Work restrictions and outcome of nonspecific low back pain

Chapter 6. Sickness absence due to back and neck disorders

The scientific evidence on the causes for sick leave attributed to back and neck disorders was reviewed. Categories were established for acute, recurring, and chronic problems based on the duration of the sick leave period. Forty-eight articles were found to be relevant, whereof two were of high quality and 26 were of medium or low quality. Quality was assessed exclusively in relation to the aim of this systematic review. The results reveal limited published research on causes for sick leave from back and neck disorders. The generalisability of the findings is also limited since most of the subjects were men and employees in manufacturing industries. Women, white-collar workers, employees in the public sector (care, social services, schools, etc) were underrepresented in the studies. Hence, these groups and areas should be studied further to verify conclusions and enhance knowledge about the causes for sick leave from back and neck disorders. The following factors were found to have consistent, but limited, support as regards their influence on the risk for sick leave due to back and neck disorders: (a) heavy physical workload, bent or twisted working position, and low work satisfaction increases the risk for short-term and long-term sick leave; (b) specific back diagnoses and previous sick leave due to back disorders increases the risk for short-term and long-term sick leave; (c) female gender, smoking, exposure to vibration, and deficient social support were not found to significantly increase the risk for short-term and long-term sick leave; (d) self-reported pain and functional impairments were associated with a high risk for long-term sick leave; (e) longer employment periods reduced the risk for short-term sick leave; (f) perceived demands at work did not influence short-term sick leave; (g) female gender and higher age increases the risk for disability pension.

Low-back pain

Low-back pain is one of the most common painful conditions experienced by humans throughout their life. Some occupational risk factors (namely, heavy manual material handling) may also contribute to the development of low-back pain: due to the high prevalence of both low-back pain and manual material handling in the adult working population, it has been estimated that low-back pain is probably the most common occupational disorder worldwide. Lifetime prevalence of low-back pain has been reported to be as high as 84%, depending on the case definition used, and no age group is spared, even children. Although low-back pain is not a lethal condition, it was estimated at the third rank among all diseases by disability-adjusted life-years in 2010 in the USA, after ischemic heart disease and chronic obstructive pulmonary disease, and at the first rank by years lived with disability. It also ranked high (13th) globally for the same year, in disability-adjusted life-years. Low-back pain is currently classified as nonspecific/specific as to putative cause and as acute (lasting less than 6 weeks), subacute (6-12 weeks), or chronic (more than 12 weeks) according to duration of symptoms. The distinction between nonspecific/specific and acute/subacute/chronic low-back pain is useful not only for epidemiologic studies, but also (mainly) for choosing the appropriate strategy for the diagnosis and treatment of the disorder. Workplace risk factors for low-back pain include manual lifting and whole-body vibration exposure. This chapter will provide an overview of modern concepts of low-back pain (in general) and will then outline some distinctive features of work-related low-back pain.

Absence from work and return to work in people with back pain: a systematic review and meta-analysis

Background

A considerable proportion of work absence is attributed to back pain, however prospective studies in working populations with back pain are variable in setting and design, and a quantitative summary of current evidence is lacking.

Objective

To investigate the extent to which differences in setting, country, sampling procedures and methods for data collection are responsible for variation in estimates of work absence and return to work.

Methods

Systematic searches of seven bibliographic databases. Inclusion criteria were: adults in paid employment, with back pain, work absence or return to work during follow-up had been reported. Random effects meta-analysis and meta-regression analysis was carried out to provide summary estimates of work absence and return to work rates.

Results

45 studies were identified for inclusion in the review; 34 were included in the meta-analysis. The pooled estimate for the occurrence of work absence in workers with back pain was 15.5% (95% CI 9.8% to 23.6%, n=17 studies, I² 98.1%) in studies with follow-up periods of ≤6 months. The pooled estimate for the proportion of people with back pain returning to work was 68.2% (95% CI 54.8% to 79.1%, n=13, I² 99.2%), 85.6% (95% CI 78.2% to 90.7%, n=13, I² 98.7%) and 93.3% (95% CI 84.0% to 94.7%, n=10, I² 99%), at 1 month, 1–6 months and ≥6 months, respectively. Differences in setting, risk of participation bias and method of assessing work absence explained some of the heterogeneity.

Conclusions

Pooled estimates suggest high return to work rates, with wide variation in estimates of return to work only partly explained by a priori defined study-level variables. The estimated 32% not back at work at 1 month are at a crucial point for intervention to prevent long term work absence.

Management of a patient with lumbar segmental instability using a clinical predictor rule

The diagnosis of low back pain is a common and costly condition in primary healthcare, which is often grouped into a homogeneous category. It has been suggested that the population of patients with low back pain are not a homogenous group and that they should be classified into subgroups. One subgroup identified in the literature is patients thought to have lumbar segmental instability. The patient in this case report is a 59-year-old female who presented with the four predictors of success demonstrated by Hicks et al. for implementing a lumbar stabilization program for a patient with lumbar segmental instability. With conservative treatment utilizing a lumbar stabilization program, the patient was able to regain strength, lumbar stability, and demonstrate functional improvement evidenced by an improvement in her Oswestry score. It is recommended that knowledge of current literature including clinical predictor rules can help to improve clinical decision making along with treatment of patients.

