What low back pain is and why we need to pay attention

Low back pain is a very common symptom. It occurs in high-income, middle-income, and low-income countries and all age groups from children to the elderly population. Globally, years lived with disability caused by low back pain increased by 54% between 1990 and 2015, mainly because of population increase and ageing, with the biggest increase seen in low-income and middle-income countries. Low back pain is now the leading cause of disability worldwide. For nearly all people with low back pain, it is not possible to identify a specific nociceptive cause. Only a small proportion of people have a well understood pathological cause-eg, a vertebral fracture, malignancy, or infection. People with physically demanding jobs, physical and mental comorbidities, smokers, and obese individuals are at greatest risk of reporting low back pain. Disabling low back pain is over-represented among people with low socioeconomic status. Most people with new episodes of low back pain recover quickly; however, recurrence is common and in a small proportion of people, low back pain becomes persistent and disabling. Initial high pain intensity, psychological distress, and accompanying pain at multiple body sites increases the risk of persistent disabling low back pain. Increasing evidence shows that central pain-modulating mechanisms and pain cognitions have important roles in the development of persistent disabling low back pain. Cost, health-care use, and disability from low back pain vary substantially between countries and are influenced by local culture and social systems, as well as by beliefs about cause and effect. Disability and costs attributed to low back pain are projected to increase in coming decades, in particular in low-income and middle-income countries, where health and other systems are often fragile and not equipped to cope with this growing burden. Intensified research efforts and global initiatives are clearly needed to address the burden of low back pain as a public health problem.

Consensus criteria for the classification of carpal tunnel syndrome in epidemiologic studies

Criteria for the classification of carpal tunnel syndrome for use in epidemiologic studies were developed by means of a consensus process. Twelve medical researchers with experience in conducting epidemiologic studies of carpal tunnel syndrome participated in the process. The group reached agreement on several conceptual issues. First, there is no perfect gold standard for carpal tunnel syndrome. The combination of electrodiagnostic study findings and symptom characteristics will provide the most accurate information for classification of carpal tunnel syndrome. Second, use of only electrodiagnostic study findings is not recommended. Finally, in the absence of electrodiagnostic studies, specific combinations of symptom characteristics and physical examination findings may be useful in some settings but are likely to result in greater misclassification of disease status.

The association of medical conditions and presenteeism

A self-reported measure of four domains of work impairment based on the Work Limitations Questionnaire was completed by 16,651 employees of a large financial services corporation. Using a multivariate model to control for coexisting conditions, age, and gender, significant relationships were observed between medical conditions and patterns of impaired work performance. Depression was highly associated with work limitations in time management (odds ratio [OR] = 2.05), interpersonal/mental functioning (OR = 2.50), and overall output (OR = 2.24). Arthritis (OR = 1.56) and low back pain (OR = 1.32) were associated with physical function limitations. These same two conditions were associated with limitations in mental/interpersonal functioning but with low back pain having the higher odds ratio (OR = 1.54 vs. 1.22). These results suggest that worksite interventions (eg, disease management programs) should be tailored to the unique effects observed with specific medical conditions. More targeted programs could have important benefits for productivity in the workplace.

Under-reporting of work-related disorders in the workplace: a case study and review of the literature

Accurate reporting of work-related conditions is necessary to monitor workplace health and safety, and to identify the interventions that are most needed. Reporting systems may be designed primarily for external agencies (OSHA or workers' compensation) or for the employer's own use. Under-reporting of workplace injuries and illnesses is common due to a variety of causes and influences. Based on previous reports, the authors were especially interested in the role of safety incentive programmes on under-reporting. Safety incentive programmes typically reward supervisors and employees for reducing workplace injury rates, and thus may unintentionally inhibit proper reporting. The authors describe a case study of several industrial facilities in order to illustrate the extent of under-reporting and the reasons for its occurrence. A questionnaire and interview survey was administered to 110 workers performing similar tasks and several managers, health, and safety personnel at each of three industrial facilities. Although less than 5% of workers had officially reported a work-related injury or illness during the past year, over 85% experienced work-related symptoms, 50% had persistent work-related problems, and 30% reported either lost time from work or work restrictions because of their ailment. Workers described several reasons for not reporting their injuries, including fear of reprisal, a belief that pain was an ordinary consequence of work activity or ageing, lack of management responsiveness after prior reports, and a desire not to lose their usual job. Interviews with management representatives revealed administrative and other barriers to reporting, stemming from their desire to attain a goal of no reported injuries, and misconceptions about requirements for recordability. The corporate and facility safety incentives appeared to have an indirect, but significant negative influence on the proper reporting of workplace injuries by workers. A variety of influences may contribute to under-reporting; because of under-reporting, worker surveys and symptom reports may provide more valuable and timely information on risks than recordable injury logs. Safety incentive programmes should be carefully designed to ensure that they provide a stimulus for safety-related changes, and to discourage under-reporting. A case-control study of similar establishments, or data before and after instituting safety incentives, would be required to more clearly establish the role of these programmes in under-reporting.

