Back statements

With back pain costing employers £5bn a year in absenteeism, managing the
problem is of fundamental importance. Recognising this, a research team has set
out new guidelines on dealing with inflicted staff.  By Lisa Birrell and Tim Carter

Disability from back pain in people of working age is one of the most
dramatic failures of healthcare in recent years. Its greatest impact is on the
lives of those affected and their families. However, it also has a major impact
on industry through absenteeism and avoidable costs: every year 40 per cent of
the population is affected by back pain and 50 million working days are lost at
a cost of about £5bn – or £200 per employee1.

New approach

A multidisciplinary working group, including occupational health nurses, for
the Faculty of Occupational Medicine (FOM), has produced guidelines for the
management of low back pain at work2. It aims to reduce the toll by providing a
new approach, based on the best available scientific evidence, and using this
to make practical recommendations on how to tackle the occupational health
aspects of the problem3.

A number of key messages and challenges for occupational health
practitioners managing low back pain at work are identified in the guidelines.
Work is only one contributor to back pain, but whatever its cause, if poorly
managed, back pain can have a devastating effect on a person’s ability to do
their job.

There are no valid methods of pre-placement screening to detect those at
risk, but a history of back pain should not generally be a reason for refusing
employment.

For people with back pain, inactivity and bed rest increase the chance of
disability – an active approach to treatment and return to work brings benefits
to everyone. And insisting on freedom from pain before someone resumes normal
work may delay recovery. OH professionals should discuss whether the inflicted
person’s job needs to be adapted to help them return quickly to full
activities. Solutions such as rest pauses, task rotation, handling aids and
extra help should be considered.

Joint initiatives

OH advisers should involve employer, employees and trade unions when
developing measures to combat back pain. This joint approach has proved
effective in reducing the impact of back pain at work. Encourage employers to
set up systems to deal promptly with reports of back pain and review these
reports to see if the prevention measures can be improved.

OH nurses should collaborate with GPs, for instance, to help people with
back pain to return to work as soon as possible if they have been absent. And
emphasise the need for active rehabilitation within a month of the start of an
episode of back pain and before it has become a chronic and largely
irremediable problem. If such services are not available locally through the
NHS, it may be possible to make arrangements through employers’ liability or
private medical insurance.

Leaflets summarising the guidelines have been produced for occupational
health practitioners, employers and people at work (see box of principle
recommendations overleaf). These complement existing guidelines produced for
primary care health professionals by the Royal College of General Practitioners
(RCGP), and should facilitate better links between the workplace and the
community for back pain management4.

The process used to develop such guidelines is well established: a
systematic review of the scientific evidence was prepared covering each of six
key occupational health areas.

Evidence statements, with weighting according to strength, were linked to
that evidence.

As far as possible, recommendations for practice were based on and linked to
these evidence statements, though there are some important areas where there is
a lack of evidence. The evidence and recommendations concentrate on
interventions and outcomes rather than on professional disciplines and so do
not make any comment on which occupational health professional should provide
advice or support.

The guidelines concern the clinical management of employees affected by
non-specific low back pain (LBP), including advice on placement, rehabilitation
and measures for prevention. They focus on actions to be taken to assist the
individual and do not specifically cover legal issues, health and safety
management, job design and ergonomics. The guidance assumes that a risk
assessment has been conducted and used to define the control measures required,
including the need for occupational health advice. It is not intended, nor
should it be taken to imply, that these guidelines override existing legal
obligations.

Any duties under the Health and Safety at Work Act 1974, the Management of
Health and Safety at Work Regulations 1992, the Manual Handling Operations
Regulations 1992, the Disability Discrimination Act 1995, or other relevant
legislation must be given due consideration.

Lisa Birrell is secretary and Tim Carter is chairman of the Faculty of
Occupational Medicine Guidelines Working Group

The report was sponsored by Blue Circle Industries, through the British
Occupational Health Research Foundation and the Faculty of Occupational
Medicine. Copies of the full evidence review and guidelines available (at £15 a
copy) from: Faculty of Occupational Medicine, 6 St Andrew’s Place, Regent’s
Park, London NW1 4LB.

www.facoccmed.ac.uk
www.rcgp.org.uk

References

1 Clinical Standards Advisory Group (1994) Epidemiology Review: The
Epidemiology and Cost of Back Pain. London, HMSO: 1-72.

2 Carter JT, Birrell LN (2000). Occupational Health Guidelines for the
Management of Low Back Pain at Work – Principal Recommendations. Faculty of
Occupational Medicine, London (www.facoccmed.ac.uk).

3 Waddell G, Burton AK (2000). Occupational Health Guidelines for the
Management of Low Back Pain at Work- Evidence Review. Faculty of Occupational
Medicine, London (www.facoccmed.ac.uk).

