CPD: Back to work – managing and supporting severe low back pain

Against the backdrop of a sedentary and ageing workforce working for longer, managing musculoskeletal disorders effectively is becoming an increasing important part of occupational health’s role and remit. Edith Assam and Professor Anne Harriss look at the vital role OH can play in enabling a worker with severe low back pain to stay in, and return to, work.

Musculoskeletal disorders (MSD) are one of the leading causes of long-term sickness absence in the UK Health and Safety Executive (2017). MSD is an umbrella term used to describe “any injury, damage or disorder of the joints or other tissues in the upper/lower limbs or the back” (Health and Safety Executive 2019) and is the second largest contributor to disability worldwide, with low back pain (LBP) being the single leading cause of disability globally (World Health Organization 2018).

This case study explores the effects of low back pain (LBP) on Olivia (a pseudonym) employed as a full-time medical secretary.

About the authors

Edith Assam is a specialist occupational health nurse and Anne Harriss is emeritus professor in occupational health

The assessment conducted by the occupational health advisor (OHA) established the impact of LBP on Olivia’s ability to perform her role and made recommendations on possible adjustments enabling her return to work after a period of two months of sickness absence.

Work-related MSD accounts for approximately 8.9 million working days, representing 35% of all days lost due to work-related ill health in the UK (Health and Safety Executive 2017). Low back disorders represent a significant workplace problem affecting employees, employers and national wellbeing (Health and Safety Executive 2017).

McBeth and Jones (2007) state that 84% of the population will have back pain at some point in their lives and around 40% have experienced it recently. Risk factors for back pain include pre-existing spinal abnormalities, age, gender, smoking habit, physical fitness, anthropometry, lumbar mobility, strength, and mental wellbeing (Health and Safety Executive 2017).

Olivia, a 48-year-old woman, had worked as a medical secretary for five years, her role being mainly administrative with duties including receiving telephone calls, receiving visitors to the department and regularly using display screen equipment (DSE) to book appointments.

Pathophysiology of low back pain

LBP is pain in the area on the posterior aspect of the body from the lower margin of the twelfth rib to the lower glutaeal folds with or without pain referred into one or both lower limbs.

According to Borenstein and Calin (2012), musculoskeletal dysfunction and tissue damage occur when a number of neurohumoral factors have been activated, when activated normal annulus fibrosus in the intervertebral discs is highly enervated by pain fibres and capable of pain response.

Multiple nerve interconnections modified by neuropeptides and other chemokines produced by nerves and surrounding tissues send signals to the central nervous system where they are experienced as pain (Borenstein and Calin 2012). LBP can be the presenting symptom of medical conditions remote from the spine, including pyelonephritis, appendicitis, pancreatitis and other upper gastrointestinal disorders (Souter 2012).

Anatomical factor in the development and progression of LBP are mechanical disorders of the lumbar spine and related to injury, overuse or spinal deformities. The most important traumatic factors in LBP relate to soft tissue structures (Borenstein and Calin 2012).

Occupational health referral

Olivia was referred for an occupational health (OH) assessment by her line manager following a two-month period of absence.

The purpose of this referral was to establish whether she was well enough to undertake the requirements of her role without posing a risk to themselves or others (Anderson-Cole et al 2018) and to advise her manager regarding the impact of her work tasks on her health providing support for productive employment (Richardson 2008).

Recommendations given by an OHA to a manager on reasonable adjustments or modifications will assist them to make decisions on how best to support the employee while at work so they remain at work.

Olivia attended for a face-to-face consultation and confirmed she was aware of the manager’s referral and had given her consent for the consultation. Olivia’s identity was confirmed and the confidential nature of the consultation explained. Her signed consent for assessment then the preparation and release of a response to management was obtained.

A full clinical history including Olivia’s current and past medical and occupational history was recorded. She reported suffering severe LBP resulting from herniated L4 and L5 spinal disks. A spinal magnetic resonance imaging (MRI) report indicated degenerative changes.

She reported that over an eight-month period she had experienced intermittent LBP, with referred pain radiating down her right leg. This had been treated three months previously with a root nerve injection with disappointing results.

One month after this treatment she experienced a further episode of severe LBP. She associated this with prolonged sitting whilst dealing with clients. Her GP prescribed analgesia, assessed her as unfit for work and referred her for an MRI scan and physiotherapy treatment.

Olivia highlighted difficulties lifting heavy objects, and walking or sitting for protracted periods. She struggled with activities of daily living including washing and dressing, requiring her daughter to assist her with her personal hygiene.