Integrating psychosocial and behavioral interventions to achieve optimal rehabilitation outcomes

INTRODUCTION

Psychosocial factors are important contributors to work disability associated with musculoskeletal conditions. The primary objectives of this paper were 1) to describe different psychosocial interventions that have been developed to prevent prolonged work disability, and 2) to identify future research directions that might enhance the impact of programs targeting psychosocial risk factors for work disability.

METHODS

Selective review of scientific literature on psychosocial and behavioral interventions and work disability.

RESULTS

Most prior interventions focused on psychosocial risk factors that exist primarily within the individual (e.g., pain catastrophizing, beliefs, expectancies). Successful disability prevention will require methods to assess and target psychosocial risk factors "outside" of the individual (e.g., interpersonal conflict in the workplace, job stress, etc.) using cost-effective, multipronged approaches. Research to explore interactions among different domains of psychosocial risk factors in relation to RTW outcomes is needed. Challenges to effective secondary prevention of work disability include developing competencies to enable a range of providers to deliver interventions, standardization of psychosocial interventions, and maximizing adherence to intervention protocols.

CONCLUSION

Effective secondary prevention of work disability will require research to develop cost-effective, multipronged approaches that concurrently target both worker-related and workplace psychosocial risk factors.

The Association of Health Risks With On-the-Job Productivity

OBJECTIVE

Decreased on-the-job productivity represents a large yet poorly characterized indirect cost to employers. We studied the impact of employee health risk factors on self-reported worker productivity (presenteeism).

METHODS

Using a brief version of the Work Limitation Questionnaire incorporated into a Health Risk Appraisal, 28,375 employees of a national company responded to the survey. The association between health risks and work limitation and each of the four domains was examined. Percentage of lost productivity also was estimated.

RESULTS

Ten of 12 health risk factors studied were significantly associated with self-reported work limitations. The strength of the associations varied between risks and the four domains of work limitation. Perception-related risk factors such as life dissatisfaction, job dissatisfaction, poor health, and stress showed the greatest association with presenteeism. As the number of self-reported health risk factors increased, so did the percentage of employees reporting work limitations. Each additional risk factor was associated with 2.4% excess productivity reduction. Medium and high-risk individuals were 6.2% and 12.2% less productive than low-risk individuals, respectively. The annual cost of lost productivity in this corporation was estimated at between 99Mdollars and 185Mdollars or between 1392dollars and 2592dollars per employee.

CONCLUSIONS

Health risk factors represent additional causes of lost productivity.

Early prognosis for low back disability: intervention strategies for health care providers

PURPOSE

Disability following acute occupational low back pain (OLBP) represents a significant and preventable health outcome, yet confusion about prognostic factors have limited the development of effective, targeted interventions for those at greatest risk. The purpose of this study was to synthesize findings from available studies of prognostic factors for OLBP disability in a clinically-relevant framework.

METHOD

A systematic search of the MEDLINE database was conducted to identify empirical studies assessing the value of various prognostic factors to predict extended disability after an acute episode of OLBP. Relevant studies were screened based on a number of inclusionary criteria. Prognostic factors were catalogued, summarized, and evaluated based on agreement across studies, and clinical recommendations were developed based on the evidence.