4 Royal College of General Practitioners 1999. Clinical Guidelines for the
Management of Acute Low Back Pain. Royal College of General Practitioners,
London (www.rcgp.org.uk).

5 Kendall NAS, Linton SJ, Main CJ (1997). Guide to Assessing Psychosocial
Yellow Flags in Acute Low Back Pain: Risk Factors for Long-term Disability and
Work Loss. 1-22. Wellington, NZ. Accident Rehabilitation and Compensation
Insurance Corporation of New Zealand and the National Health Committee.

6. The Back Book (1997). The Stationery Office (ISBN 0 1170 2078 8).

Principle Recommendations

Evidence * * * Strong * * Moderate * Limited or contradictory

Background

Make employers and workers aware that:

– LBP is common and frequently recurrent but usually brief and self-limiting

– Physical demands at work are only one factor influencing LBP

– Prevention and case management need to be directed at both physical and
psychosocial factors

* * * Physical demands at work can be associated with increased back
symptoms and ‘injuries’, but they do not generally produce lasting physical damage.
Overall, they are less important than other individual, non-occupational and
unidentified factors

* * * Disability due to LBP depends more on psychosocial factors

Pre-placement assessment

– LBP is not a reason for denying employment in most circumstances. Care
should be taken when placing individuals with a strong history of LBP in
physically demanding jobs

– Placement should take account of the risk assessment and requirements
under the Disability Discrimination Act 1995, but is ultimately a question of
professional judgement

* * * A strong history of LBP is the best predictor of future problems:
frequency and duration of previous attacks, time since last attack, radiating
leg pain, back surgery and sickness absence

* * Clinical examination, x-ray, MRI, back-function testing machines and
psychosocial screening are not reliable predictors

Prevention

– Advise on current good working practices such as specified in the Manual
Handling Regulations and associated guidance

Encourage employers to:

– Consider joint employer-worker initiatives to identify and control
occupational risk factors
– Monitor back problems and sickness absence due to LBP
– Improve safety and develop a "safety culture"
– Recognise the importance of providing satisfying work in a climate of good
industrial relations

* * * Traditional biomedical education and lumbar supports do not reduce
future LBP and work loss

* There is conflicting evidence whether general exercise/physical fitness
programmes have much preventive effect

* Joint employer-worker initiatives to monitor and improve safety can reduce
the number of reported back "injuries" and sickness absence

Assessment of the worker with back pain

– Screen for serious spinal diseases and nerve root problems

– Take a detailed clinical, disability and occupational history

– Consider psychosocial risk factors for chronicity (see "Yellow
Flags" box).

* * Patients over 50, with prolonged and severe symptoms or radiating leg
pain are at more risk of long-term disability

* * Clinical examination, x-ray and MRI do not predict clinical symptoms or
work capacity

* * * Individual and work-related psychosocial factors play an important
role in persisting symptoms and disability

Management principles for the worker with back pain

– Ensure that workers with LBP receive the key information in a form they
understand (The Back Book6) and that their clinical management follows the RCGP
Guidelines 4. Discuss expected recovery times

– Encourage the worker to continue as normally as possible and to remain at
work, or to return to work at an early stage, even if they still have some LBP

– Consider temporary adaptation of the job or pattern of work if necessary
to achieve this

* * * Staying active and returning to ordinary activities as early as
possible leads to faster recovery and fewer recurrences

* * * Most workers with LBP are able to continue working or to return to
work within a few days or weeks: they do not need to wait until they are
completely pain free

* * Joint employer-worker initiatives to provide optimum management and to
facilitate and support workers remaining at work or returning to work as early
as possible may reduce sickness absence

Management of the worker having difficulty returning to normal work
duties at 4-12 weeks

– Address the common misconception among workers and employers that you need
to be pain-free to return to work

– Advise on ways in which the job can be adjusted to facilitate return to
work

– Communicate and collaborate with primary healthcare professionals to shift
the emphasis from dependence on symptomatic treatment to rehabilitation and
self-management strategies. Where practicable refer to an active rehabilitation
programme

* * * The longer a worker is off work with LBP, the lower their chances of
ever returning to work

* * Temporary provision of modified or lighter duties facilitates return to work
and reduces time off work

* * Changing the focus from purely symptomatic treatment to an active
rehabilitation programme can produce faster return to work and less chronic
disability. This is more effective in an occupational than in a healthcare setting

* * A combination of optimum clinical management, a rehabilitation
programme, and organisational interventions designed to assist the worker with
LBP return to work, is more effective

Psychosocial ‘Yellow Flags’

Patient beliefs and behaviours which may predict poor outcomes

– A belief that back pain is harmful or potentially severely disabling

– Fear-avoidance behaviour and reduced activity levels

– Tendency to low mood and withdrawal from social interaction

– Expectation of passive treatment(s) rather than a belief that active
participation will help

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