Olivia scored the pain she was experiencing as eight on a 1-10 scale, describing the quality and position of the pain as a burning sensation in the lumbar region radiating down her right leg. She identified triggers to her pain as prolonged periods spent seated. Her pain also increased on changing position in bed.

A wide variety of non-surgical options for treating LBP is available. Commonly prescribed medication includes acetaminophen, narcotics, muscle relaxants, anti-depressants, steroids and non-steroidal anti-inflammatories (NSAID). Each of these has strengths, limitations and risks.

The particular low back problem and overall health status will determine which analgesic is indicated (Spine Health 2019). NICE (2016) recommends NSAIDs as the analgesic of first choice. Weak opioids only being prescribed should NSAID be ineffective, contraindicated or poorly tolerated. Olivia had been prescribed Ibuprofen 400mg and Tramadol 100mg when required.

At the end of the assessment, the OHA explained to Olivia the recommendations she would be sending to her manager and provided her with a copy of the password encrypted report to review. This gave her the opportunity to correct factual inaccuracies, but not the professional opinion of the OHA.

Psychological aspects of lower back pain

Abnormalities in the regulation of the brain’s chemistry and usual brain functions in emotional control, anxiety and attention can be disrupted with LBP (Harvard 2016). Olivia reported that, when her physical movement was limited, she relied on family members to assist her with simple tasks. This caused her psychological distress worsening her pain perception.

Impact of low back pain on quality of life

Olivia reported during the assessment that prolonged periods of standing and sitting exacerbated her pain, as did rising from a seated position as this required her to use her arm for leverage to get out of a chair. She noted a worsening of LBP when getting out of bed in the mornings. Driving also caused her difficulties and she was only able to drive short distances.

LBP was making her life miserable. Activities including walking, standing, bending, driving, computer work and catching up on household chores were difficult. Sneezing and coughing caused sudden, intense pain.

Olivia had used to swim three times a week and attend an exercise dance class twice each week. However, she had discontinued these hobbies because of her fear of exacerbating the pain.

Functional assessment and impact of condition on role

The primary objective for the analysis of a disability in the context of an OH consultation is not to diagnose or treat, but to assess the functional effects of a person’s condition on their day to day living and to determine if the individual is fit for work.

According to Murugiah et al (2002), assessment of fitness to work should evaluate personal aspects, work characteristics, work environment and legal aspects.

The functional assessment undertaken took into account Olivia’s ability to perform her day-to-day activities of daily living. A specific back pain assessment was completed using the questionnaire routinely used in the organisational assessment indicated Olivia’s condition was limiting her mobility and her ability to sit or stand for long periods. It confirmed her inability to lift or move even moderately heavy loads.

Her ability to undertake activities of daily living including household chores and self-care were significantly impaired. In the workplace her LBP posed a significant problem for sedentary tasks. Olivia was generally positive that her condition would improve but frustrated regarding the impact it was having on her daily living activities.

In her office environment, Olivia reported that her chair provided insufficient back support and she had difficulties getting out of the chair, requiring her to use her hand as leverage to get up. As she was of small stature, when her chair was adjusted to fit the height of her desk she was unable to keep her feet flat on the floor.

Biopsychosocial model

A biopsychosocial approach is essential to the history taking. The OH advisor requires the knowledge of the job demands, abilities of the individual and clinical knowledge of any health condition to inform the opinion about fitness to work. The biological component of disease and illness should be considered regardless of whether it relates to a physical or mental health condition.

The holistic biopsychosocial approach to assessing clients incorporating clinical flags (Engel 1980) and identifying barriers to work was integral to this assessment. Each flag representing a different facet. Starting with red flags focusing on biological issues, red flags for Olivia were the impact of work tasks that might have caused, contributed to or exacerbated her current symptoms. Olivia’s role encompassed static working postures and involved repetitive tasks including typing.

Yellow flags, representing psychological factors, encompass thoughts, feeling and behaviours incorporating her beliefs about pain and work, her fear of movement and of re-injury. Olivia expressed fears of her return to work exacerbating her LBP.

Pain beliefs have been identified as predictive of prolonged work disability and progression into chronicity (Waddell and Burton 2001). Providing health education regarding back pain was an essential part of this OH consultation. The OHA therefore educated Olivia on initiatives she could undertake to reduce her LBP, including appropriate working and leisure postures, ensuring her workstation was appropriately set up, and the importance of regular, gentle, exercise. The aim of all this was to alleviate her anxiety and stress (Adams et al., 2006).