RESULTS

Of 361 studies of OLBP disability found, 22 met specific criteria for inclusion. Significant prognostic factors included low workplace support, personal stress, shorter job tenure, prior episodes, heavier occupations with no modified duty, delayed reporting, severity of pain and functional impact, radicular findings and extreme symptom report. Physicians can decrease OLBP disability by using standardized questionnaires, improving communication with patients and employers, specifying return to work accommodations, and employing behavioural approaches to pain and disability management. Future studies should evaluate interventions guided by prognosis.

A literature review describing the role of return-to-work coordinators in trial programs and interventions designed to prevent workplace disability

OBJECTIVE

Return-to-work (RTW) coordination has been suggested as an effective strategy for preventing workplace disability, but the scope of these services is not well described. The objective of this study was to describe the activities of RTW coordinators in published trials to provide a basis for establishing necessary competencies.

METHODS

A keyword search of MEDLINE and CINAHL databases was conducted to identify intervention studies with a RTW coordinator providing direct, on-site workplace liaison to reduce work absences associated with physical health ailments. This search yielded 2,383 titles that were inspected by two examiners. Using a stepwise process that allowed for assessment of inter-observer agreement, 90 full articles were selected and reviewed, and 40 articles (22 studies) met criteria for inclusion.

RESULTS

All but two studies (of traumatic brain injury) focused on musculoskeletal conditions or work injuries. Twenty-nine RTW coordinator activities were identified, but there was variation in the training background, workplace activities, and contextual setting of RTW coordinators. Based on reported RTW coordinator activities, six preliminary competency domains were identified: (1) ergonomic and workplace assessment; (2) clinical interviewing; (3) social problem solving; (4) workplace mediation; (5) knowledge of business and legal aspects; and (6) knowledge of medical conditions.

DISCUSSION

Principal activities of RTW coordination involve workplace assessment, planning for transitional duty, and facilitating communication and agreement among stakeholders. Successful RTW coordination may depend more on competencies in ergonomic job accommodation, communication, and conflict resolution than on medical training.

Measuring functional outcomes in work-related upper extremity disorders. Development and validation of the Upper Extremity Function Scale

Questionnaire-based measures of function have been validated extensively in studies of chronic illness and work-related low back pain. These measures have only recently been developed for upper extremity disorders (UEDs), and there is little information on their utility in evaluation of injured workers. We developed the Upper Extremity Function Scale (UEFS), an eight-item, self-administered questionnaire, to measure the impacts of UEDs on function. This instrument was tested in a cohort of 108 patients with work-related UEDs and 165 patients with the carpal tunnel syndrome (CTS); both groups were enrolled in prospective follow-up studies. The UEFS demonstrated excellent psychometric properties, including good internal consistency (Cronbach's alpha > 0.83), relative absence of floor effects, and excellent convergent and discriminant validity, compared with measures of symptom severity and clinical findings. In the CTS group, the UEFS was more responsive to significant improvements over time than clinical measures such as grip and pinch strength. These data support the use of a self-reported functional scale as a measure of outcome in studies of work-related UEDs. Further investigations in working populations are needed to substantiate its utility in workers with UEDs who have not yet sought medical care.

Occupational risks and injuries in non-agricultural immigrant Latino workers

BACKGROUND

To investigate occupational health in urban immigrant Latino workers, using a community-based method.

METHODS

A survey was administered through consecutively selected door-to-door interviews.

RESULTS

Response rate was 80% (n = 427). Average time in the US was 7.6 years, and average job tenure was 2.8 years. Twenty-five reported exposures to over 10 different hazards, and 18% thought these hazards had harmed their health. Only 31% received any job safety training; 55% had no workers' compensation coverage. Of the 47 (11%) with a work injury in the past 3 years, 27% reported difficulty obtaining treatment, 91% lost time from work (median = 13 days) and 29% had to change jobs because of the injury. The annual occupational injury rate was 12.2/100 full-time workers, compared to an expected rate of 7.1.

CONCLUSIONS

Urban immigrant workers have increased risk of occupational injuries, with adverse outcomes.

Outcomes in work-related upper extremity and low back injuries: results of a retrospective study

BACKGROUND

The outcomes of treatment for work-related injuries and illnesses are multidimensional and complex, but have rarely been explored in detail. This study was intended to provide information on a sample of workers representing a range of jobs and employers typical of the workers compensation system.

