BACK PAIN

ARTICLE #12: RISK FACTORS FOR WORK RELATED LOW BACK PAIN AND STRATEGIES TO PREVENT LONG TERM DISABILITY

The source of this article is RTWKnowledge.org

At a glance:
Work-related low back pain sometimes leads to long-term disability.

Some risk-factors for long-term disability can be identified soon after pain begins. Early treatment or intervention which targets these risk factors may reduce the risk of long term disability.

PERSPECTIVES:

Employee
Back pain is very common. By the age of 40, 90% of the population has had a significant episode, and one person in six has a long term problem. There are many factors that determine whether people remain active and functional after back pain, most are not medical.

Make sure you understand your back problem. Talk to your doctor, ask to see a specialist, get advice on remaining active, and find out what you can do to look after yourself. Professional athletes with medical problems can often continue to play high-level sport because they manage their condition well. They may restrict their activity at times, but usually good management means they can continue with their normal training and competition.

Most people can do a lot to improve their back problem, provided they understand it, and know which behaviors are likely to be helpful. What you understand about your condition and the approach you take to managing it has a major effect on the results you achieve.

Employer
The workplace environment affects recovery from low back pain. If an employee perceives their work to be demanding, they are more likely to experience long term disability. Workplace relations also affect the outcome, especially if disputes are occurring at work.

Anything an employer does to create a positive atmosphere at work and encourage good communication is likely to be helpful. Employees' concerns need to be taken seriously. Employees who do not feel welcome and wanted in the workplace are at a higher risk of work disability.

Treater
Long-term back problems can be difficult to manage. Hands-on treatment can be helpful in the short term, but generally doesn't improve outcomes for longer term back problems.

Treaters sometimes instruct patients to restrict their activity, which can contribute to long term disability. Studies have shown that encouraging people to return to their usual tasks improves their long term outlook. Confidence building is usually helpful too: people who are fearful of their back problem tend to avoid activity, which impedes rehabilitation.

Treating practitioners can manage long-term back problems and reduce disability by:

• Encouraging employers to provide regular and supportive contact
• Encouraging employers to provide modified work duties so the person can get back to work sooner
• Teaching the person how to prevent and manage future back problems through exercise
• Emphasizing the importance of a return to work
• Reassuring the person that low back pain is common, and usually improves with time
• Advising the person that a return to activity is not expected to cause re-injury
• Avoiding medicalization of the problem and avoiding over-treatment

Insurer
Long term disability caused by back pain is a significant burden on patients and the compensation system.

Disability can be reduced by managing relationships at the workplace, and providing early treatment that focuses on advice and explanation.

Claims managers can improve outcomes by avoiding delays and helping employers to understand their role as return to work managers. Delays in getting treatment demotivate everyone involved in return to work management.

Above all, employees need to feel supported: those who do not are less likely to return to work.

Original Article, Authors & Publication Details:
W. S. Shaw, G. Pransky and T. E. Fitzgerald (2001).

Early prognosis for low back disability: intervention strategies for health care providers. Disability & Rehabilitation 23(18): 815-28.

1 Liberty Mutual Center for Disability Research, 71 Frankland Road, Hopkinton, MA 01748, USA
2 Liberty Mutual Center for Disability Research and Department of Family Medicine and Community Health, University of Massachusetts Medical School, MA, USA
3 Center for Occupational Rehabilitation, Asheville, North Carolina, USA

Background, Study Objectives, How It Was Done:
When low back pain is work related, people tend to receive more treatment and have worse outcomes.

Of those eligible for compensation for work-related low back pain, 10% suffer chronic pain and disability for more than three months. These cases account for 90% of the cost associated with work-related low back pain.

This study aimed to identify the risk-factors for long-term disability following work-related low back pain. 22 studies dating from 1970 to 2000 have been reviewed.

Study Findings:
Risks of long-term disability

The factors below were found to be associated with a risk of long-term disability following work-related low back pain.

Workplace factors:
The employee describes their work as heavy or demanding.
The workplace is not flexible enough to accommodate employees with changed capabilities.
The employee works in the construction industry
The employee has been hired recently.

Relationship factors:
Poor relationships with co-workers
Stress outside the workplace

Circumstances of the injury:
Having had a chronic, disabling lower back injury in the past
Delays in getting treatment
Delays in reporting the injury (sometimes an indicator of a poor relationship with the employer)
The type of injury (Injuries such as falls seem to be associated with greater risk of long term disability)

• Severe pain
• Pain that is constant rather than intermittent
• Pain that severely limits the person’s activities

Patient's expectations and beliefs:

• Patient does not expect to recover or return to work
Patient overly concerned with avoiding pain
Patient coping poorly with pain

• Pain that radiates to below the knee
• Diagnosis of a disc-related problem
• Poor performance on functional tests (e.g. restricted range of motion, gait tests)
• Patients exaggerating their symptoms

All of these risk-factors can be identified soon after an injury occurs, allowing early intervention aimed at disability prevention.

Diagnostic tools such as X-rays and MRIs were found not to be good indicators of the risk of long-term disability. Many clinical tests and even the doctor's overall impression have also been found to be poor predictors.

Management of risks

The study also investigated the strategies that can be used to address these risk factors for long term disability. The following strategies were found to be useful.

Reducing workplace risks

The researchers stressed that positive communication between employee, employer and doctor helps to minimize workplace and relationship risks. This communication should be established as early as possible.

Providing alternative, more manageable work duties reduces the risk of long-term disability. A program of modified duties is likely to be more successful if the worker and their supervisor are both involved in modifying duties.

Reducing risks related to pain

Because severe pain is associated with a higher risk of disability, pain relief should be a high priority. Useful pain relief strategies include:

• Medication
• Relaxation techniques
• Training in cognitive distraction (a technique for shifting ones attention away from pain)
• Training in self-efficacy (ones belief in ones ability to cope with pain)
• Some complementary medicine techniques such as massage and acupuncture

Reducing risks related to patient beliefs and expectations

Patients' thoughts and beliefs influence their recovery, so it's important to provide reassurance that back pain is common and that most people recover without treatment.

People with low back pain often fear that returning to their normal activities will make their condition worse. In the vast majority of cases, this is not so. An early return to normal activities is rarely harmful and is associated with a better recovery.

Psychological treatments can also be useful. These include:

• Referral to specialists for positive reinforcement
• Cognitive-behavioral skills training or cognitive restructuring.

Conclusions:
Work-related low back pain usually passes quickly and needs little treatment, but sometimes it can lead to long term disability. Some of the factors that seem to put people at risk of long term disability can be identified soon after pain begins, allowing early treatment. This might reduce the chances of long term disability.

The risk factors for long term disability can be related to:

• The person's relationships at work and outside of work
• The nature of the patient's work and their work environment
• How the injury occurred
• Whether the injury was reported and treated quickly
• How the patient perceives their pain and responds to their situation

If a person is at risk of long term disability, it is important to identify the risk early, and provide treatments and interventions as soon as possible. A successful response requires cooperation between worker, employer, doctor, insurer and the person's family.

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