Risk factors for sickness absence due to low back pain and prognostic factors for return to work in a cohort of shipyard workers

The purpose of this study was to determine risk factors for the occurrence of sickness absence due to low back pain (LBP) and to evaluate prognostic factors for return to work. A longitudinal study with 1-year follow-up was conducted among 853 shipyard workers. The cohort was drawn around January 2004 among employees in the shipyard industry. Baseline information was obtained by questionnaire on physical and psychosocial work load, need for recovery, perceived general health, musculoskeletal complaints, sickness absence, and health care use during the past year. During the 1-year follow-up for each subject medical certifications were retrieved for information on the frequency and duration of spells of sickness absence and associated diagnoses. Cox regression analyses were conducted on occurrence and on duration of sickness absence with hazard ratios (HR) with 95% confidence interval (95% CI) as measure of association. During the 1-year follow-up period, 14% of the population was on sick leave at least once with LBP while recurrence reached 41%. The main risk factors for sickness absence were previous absence due to a health problem other than LBP (HR 3.07; 95%CI 1.66–5.68) or previous sickness absence due to LBP (HR 6.52; 95%CI 3.16–13.46). Care seeking for LBP and lower educational level also hold significant influences (HR 2.41; 95%CI 1.45–4.01 and HR 2.46; 95%CI 1.19–5.07, respectively). Living with others, night shift and supervising duties were associated with less absenteeism due to LBP. Workers with a history of herniated disc had a significantly decreased rate of returning to work, whereas those who suffered from hand-wrist complaints and LBP returned to work faster. Prior sick leave due to LBP partly captured the effects of work-related physical and psychosocial factors on occurrence of sick leave. Our study showed that individual and job characteristics (living alone, night shift, lower education, sick leave, or care seeking during the last 12 months) influenced the decision to take sick leave due to LBP. An increased awareness of those frequently on sick leave and additional management after return to work may have a beneficial effect on the sickness absence pattern.

Is preoperative occupation related to long-term pain in patients operated for lumbar disc herniation?

Lumbar disc herniation (LDH) is a common cause of back and sciatic pain. When clinical treatment fails, surgery may be indicated in selected patients. Although surgery is effective in most cases, some of these patients may have a poor outcome. Different factors may influence these results and poor adaptation at work is one well-known cause of treatment failure. This study examines 350 patients on long-term follow-up after surgery for first-time LDH. The relationship was analyzed between occupation before surgery and outcome (maintenance of lumbar and leg pain, satisfaction with the surgical treatment and return to work). The preoperative occupation (employed in public or private services, autonomous, unemployed, housewife, retired or student) and the exertion at work were analyzed as prognostic factors for different clinical outcomes. Although unemployed people had higher numerical analog scale for lumbar pain and retired patients had a higher leg pain, this difference was not statistically significant. Retired people were significantly less satisfied with the surgical result. Higher exertion at work showed a statistically insignificant higher level of pain and lower degree of satisfaction. The authors conclude that preoperative occupation was not a statistically significant factor in this series of patients.

The impact of low back pain on work: a study in primary care consulters

BACKGROUND

The cost of low back pain (LBP) to employers is high, with an estimated pound 9090 million lost in the United Kingdom in 1998. Economic analysis of LBP has focused on work absence among the employed. There is little research characterising individuals who report reduced duties or who are not in employment because of LBP.

AIMS

To compare the health related characteristics of primary care LBP consulters reporting usual employment, reduced duties, sick leave and non-employment as a result of LBP.

METHODS

Prospective cohort study recruiting LBP consulters aged 30-59 years of age from five general practices in North Staffordshire.

RESULTS

Nine hundred and thirty-five participants completed the baseline phase, 65% were in employment and 35% were not in employment. Of the employed participants over 1 in 10 (11%) were undertaking reduced duties and almost one-fifth were reporting sick leave (22%). Furthermore, 37% of non-employed consulters reported that LBP was the reason for non-employment. Significant differences at baseline in socioeconomic status, self-rated health, anxiety, depression and disability were found between those undertaking their usual job, those on reduced duties and those on sickness absence due to LBP, with those participants further removed from the work force reporting worse health across all measures. Significant differences were also found in self-rated health between those not working due to LBP and those not working for other reasons, with participants not working due to LBP reporting worse self-rated health. At follow-up, work status was found to be relatively stable.

CONCLUSION

These findings indicate that the economic impact of LBP may be higher than previously estimated when data on reduced duties is combined with work absence. The additional impact of unemployment due to LBP should also be included in future assessments of the impact of LBP on the workforce.