METHODS

A mailed, self-report survey measuring multiple dimensions was conducted. Identified through the New Hampshire Division of Workers' Compensation First Report of Injury database, a sample of workers with injuries to their lower back (60%) or upper extremities (40%) a year prior to the study were surveyed. Response rate was 80% (N=169; upper extremity cases=70; low back cases=99).

RESULTS

Most (82.8%) were working one year post-injury. Over half reported residual effects of the injury on work or activities of daily living. Many working subjects reported persistent injury-related anxiety and pain at the end of the work day, worse in those with low back pain compared to those with upper extremity injuries. Almost 40% of those who returned to work suffered a reinjury. Forty-four percent of respondents suffered significant injury-related financial problems, which were worse in those who had been out of work for longer periods.

CONCLUSIONS

Occupational musculoskeletal injuries do result in significant, long-term adverse physical, economic, and psychological consequences, as demonstrated in self-reported surveys.

Work disability and costs caused by recurrence of low back pain: longer and more costly than in first episodes

STUDY DESIGN

Retrospective analysis of workers' compensation (WC) claims data for nonspecific low back injuries (LBI) in a single jurisdiction.

OBJECTIVE

To examine whether recurrences, defined as post-initial episodes of work disability or medical care, substantially contribute to total medical and indemnity costs, and total duration of work disability.

SUMMARY OF BACKGROUND DATA

Previous studies have not measured the proportion of care seeking and work disability that are associated with recurrences in claims for work-related LBI.

METHODS

All persons with new lost-time claims for nonspecific LBI reported in New Hampshire to a large WC provider from 1996 to 1999 were selected (N = 1867). Three years of follow-up data, starting at the beginning of the first episode, were collected. Previously validated definitions of recurrence were used identify new episodes of care and new episodes of lost work time (work disability). Total duration of work disability, total medical costs, and total indemnity costs were investigated. For individuals with recurrences, these variables were separated into first-episode and recurrent period duration and costs.

RESULTS

The rate of recurrent work disability was 17.2%, and the rate of recurrent care seeking was 33.9%. Individuals with recurrence had significantly higher total length of work disability, and higher medical and indemnity costs. For those with recurrent work disability, 69% of total lost time from work, 71% of associated indemnity costs, and 84% of total medical costs occurred during the recurrent period. For those with recurrence of care, the respective values were 48%, 47%, and 42%.

CONCLUSIONS

Recurrences contributed disproportionately to the total burden of work-related nonspecific LBI, through both additional care seeking and work disability. Results imply that those who have recurrences may be an especially important target for secondary prevention efforts.

Disability prevention and communication among workers, physicians, employers, and insurers—current models and opportunities for improvement

PURPOSE

To review prevailing models of disability management and prevention with respect to communication, and to suggest alternative approaches.

METHOD

Review of selected articles.

RESULTS

Effective disability management and return to work strategies have been the focus of an increasing number of intervention programmes and associated research studies, spanning a variety of worker populations and provider and business perspectives. Although primary and secondary disability prevention approaches have addressed theoretical basis, methods and costs, few identify communication as a key factor influencing disability outcomes. Four prevailing models of disability management and prevention (medical model, physical rehabilitation model, job-match model, and managed care model) are identified. The medical model emphasizes the physician's role to define functional limitations and job restrictions. In the physical rehabilitation model, rehabilitation professionals communicate the importance of exercise and muscle reconditioning for resuming normal work activities. The job-match model relies on the ability of employers to accurately communicate physical job requirements. The managed care model focuses on dissemination of acceptable standards for medical treatment and duration of work absence, and interventions by case managers when these standards are exceeded. Despite contrary evidence for many health impairments, these models share a common assumption that medical disability outcomes are highly predictable and unaffected by either individual or contextual factors. As a result, communication is often authoritative and unidirectional, with workers and employers in a passive role.

CONCLUSION

Improvements in communication may be responsible for successes across a variety of new interventions. Communication-based interventions may further improve disability outcomes, reduce adversarial relationships, and prove cost-effective; however, controlled trials are needed.

Early disability risk factors for low back pain assessed at outpatient occupational health clinics

STUDY DESIGN

Inception cohort (<or=14 days after pain onset) with 1-month follow-up.

