al. (<xref ref-type="bibr" rid="CR14">2006</xref>)</td><td align="left">Netherlands</td><td align="left">Industrial workers</td><td align="left">Prospective cohort 18 months</td><td align="left">Risk and recovery from LBP in a work setting</td><td align="left">Current pain intensity (NRS) pain radiation</td><td align="left">Karasek Demand Control model—GWS</td><td align="left">No significant associations found for GWS and risk of LBP<break></break>No significant associations found for GWS and short term recovery<break></break>No associations found for long term recovery</td><td align="left">OR 1.19 (0.98, 1.44)<break></break>OR 0.88 (0.72, 1.07)<break></break>OR 0.97 (0.87, 1.07)</td></tr><tr><td align="left">Gonge et al. (<xref ref-type="bibr" rid="CR15">2002</xref>)</td><td align="left">Denmark</td><td align="left">Nursing personnel</td><td align="left">Prospective cohort 6 months</td><td align="left">Impact of psychosocial factors on LBP</td><td align="left">Presence of LBP, pain intensity and pain over 3 months</td><td align="left">Questions on the frequency of GWS</td><td align="left">There was no association between GWS and LBP</td><td align="left">OR 1.7 (0.7, 4.3)</td></tr><tr><td align="left">Harkness et al. (<xref ref-type="bibr" rid="CR16">2003</xref>)</td><td align="left">UK</td><td align="left">General workers sample</td><td align="left">Prospective 1 year and 2 year study</td><td align="left">Risk factors for new onset LBP in workers</td><td align="left">Back pain presence in the past month for 1 day or longer</td><td align="left">Karasek Demand Control model—GSW</td><td align="left">No significant association found for GWS and risk of LBP</td><td align="left">OR 1.4 (0.5–3.7)</td></tr><tr><td align="left">Helmhout et al. (<xref ref-type="bibr" rid="CR19">2010</xref>)</td><td align="left">Netherlands</td><td align="left">Military personnel</td><td align="left">Prospective 6 months</td><td align="left">Prognostic factors for clinical improvement for those with LBP</td><td align="left">4 weeks of recurring LBP at least 3 times per week</td><td align="left">Karasek Demand Control model—CWS and SS</td><td align="left">No significant association of CWS and disability related to LBP<break></break>No significant association of SS and disability</td><td align="left">OR 0.88 (0.64, 1.21)<break></break>OR 1.07 (0.82, 1.09)</td></tr><tr><td align="left">Heymans et al. (<xref ref-type="bibr" rid="CR20">2006</xref>)</td><td align="left">Netherlands</td><td align="left">General workers sample</td><td align="left">Prospective 1 year study</td><td align="left">Beliefs and expectations of those with LBP about RTW</td><td align="left">Presence of LBP, RMDQ and RTW status</td><td align="left">Karasek Demand Control model—GWS</td><td align="left">Increased GWS was shown to increase RTW status for those with back pain</td><td align="left">HR 1.04 (1.0, 1.08)</td></tr><tr><td align="left">Hoogendoorn et al. (<xref ref-type="bibr" rid="CR22">2001</xref>)</td><td align="left">Netherlands</td><td align="left">General workers sample</td><td align="left">Prospective 3 year study</td><td align="left">Psychosocial work factors and LBP</td><td align="left">Nordic questionnaire. Regular or prolonged back pain in previous 12 months</td><td align="left">Karasek Demand Control model—SS and CWS</td><td align="left">There was no significant association between SS and risk of LBP<break></break>There was no significant association between levels of CWS and risk of LBP</td><td align="left">RR 1.30 (0.75, 2.26)<break></break>RR 1.59 (0.89, 2.86)</td></tr><tr><td align="left">Ijzelenberg and Burdorf (<xref ref-type="bibr" rid="CR23">2005</xref>)</td><td align="left">Denmark</td><td align="left">Industrial workers</td><td align="left">Prospective 6 month study</td><td align="left">Work-related psychosocial factors and risk of MSK</td><td align="left">Nordic questionnaire. MSK pain within previous 12 months (BL) and previous 6 months (FU)</td><td align="left">Karasek Demand Control model—SS and CWS</td><td align="left">Less SS was associated with increased risk of LBP<break></break>Less CWS was not associated with increased risk of LBP</td><td align="left">OR 2.06 (1.35, 3.14)<break></break>OR 1.52 (0.97, 2.38)</td></tr><tr><td align="left">Josephson and Vingard (<xref ref-type="bibr" rid="CR26">1998</xref>)</td><td align="left">USA</td><td align="left">Nursing personnel</td><td align="left">Case control</td><td align="left">Workplace factors as risk for LBP in female nursing cohort</td><td align="left">Clinical examination and referral for treatment for LBP</td><td align="left">2 interview questions and 6 items within questionnaire on GWS</td><td align="left">No significant association between low GWS and increased