Blue biopsychosocial flags, represent social factors impacting work, were of no significant concern in this context. Olivia enjoyed her role, there were no conflict issues at work, and she had excellent family support at home.

Within the BPSM, black flags represent financial and legal issues. Olivia explained that her husband had retired on health grounds, making her the sole earner. The associated financial implications of her long-term back pain and the effect on her job role were therefore a significant concern for her.

Waddell and Burton (2006) emphasis that people on sick leave should be encouraged and supported to return to work as soon as possible, even if on a phased basis as work is therapeutic, promoting recovery.

Legal considerations

The legal aspects of the Murugiah framework incorporates the employer’s duty of care to employees as required by the Health and Safety at Work etc. Act (1974). There is also the framework to be considered that includes the employers’ duty of care under Section 2 of the Health and Safety at Work etc. Act 1974 ensuring, so far as reasonably practicable, the health, safety and welfare of their employees.

The advice given by the OHA must be based on sound legal principles (Murugiah et al, 2002), and the provisions of the Equality Act (2010) are of particular relevance. Section 6(1) of the Equality Act (2010) states that a person has a disability should they have a physical or mental impairment causing substantial and long-term adverse effects on their ability to conduct normal day-to-day activities, work being considered to be such an activity.

Although a legal rather than a medical decision, Olivia may be covered by this Act because of the recurrent nature of her condition and the significant adverse effect on her ability to perform normal daily activities of daily living.

Other key legislation pertinent to back pain in the workplace includes the Manual Handling Operations Regulations 1992 for those whose work involves moving and handling tasks and the Health and Safety (Display Screen Equipment) Regulations 1992 for those whose work tasks involve computer use.

Adjustments to support a prompt return to work

According to Waddell and Burton (2006) work has benefits for an individual’s wellbeing and health, both psychologically and physically. They note that worklessness leads to declining physical and mental health and the benefits of work far outweighing the risks associated with workplace hazards.

The longer Olivia withdrew from work because of her levels of pain, the greater the risk of developing chronic pain and disability, and the less likely of her ever returning to work (Waddell and Burton 2006). Through early intervention and putting in place return to work arrangements, employers can therefore avoid losing workers through long-term sickness.

The outcome of the OHA consultation, based on the information provided, was that Olivia was fit to return to work with some adjustments to support her continuing in her role. The OHA’s role was to give advice on functional capacity and make suggestions regarding possible adjustments. But, ultimately, the decision on whether an adjustment is reasonable is made by the manager (Kloss 2012).

The OHA recommended that Olivia would benefit from having a phased return to her role. An appropriate approach would be for her to work for four hours each day for the first two weeks following her return and scheduled to enable her to avoid rush-hour commuting.

Her working hours should then be increased for the following two weeks to six hours per day. Provided she was able to manage these hours she should then recommence her normal contractual hours. During the initial phased return working alternate days could also be considered if practicable to allow her to rest and manage her pain symptoms.

Other recommendations included:

  • Olivia should meet with her line manager to discuss any concerns or issues she may have on her return to work.
  • A DSE workstation assessment be carried out to establish that it was set up appropriately. This assessment should include work planning to ensure she was aware of the importance of varying her work tasks and avoiding long periods entailing static seated postures. Taking her allocated breaks would also help to avoid overtiredness and enable her to change posture.
  • She should avoid workplace manual handling tasks whilst symptomatic.

Conclusions

Severe LBP can be a debilitating, emotionally distressing condition affecting the ability of the sufferer to perform their activities of daily living and function within their work role.

The OHA used the biopsychosocial model in the assessment of a client with severe LBP. Appropriate adjustments were discussed with Olivia’s manager enabling her to achieve a successful return to work.

References:
Adams, M A (2004). “Biomechanics of back pain”. Acupunctured in Medicine 22(4); pp.178-188.

Anderson-Cole, L, Everton, S, Mogford, S, Romano-Woodward, D, Thornbory, G (2018). “Health assessment, case management and rehabilitation” in Thornbury G and Everton S (ed) Contemporary occupational health nursing, a guide for practitioners. 2nd ed.

Borenstein, D G, and Calin, A (2012). “Fast Facts: Lower Back Pain”. Health Press Ltd 2nd ed. Oxford.