OBJECTIVE

To determine whether disability risk factors provided by patients and clinicians at a first medical visit for acute occupational low back pain predict outcomes.

SUMMARY OF BACKGROUND DATA

Improving health and work outcomes for patients with occupational low back pain may require early identification of risk factors for persistent pain and disability. Previous studies of back pain prognosis have not assessed patients at the time of initial provider contact, and many have not differentiated between occupational and nonoccupational injuries.

METHOD

Patients (183 female, 385 male) presenting to occupational health clinics with recent onset occupational low back pain (<or=14 days duration) completed a 16-item survey of potential disability risks including demographic, injury, workplace, psychosocial, and symptom factors. After the initial visit, clinicians completed an additional 10-item questionnaire of symptoms and initial prognosis. Outcome variables of functional limitation and work status were assessed 1 month after pain onset.

RESULTS

In multivariate analyses, functional improvement and return to work were more strongly predicted by employer factors (job tenure, physical work demands, availability of modified duty, earlier reporting to employer) and self-ratings of pain and mood than by health history or physical examination. A logistic regression model had a sensitivity of 74.3% to predict those remaining out of work and a specificity of 70.1%.

CONCLUSIONS

Early screening for disability risk factors may be helpful to identify those patients at greatest risk for delayed recovery from occupational low back pain. Intervention strategies for high-risk patients might be improved by focusing on job factors, pain coping strategies, and expectations for recovery.

Improving return to work research

BACKGROUND

Despite considerable multidisciplinary research on return to work (RTW), there has been only modest progress in implementation of study results, and little change in overall rates of work disability in developed countries.

METHODS

Thirty RTW researchers, representing over 20 institutions, assembled to review the current state of the art in RTW research, to identify promising areas for further development, and to provide direction for future investigations.

RESULTS AND CONCLUSION

Six major themes were selected as priority areas: early risk prediction; psychosocial, behavioral and cognitive interventions; physical treatments; the challenge of implementing evidence in the workplace context; effective methods to engage multiple stakeholders; and identification of outcomes that are relevant to both RTW stakeholders and different phases of the RTW process. Understanding and preventing delayed RTW will require application of new concepts and study designs, better measures of determinants and outcomes, and more translational research. Greater stakeholder involvement and commitment, and methods to address the unique challenges of each situation are required.

Reducing sickness absence from work due to low back pain: how well do intervention strategies match modifiable risk factors?

OBJECTIVE

To assess, from the review literature, the extent to which effective strategies for reducing work absence after acute low back pain (LBP) match empirical risk factors.

METHODS

From 17 recent review articles (2000-2005), disability risk factors and interventions were cross-tabulated to assess levels of relative concordance.

RESULTS

Potentially modifiable risk factors included 23 variables describing 3 workplace and 3 personal domains. Effective interventions included 25 strategies that were personal (physical or behavioral), engineering, or administrative in nature. There was a strong risk factor concordance for workplace technical and organizational interventions, graded activity exposure, and cognitive restructuring of pain beliefs. There was less risk factor concordance for exercise, back education, and RTW coordination. Few interventions focused on relieving emotional distress or improving job dissatisfaction, two well-supported risk factors.

DISCUSSION

Gaps between the epidemiological and intervention research of back disability prevention could be reduced by testing mediators of intervention effects or by stratifying outcomes according to pre-intervention risk factors.

Prognosis and the identification of workers risking disability: research issues and directions for future research

INTRODUCTION

Screening procedures based on prognostic data are an important prerequisite for prevention of disability due to low-back pain. This paper reviews the research on prognosis to delineate the most pertinent research challenges, and outlines directions for future research to improve the scientific quality and screening accuracy of prognostic efforts.

METHODS

Reviews of prognosis research were examined to identify key methodological and research issues.

RESULTS

Certain issues such as sampling procedures, research designs, data analyses, prognostic indicators, and follow-up procedures limit the value of prior studies. Absence of a clear conceptual framework hampers interpretation of findings and moving research questions forward. The recurrent nature of back pain and the need to effectively include the impact of employer actions and the job market were also identified as significant issues.