risk of LBP</td><td align="left">OR 2.4 (0.9, 6.4)</td></tr><tr><td align="left">Kaila-Kangas et al. (<xref ref-type="bibr" rid="CR27">2004</xref>)</td><td align="left">Finland</td><td align="left">Metal industry workers (blue and white collar)</td><td align="left">Prospective design linked to hospitalisation records 28 years</td><td align="left">ICD codes for hospitalisation for back disorder</td><td align="left">ICD codes</td><td align="left">Karasek Demand Control model—SS and CWS</td><td align="left">Significant association found for SS<break></break>No significant association found for CWS</td><td align="left">RR 3.28 (1.32–8.17)<break></break>RR 1.08 (0.46–2.54)</td></tr><tr><td align="left">Karlsson et al. (<xref ref-type="bibr" rid="CR29">2010</xref>)</td><td align="left">Sweden</td><td align="left">Random population</td><td align="left">Prospective cohort 2 years</td><td align="left">Psychosocial factors related to sickness absence</td><td align="left">Presence of LBP in past 5 years</td><td align="left">Karasek Demand Control model with general question on support at work - GWS</td><td align="left">No significant effect for general social support at work and sickness absence due to LBP</td><td align="left">RR/OR 0.97 (0.088, 1.07)</td></tr><tr><td align="left">Kerr et al. (<xref ref-type="bibr" rid="CR30">2001</xref>)</td><td align="left">Canada</td><td align="left">Industrial workers</td><td align="left">Case control</td><td align="left">Psychosocial factors associated with LBP</td><td align="left">Biomechanical assessment</td><td align="left">Karasek Demand Control model—CWS</td><td align="left">Higher levels of CWS increased risk of LBP</td><td align="left">OR 1.6 (1.07, 2.32)</td></tr><tr><td align="left">Krause et al. (<xref ref-type="bibr" rid="CR31">1998</xref>)</td><td align="left">USA</td><td align="left">Transit operators</td><td align="left">Prospective cohort 5 year study</td><td align="left">Work-related risk factors of back injury</td><td align="left">Compensation claims for back injury</td><td align="left">Karasek Demand Control model—SS and CWS</td><td align="left">No significant association found for CWS and spinal injury<break></break>Non-significant trend reported for lower SS and risk of spinal injury</td><td align="left">OR 1.00 (0.75, 1.35)<break></break>OR 1.30 (0.99, 1.72)</td></tr><tr><td align="left">Larsman and Hanse (<xref ref-type="bibr" rid="CR35">2009</xref>)</td><td align="left">Sweden</td><td align="left">Female human service workers</td><td align="left">Prospective cohort 18 month study</td><td align="left">Impact of the demand control model on neck, shoulder and back pain in workers</td><td align="left">Nordic questionnaire (MSK)</td><td align="left">Karasek Demand Control model - GWS</td><td align="left">No significant association found for GWS and back pain</td><td align="left">OR 1.37 (0.97, 1.92)</td></tr><tr><td align="left">Leino and Hanninen (<xref ref-type="bibr" rid="CR36">1995</xref>)</td><td align="left">Finland</td><td align="left">General workers sample</td><td align="left">Prospective cohort 10 year study</td><td align="left">Psychosocial work factors and back pain</td><td align="left">Presence of pain symptoms within previous 12 months</td><td align="left">6 questions on social relationships at work</td><td align="left">Significant association found between lower GWS support at work and greater risk of LBP</td><td align="left">Beta (0.146), <italic>p</italic> = 0.001</td></tr><tr><td align="left">Lotters and Burdorf (<xref ref-type="bibr" rid="CR37">2006</xref>)</td><td align="left">Netherlands</td><td align="left">Workers registered on an occupational health register</td><td align="left">Prospective cohort 1 year</td><td align="left">Prognostic factors of sickness absence due to MSK</td><td align="left">Consultation registry Nordic and RMDQ</td><td align="left">Karasek Demand Control model—GWS</td><td align="left">No significant effect for relation with colleagues and sickness absence in those with LBP</td><td align="left">HR 1.05 (0.86–1.28)</td></tr><tr><td align="left">Mielenz et al. (<xref ref-type="bibr" rid="CR40">2008</xref>)</td><td align="left">USA</td><td align="left">General workers sample</td><td align="left">Prospective 8 week study</td><td align="left">Work-related psychosocial factors associated with LBP</td><td align="left">Biomechanical assessment</td><td align="left">Work APGAR—7 questions on CWS and SS</td><td align="left">No association between levels of SS and recovery<break></break>There was an increase in recovery rates for those with higher levels of CWS</td><td align="left">RR 0.71 (0.34, 1.48)<break></break>RR 1.55 (1.04, 2.34)</td></tr><tr><td align="left">Morken et al. (<xref