Medical reports recommending work restrictions at a teaching hospital in Brazil

This non-experimental and cross-sectional descriptive study aimed to evaluate medical reports recommending work restrictions for workers at a teaching hospital in Brazil. A form was used for data collection, characterizing the medical reports and work restrictions, with its content previously validated. A total of 176 medical reports was analyzed, containing 337 work restrictions, recommended from January 2001 to January 2004. The results demonstrated a high rate of work restrictions in the study hospital. The most restrictions frequent were ergonomic (78.6%), and the most often prescribed were: no weight lifting or carrying and no repetitive movements. There was an average of two restrictions per medical report, 79.5% of which were definitive and the mean restriction period was 13 months.

Changes in Disability Following Physical Therapy Intervention for Patients With Low Back Pain: Dependence on Symptom Duration

OBJECTIVES

To assess the impact of symptom duration on functional outcome, functional improvement, pain, and patient perception of recovery after a physical therapy (PT) program for low back pain (LBP) and to determine what variables are significantly associated with improved function.

DESIGN

Retrospective case series.

SETTING

Outpatient setting at a tertiary care facility.

PARTICIPANTS

Patients (N=130) who were seen for PT between June 2003 and November 2004.

INTERVENTIONS

A customized rehabilitation program was developed for each patient based on examination findings and included a combination of the following interventions: mobilization/manipulation, flexibility exercises, strengthening exercises, endurance exercises, massage techniques, and heat and cold modalities.

MAIN OUTCOME MEASURES

Functional outcome, functional improvement, perceived pain, and perceived improvement scores in the CareConnections Outcomes System (formerly TAOS) database.

RESULTS

Persons whose symptom duration was greater than 6 months had significantly less functional improvement than persons whose symptom duration was less than 1 month. The median percentage improvement score for perceived recovery was also significantly lower for the chronic group than for the acute group. There was no significant difference in the percentage decrease in pain among the acute, subacute, and chronic groups. In regression analyses, a model with age (P=.001), symptom duration (P=.002), and inclusion of strengthening, flexibility, and mobilization and manipulation exercises (P=.001) fit the data well and explained 55.5% of the variance in functional improvement score for all 3 groups combined.

CONCLUSIONS

Patients showed improvements in function following a rehabilitation program for LBP. The functional improvement score is influenced by age, symptom duration, and inclusion of mobilization/manipulation and strengthening and flexibility exercises.

Triage for nonspecific lower-back pain

Unremitting lower-back pain has long been a costly and personally devastating problem in society. Guidelines for the treatment of lower-back pain have provided evidence-based recommendations to help identify patients who will benefit from specific types of treatment in an effort to reduce costs and human suffering. However, there is little evidence that these guidelines are being applied in the daily practice of health care providers. Practical information is required to assist health care providers in triaging patients for specific treatments so that interventions can be targeted only to those who need them. In this way, iatrogenic complications and unnecessary costs can be contained. This chapter provides information on how to triage the patient with nonspecific lower-back pain for optimal care. The recommendations are supported by evidence-based guidelines, and when these are not available, best practice principles. Because appropriate treatment varies depending on the length of time a patient is suffering from lower-back pain, the chapter is divided into recommendations for acute, subacute, chronic and recurrent phases of lower-back pain.

LEVEL OF EVIDENCE

Level V (expert opinion). See the Guidelines for Authors for a complete description of the levels of evidence.

Pragmatic application of a clinical prediction rule in primary care to identify patients with low back pain with a good prognosis following a brief spinal manipulation intervention

Background

Patients with low back pain are frequently encountered in primary care. Although a specific diagnosis cannot be made for most patients, it is likely that sub-groups exist within the larger entity of nonspecific low back pain. One sub-group that has been identified is patients who respond rapidly to spinal manipulation. The purpose of this study was to examine the association between two factors (duration and distribution of symptoms) and prognosis following a spinal manipulation intervention.

Methods

Data were taken from two previously published studies. Patients with low back pain underwent a standardized examination, including assessment of duration of the current symptoms in days, and the distal-most distribution of symptoms. Based on prior research, patients with symptoms of <16 days duration and no symptoms distal to the knee were considered to have a good prognosis following manipulation. All patients underwent up to two sessions of spinal manipulation treatment and a range of motion exercise. Oswestry disability scores were recorded before and after treatment. If ≥ 50% improvement on the Oswestry was achieved, the intervention was considered a success. Sensitivity, specificity, and positive likelihood ratio were calculated for the association of the two criteria with the outcome of the treatment.

Results

141 patients (49% female, mean age = 35.5 (± 11.1) years) participated. Mean pre- and post-treatment Oswestry scores were 41.9 (± 10.9) and 24.1 (± 14.2) respectively. Sixty-three subjects (45%) had successful treatment outcomes. The sensitivity of the two criteria was 0.56 (95% CI: 0.43, 0.67), specificity was 0.92 (95% CI: 0.84, 0.96), and the positive likelihood ratio was 7.2 (95% CI: 3.2, 16.1).

Conclusion

The results of this study demonstrate that two factors; symptom duration of less than 16 days, and no symptoms extending distal to the knee, were associated with a good outcome with spinal manipulation.