CONCLUSIONS

Future research will be enhanced by addressing conceptual and definitional issues, applying tested and sensible measures, and careful follow-up of the study population.

Geographic variation in opioid prescribing for acute, work-related, low back pain and associated factors: a multilevel analysis

BACKGROUND

Given reports about variation in opioid prescribing, concerns about increasing opioid use and its associated negative consequences make understanding the sources of variability important. The aims of the study were to assess the extent of and factors associated with geographic variation in early opioid prescribing for acute, work-related, low back pain (LBP).

METHODS

Cases were selected from workers compensation administrative data filed between January 1, 2002 and December 31, 2003 and included claims from states with more than 40 cases. Early opioid prescribing (one or more prescriptions within first 15 days) was the outcome. Weighted coefficient of variation (wCOV) estimated geographic variation, and multilevel models measured variability controlling for individual and contextual factors.

RESULTS

Of the 8,262 claimants, 21.3% received at least one early opioid prescription. Significant between-state variation was found (wCOV = 53%), from 5.7% (Massachusetts) to 52.9% (South Carolina). Seventy-nine percent of the between-state variation was explained by three contextual factors: state household income inequality (prevalence ratio [PR] 1.06, 95% confidence interval [CI] = 1.01, 1.12), number of physicians per capita (PR 0.99, 95% CI = 0.98, 0.99), and workers compensation cost containment effort score (PR 1.12, 95% CI = 1.02, 1.24). Individual-level factors, including severity, explained only a small portion of the geographic variability.

CONCLUSION

Geographic variation of early opioid prescribing for acute LBP is important and almost fully explained by state-level contextual factors. The study suggests that clinician and patient interaction and the subsequent decision to use opioids are substantially framed by social conditions and control systems. Am. J. Ind. Med. 52:162-171, 2009. (c) 2008 Wiley-Liss, Inc.

Work-related outcomes in occupational low back pain: a multidimensional analysis

OBJECTIVES

This pilot study explored a broad range of work-related outcomes for occupational low back injuries.

METHODS

A model of occupational outcomes and a survey instrument were developed on the basis of interviews, expert opinion, and literature reviews. New Hampshire workers who had an occupational back injury a year before the study were sampled from first reports of injury and sent a mailed survey about their postinjury experiences and related factors.

RESULTS

Of 251 randomly selected cases, a valid address could be identified for 121, and 99 patients responded. Almost 60% of the respondents had lost 1 week of work or more. At 1 year after injury, half of the respondents had returned to their preinjury job and employer, and 20% were unemployed, half of them because of the injury. Most working respondents reported no decrease in their work capacity. However, 68% still had pain exacerbated by work, and 47% worried that their condition would worsen with continued work. Reinjury occurred in 42% of the respondents. The work-related outcome measures were largely independent of each other. Exploratory multivariate analyses demonstrated unique patterns of factors associated with each outcome. Reinjury risk was significantly greater in respondents whose employers offered accommodations or whose postinjury jobs had greater ergonomic risk. The small sample size limited the ability to achieve statistically significant results in multivariate analyses.

CONCLUSIONS

Simply measuring return to work did not appear to capture the full range of job-related consequences from occupational back injuries in this pilot evaluation. Timing of return to work, occupational ergonomic risks, and appropriate job modifications appeared to be particularly important in a safe return to the job after an occupational low back injury. Results suggest opportunities to address risk factors that may improve work outcomes.

Development and validation of competencies for return to work coordinators

INTRODUCTION

Return to work (RTW) coordinators are a key element in programs that facilitate RTW of injured or ill workers, yet little research documents the competencies required for success in this role.

METHODS

Competencies were defined as knowledge, skills, attitudes, and behaviors. Eight focus groups were conducted with 75 experienced RTW coordinators to identify 904 individual competencies. These were subsequently reduced to 234 unique items through affinity mapping, and sorted into eight groups: administration, individual personal attributes, information gathering, communication, professional credibility, evaluation, problem-solving, and conflict management. A subset of 100 items, including 88 items most often cited, were incorporated in an Internet-based survey that sampled a broad range of RTW coordinators from three countries.