ref-type="bibr" rid="CR41">2003</xref>)</td><td align="left">Norway</td><td align="left">Industrial workers</td><td align="left">Prospective 2 year study</td><td align="left">Long and short term sickness absence due to pain and LBP</td><td align="left">Nordic questionnaire for presence of pain in previous 12 months</td><td align="left">Karasek Demand Control model—GWS</td><td align="left">No association between GWS and LBP for long term sickness absence<break></break>Significant association found between low levels of GWS and increased short term sickness absence</td><td align="left">RR 1.0 (0.8, 1.3)<break></break>RR 1.28 (1.11, 1.49)</td></tr><tr><td align="left">Rugulies and Krause (<xref ref-type="bibr" rid="CR43">2005</xref>)</td><td align="left">USA</td><td align="left">Transit operators</td><td align="left">Prospective cohort 7.5 year study</td><td align="left">Job strain and incidence of LBP and neck pain</td><td align="left">Worker compensation claims and ICD coding for back and neck disorders</td><td align="left">Karasek Demand Control model—SS and CWS</td><td align="left">No associations found for CWS with LBP<break></break>No associations found for SS with LBP</td><td align="left">HR 1.00 (0.78, 1.29)<break></break>HR 1.02 (0.77, 1.34)</td></tr><tr><td align="left">Schultz et al. (<xref ref-type="bibr" rid="CR44">2004</xref>)</td><td align="left">Canada</td><td align="left">General workers sample (compensation claimants)</td><td align="left">Prospective cohort study 3 month</td><td align="left">Psychosocial factors predictive of LBP disability and RTW status</td><td align="left">McGill pain questionnaire CPG</td><td align="left">Karasek Demand Control model—CWS</td><td align="left">Low levels of CWS predicted quicker RTW status</td><td align="left">Beta 0.2, p = 0.079</td></tr><tr><td align="left">Shannon et al. (<xref ref-type="bibr" rid="CR45">2001</xref>)</td><td align="left">Canada</td><td align="left">Hospital workers</td><td align="left">Prospective cohort 3 year study</td><td align="left">Predictors of changes in MSK health</td><td align="left">Presence and pain level of back pain in previous week</td><td align="left">10 item measure of emotional and instrumental support at work GWS</td><td align="left">GWS did not remain as a predictive factor of MSK status</td><td align="left">N/S</td></tr><tr><td align="left">Soucy et al. (<xref ref-type="bibr" rid="CR46">2006</xref>)</td><td align="left">Canada</td><td align="left">General workers sample (compensation claimants)</td><td align="left">Prospective cohort study 6 month</td><td align="left">Work-related factors contributing to chronic disability in those with LBP</td><td align="left">Pain intensity and RMDQ</td><td align="left">8 item questionnaire on work social support GWS</td><td align="left">Low GWS increased risk of chronic disability</td><td align="left">OR 1.11 (1.02, 1.22)</td></tr><tr><td align="left">Stevenson et al. (<xref ref-type="bibr" rid="CR48">2001</xref>)</td><td align="left">Canada</td><td align="left">Industrial workers</td><td align="left">Prospective cohort 2 year study</td><td align="left">Risk of LBP</td><td align="left">Self rate question on presence of LBP in previous 6 months. Mechanical lifting test</td><td align="left">1 question on having a confidante at work GWS</td><td align="left">Absence of confidante at work increased risk of LBP</td><td align="left">Beta 0.27, OR 1.7, <italic>p</italic> = 0.039</td></tr><tr><td align="left">Tubach et al. (<xref ref-type="bibr" rid="CR50">2002</xref>)</td><td align="left">France</td><td align="left">Industrial workers</td><td align="left">Prospective cohort 4 year study</td><td align="left">Risk factors for sickness absence due to LBP</td><td align="left">Nordic questionnaire for LBP</td><td align="left">Karasek Demand Control model—GWS</td><td align="left">Lower levels of GWS were shown to significantly increase sickness long term absence (> 8 days)<break></break>There was no association between GWS and shorter term sickness absence</td><td align="left">OR 3.4 (1.6, 7.3)<break></break>OR 1.4 (0.9, 2.3).