Engel, G (1980). “The Clinical Application of the Biopsychosocial Model”. AMJ Psychiatry; 137: 535-805.

Harvard Health Publishing (2016). “The Psychology of low back pain”. Available from:
https://www.health.harvard.edu/blog/psychology-low-back-pain-201604259537

Health and Safety Executive (2017). “Work-related Musculoskeletal Disorders (WRMSDs) Statistics in Great Britain 2017”. Available from: http://www.hse.gov.uk/Statistics/causdis/musculoskeletal/msd.pdf

Health and Safety Executive (2019). “Musculoskeletal Disorders”. Available from: http://www.hse.gov.uk/msd/

Keith, T, Palmer (2013). “Fitness for Work, The Medical Aspects”, Oxford University Press USA – OSO. ProQuest Ebook Central, Available from: http://ebookcentral.proquest.com/lib/lsbuuk/detail.action?docID=1132328

Kloss, D (2012). “Disability management and law”, in: Kloss, D, and Ballard, J, (eds.) Discrimination law and occupational health practice. Barnet: the work partnership Ltd, pp.72-99.

Maniadakis, N and Gray, A (2000). “The economic burden of back pain in the UK”. Pain 84:95-103.

McBeth, J, and Jones, K (2007). “Epidemiology of chronic musculoskeletal pain”. Best Pract Res Clin Rheumatology 21 (3): 403-25.

Murugiah, S, Thornbory, G, and Harriss, A (2002). “Assessment of fitness”. Available from: https://www.personneltoday.com/hr/assessment-of-fitness/

National Institute for Health and Care Excellence (2009). “Workplace health: long-term sickness absence and incapacity to work: Public Health Guidance (PH19)”. Available at https://patient.info/doctor/long-term-sickness-and-incapacity

National Institute for Health and Care Excellence (2016). “Low back pain and sciatica in over 16s: assessment and management [NG59]”. Available at: https://www.nice.org.uk/guidance/ng59/resources/low-back-pain-and-sciatica-in-over-16s-assessment-and-management-pdf-1837521693637

Richardson, P, R (2008). “Case Management in Occupational Health Nursing”, 3rd edition,
Edited by K. Oakley. Jon Wiley & Sons Ltd.

Souter, A. (2012) Anatomy and pathophysiology of back pain in Souter A, Cregg R, Back Pain (ed) Oxford University Press.

Spine Health (2019). “Non-surgical treatments for lower back pain”. Available from:
https://www.spine-health.com/conditions/lower-back-pain/non-surgical-treatments-lower-back-pain

Waddell G, Burton K (2001). “Occupational Health Guidelines for the Management of Low Back Pain at Work – Evidence Review”. London: Faculty of Occupational Medicine

Waddell, G and Burton, K A (2006). “Is work good for your health and wellbeing?” Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/214326/hwwb-is-work-good-for-you.pdf

World Health Organization (2018). “Musculoskeletal conditions.” Available from: https://www.who.int/news-room/fact-sheets/detail/musculoskeletal-conditions

One Response to CPD: Back to work – managing and supporting severe low back pain

  1. Avatar
    Richard Chandler 6 Mar 2020 at 12:49 pm #

    An interesting article and one that describes a case so similar to many others.

    Musculoskeletal conditions can prove very difficult for line managers to deal with and that it is often only when there has been a significantly lengthy duration of absence that a referral to OH is considered and/or made.

    What is often missed or certainly has a smaller profile is the shorter duration absences that are often the precursor to the big visible absence. And does HR or the line manager have the time and data easily available to spot any developing trends?

    We access to over 15 years of absence data we see clearly recognisable trends within organisations relating to MSK conditions. For example the rate of reoccurrence of an MSK condition within 3 months is 9%. With this in mind our client can cross examine and view what roles and functions are most likely to be represented in this 9%. This helps them start to get ahead of the underlining absence issues (whether long and short duration) and become more proactive rather than reactive.

    Also for these types of absence our data demonstrates clearly that line manager engagement is essential and to help with this we introduced dynamic Return to Work interview forms tailored specifically Musculoskeletal (and also Stress) reasons.

    These forms encourage managers to ask more informative questions regarding an employees’ absence and also provide prompts to refer employees to an Employee assistant programme (EAP) or Occupational Health.

    Early interventions really help and have reduced the average length of Musculoskeletal absences by as much as 76%.

    We work closely with our clients OH departments and outsourced OH contractors, early intervention can make a huge difference to all. Employee, Employer, OH Provider.

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