RESULTS

Eighty-three of the questionnaire items were rated 4 or 5 (very important or essential) by over half of the 148 respondents. There were no differences in affinity group mean ratings by country, employer, profession, or type of clients. The highest-rated items reflect general personal characteristics, or specific skills related to coordinating among all involved with the RTW process. RTW coordinators with nursing backgrounds provided slightly higher ratings for items related to medical knowledge, but otherwise their ratings were similar to non-nurses.

CONCLUSIONS

These findings indicate a consensus across a wide range of RTW coordinators, and results can be applied to improve coordinator selection, training, and development. Certain key competencies may be well-established individual attributes, and others may be best developed through mentorship. Most of these competencies are probably best evaluated by direct observation.

Risk Factors for Recurrent Episodes of Care and Work Disability: Case of Low Back Pain

Recurrences of injuries are common and have significant socioeconomic consequences; it is important to identify associated risk factors as potential opportunities for prevention. This study was conducted to identify risk factors for low back pain (LBP) recurrence and the extent that variation in recurrence definition impacts identified risk factors. Patients with new claims for LBP reported in New Hampshire to a workers' compensation provider were selected (n = 2023) with a minimum of 3-year follow up. Alternative definitions of recurrence included a new episode of medical care and a new episode of lost work time (work disability). Risk factors better predicted disability-based than treatment-based recurrence. Longer durations of the initial episode of care or work disability were the most powerful predictors of recurrence, implying that shorter episodes of care and early return to work contribute to better outcomes.

Improving the physician role in evaluating work ability and managing disability: a survey of primary care practitioners

PURPOSE

In the US health care system, most work-related issues are addressed by primary care practitioners (PCP's). Prior investigations of PCP's have focused on disability claims, whereas evaluations of work status and work capacity are more common. This study was conducted to identify challenges and opportunities for improvement in this area from a physician perspective.

METHODS

A validated survey was mailed to a random sample of 423 Massachusetts PCP's, with a 43% response rate.

RESULTS

On average, PCP's were requested to provide opinions regarding work ability in 9% (range, 1-100%) of all visits, about half of which involved non-work-related conditions. Their assessments were largely based on patient input and observations; direct communication with employers was rare. Only 6% agreed that PCP's should not have a role in facilitating safe return to work (RTW). However, 25% believed they had little influence over disability outcomes. While patient-specific factors were viewed as significant barriers to providers' efforts to successfully encourage RTW, lack of alternative work at the workplace was seen as the most significant problem.

CONCLUSIONS

Evaluations of work status and work ability are common PCP activities, but little formal training has been provided in this area. Rehabilitation professionals can have a significant role through provider education, developing improved systems for communication with employers, and encouraging employers to provide more alternative duty assignments.

Back pain and work

Low back pain is a leading cause of work disability and constitutes a significant socioeconomic burden worldwide. In an attempt to stem the serious consequences of long-term disability, a new approach for back pain in primary care is being disseminated. It mainly focusses on identifying the relationship between pain/disability and work, recognising important workplace and psychosocial issues, providing patients reassuring messages about activity, facilitating the return to work process and engaging other resources as needed. This article examines current expert opinion and available evidence on work issues for effective back pain management. In general, return to work, if safe, is beneficial for recovery and well-being. Some cases might require physicians to actively communicate with employers, claims managers and others in order to achieve safe and sustained return to work, while in most instances, simple efforts to identify and discuss work issues directly with the patient can lead to better work outcomes.

Caregiving for ill dependents and its association with employee health risks and productivity

This study examined the loss of productivity and health risk status associated with employees who provide care for an ill dependent. A total of 16,651 employees (23% response rate) of a major financial services company completed a confidential Health Risk Appraisal (HRA) that included an eight-item version of the Work Limitations Questionnaire and a self-report of time missed from work during the previous 2 weeks to care for an ill dependent. A total of 10.6% of the respondents reported an average of 7.7 hours absent from work during the previous 2-week period to provide care for an ill dependent. Caregiving also was associated with a significant increase in the number of health risks for the employee. As the demand for caregiving time increased, caregivers reported a significant increase in work limitations. Caregiving for an ill dependent is associated with increased absenteeism and significant work limitations while on the job. Programs and work organization that helps employees balance their caregiving responsibilities for ill dependents may have a positive effect on health and productivity.