</td></tr><tr><td align="left">van den Heuvel et al. (<xref ref-type="bibr" rid="CR51">2004</xref>)</td><td align="left">Netherlands</td><td align="left">General workers sample</td><td align="left">Prospective cohort 3 year</td><td align="left">Sickness absence due to LBP</td><td align="left">Nordic questionnaire, presence in previous 12 months, pain intensity and RMDQ</td><td align="left">Karasek Demand Control model—SS and CWS</td><td align="left">Significant effect found for low CWS and increased sickness absence<break></break>No significant effect found for SS and sickness absence</td><td align="left">OR 4.08 (1.59–10.05)<break></break>OR 2.69 (0.85–8.44)</td></tr><tr><td align="left">van der Giezen et al. (<xref ref-type="bibr" rid="CR52">2000</xref>)</td><td align="left">Netherlands</td><td align="left">General workers</td><td align="left">Prospective cohort 12 month study</td><td align="left">Precdictors of RTW status for those sick listed (>90 days) due to LBP</td><td align="left">ICD codes for back pain disorder and pain manikin</td><td align="left">Karasek Demand Control model—GWS</td><td align="left">Greater levels of GWS predicted a quicker RTW status</td><td align="left">OR 1.16 (1.03, 1.30)</td></tr></tbody></table><table-wrap-foot><p><italic>LBP</italic> low back pain, <italic>RTW</italic> return to work, <italic>SS</italic> Supervisor support, <italic>CWS</italic> co-worker support, <italic>GWS</italic> general work support, <italic>N/S</italic> not significant, <italic>OR</italic> odds ratio, <italic>HR</italic> hazard Ratio, <italic>RR</italic> relative risk</p></table-wrap-foot></table-wrap></p></sec><sec id="Sec30"><title>Appendix 4: Assessment of employment social support</title><p>As evidenced from this review the assessment of employment support is multifaceted. Initially Johnson and Hall (<xref ref-type="bibr" rid="CR25">1988</xref>) introduced the concept of work social support in the context of Karasek’s (1981) ‘Demand Control Model’ of job strain and illness outcomes. They showed that the level of social interaction between workers modified the association between job strain and cerebrovascular disease. Initial conceptualisation and measurement was restricted to a measure of the social interaction between workers with measurement of the level of communication between workers in times of work breaks, and as part of their working day in addition to the social interaction between workers outside of the employment context. Karasek et al. (<xref ref-type="bibr" rid="CR28">1998</xref>) added to this concept by assessing the level of emotional support from both co-workers and supervisors as well as assessing the level of instrumental support (i.e. getting assistance to get their job done). The majority of the studies included within this review have based their assessment on the Karasek model, or the Work Apgar measure (Bigos et al. <xref ref-type="bibr" rid="CR3">1991</xref>); both of which primarily assess relationships between the worker and co-worker or supervisor, as well as the general work atmosphere. However Woods’ (<xref ref-type="bibr" rid="CR54">2005</xref>) qualitative review acknowledged that other aspects of support may be equally important and included additional concepts such as; acceptance by peers at work, structural support (i.e. health and safety policy, management of occupational health), health specific (i.e. the ability to discuss health issues with employers), work and personal issues (the ability to discuss issues with employers both about work and personal), level of satisfaction, level of conflict and hostility within work, working alone and feeling isolated, social support outside of the work context.</p><p>This additional level of complexity is reflected within research on social support in general. Chronister et al. (<xref ref-type="bibr" rid="CR5">2006</xref>) discusses the issue on the assessment of general social support and conceptualises the contingencies for social support on a number of differing levels. The first level is the structure; network (who offers the support), size (what size is the network, how many people), frequency (how frequent is the support available). The second level is support type; instrumental (actual practical support given by others), emotional (ability to discuss emotional issues), advice (having the availability to source advice specific to the issues the person faces), appraisal/affirmation (being affirmed and acknowledged by others). The third level is the perception of the support; it may be that all these levels of support are in place but the perception by the person will still be key as to whether the support is seen as helpful. For example, a study by Masters et al. (<xref ref-type="bibr" rid="CR39">2007</xref>) considered social support within a health context and showed that social support can be perceived differently dependent on who is giving the support, over and above having the availability of the support.</p><p>The above evidence illustrates the complexity inherent when assessing employment social support. Future research of employment support needs to acknowledge and accommodate the complexity if we are to assess the estimates of the effect of employment social support on the outcomes for those with back pain.</p></sec></app></app-group></back></pmc></record>Pour manipuler ce document sous Unix (Dilib)
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