• Erik L Werner, Pierre Côté, Brona M Fullen, and Jill A Hayden.
• Research Unit for General Practice, Uni Health, Bergen, Norway. loewern@online.no
• Clin J Pain. 2012 May 1;28(4):364-71.

Study DesignA systematic review of the literature.ObjectivesSick-listing is a complex process that involves stakeholders at several levels. Although the physicians are the ones who issue a sick note, little is known about the mechanisms and determinants they use in making a decision about whether to sick-list a patient with low back pain (LBP). The aim of this systematic review is to describe the evidence on determinants used by physicians to sick-list patients with LBP.MethodsElectronic searches of Medline, EMBASE, PsychInfo, and Cochrane Central were conducted (all years to June 2011). Inclusion criteria included studies of workers with LBP presenting to a physician where sick-listing certification was an outcome of the consultation process. Studies were critically appraised for their internal validity by 2 independent reviewers using a modified version the criteria proposed by Hayden et al. Findings from papers were synthesized into internal and external factors related to the physician.ResultsThe search identified 1419 unique citations from which 11 papers met the inclusion criteria. The evidence suggests that 2 internal factors are important determinants of sick listing: physicians' personal fear avoidance and distress regarding the complexity of LBP. External factors included patients' expectations, the presence of clinical findings, and the support and general attitude demonstrated by a patients' employer and the availability of modified work.ConclusionsThe current review suggests that physicians need to improve their knowledge regarding options for modified work in the workplace, and about the management of LBP in general. The otherwise beneficial patient-physician relationship and physicians' care for their patients may be an obstacle to following guidelines on LBP management in the sick-listing process. Future studies should address these issues.

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