Back to work

Back problems have a nasty tendency to become chronic and the outcome is
heavily dependent on the attitude of the patient and the healthcare
professional. Unhelpful beliefs must be challenged and individuals involved in
their own recovery programme, by Dr Grahame Brown

Disability attributable to back pain in people of working age is one of the
most spectacular failures of modern health care in the industrialised world.
Its greatest impact is on the lives and families of those affected. However, it
also has a major effect on industry through absenteeism and avoidable costs, on
social security costs and on pension schemes. This article looks at ways in
which health care professionals can reduce the risk of adding to this massive
personal, social and economic burden when individuals present with the
complaint of back pain.

All healthcare professionals involved in managing people with back pain must
be familiar with a paradigm shift in thinking about this problem with the
publication of Waddell’s The Back Pain Revolution.1 However, attitudes, beliefs
and behaviour must change in healthcare professionals as well as patients, and
frequently it is the former who are more resistant to change.

A recent evidence review from the Faculty of Occupational Medicine, London2
highlights our current state of knowledge and makes recommendations that are
essential reading for any OH professional.

It is clear that attempts over the past few decades (supported by
legislation) to prevent back pain occurring in the workplace (primary
prevention) have been unsuccessful. These methods have been largely based on
the injury model of back pain (for example, manual-handling training) and
concentrate on the orthodox, disease model of medicine. The only evidence to
date that activity in the workplace aimed at primary prevention has had any
effect on outcomes that matter to individuals and employers is the promulgation
of information that challenges attitudes and beliefs based on a
cognitive-behavioural model.3-5 At present, these methods, and secondary and
tertiary prevention strategies, provide the most effective means of reducing
the risk of costly chronicity and disability.

Treatment aims

The goals are to prevent disability and chronicity developing. Occupational
Health professionals are in an ideal position to see workers who are having
difficulty with back pain early in the course of events and to influence
positively the outcome.

The first consultation a person troubled by back pain has with a health care
professional is probably the most important. It will either set that person on
the road to recovery and restoration of function or, as happens all too often,
it will precipitate despair, depression and disability. So, at this important
stage, it is helpful for the health care professional to have in mind a few
important facts and questions:

– The complaint of back pain affects everyone at some time, with 90 per cent
of us experiencing significant interference with daily activities for at least
48 hours at some time in our lives. And 40 per cent will experience recurring
problems with our backs

– Psychosocial factors may operate at different stages in the development
and perpetuation of low back pain. These factors may have precipitated the
first consultation for the complaint. Often, unfortunately, causation is
wrongly attributed to what the person was physically doing when first
complaining of symptoms. It is important to know the risk factors for
chronicity and disability

– Make an initial assessment of the clinical problem: Is it ‘simple back pain’,
nerve root pain or is there possible serious pathology? If there are any
symptoms that give cause for alarm, for example, age of onset less than 20 or
greater than 55 years, or the presence of constant progressive pain, the
patient should be referred promptly to a surgeon. Referring a patient will
ensure laboratory tests, including full blood count, sedimentation rate and
biochemistry screen are performed to rule out occult pathology

– Ask yourself the question: "What can I do right now to reduce the risk
of this person becoming disabled or a chronic sufferer?" Most often this
will not involve skilled physical treatments but will be achieved by reducing
anxiety and emotional arousal, challenging unhelpful attitudes and beliefs,
providing positive information and involving individuals in their own recovery
programme. Giving the person a copy of The Back Book4 to read is likely to be
very effective

The interview with the patient is vitally important. Remember three
functions of the medical interview:

– Establish rapport: Greet the patient warmly and by name. Listen actively
and reflectively. Detect and respond to emotional cues

– Collect data: Do not interrupt the patient. Use open questions first and
collect accurate information with closed questions later. Elicit patient’s
explanatory model. Develop a shared understanding

– Negotiate and agree a management plan. Provide information. Use
reassurance appropriately. Make links. Negotiate behaviour change

An interview conducted in this way can be very therapeutic in itself. This
person-centred (as compared with a purely disease-based) approach improves
outcomes that matter to patients, shortens follow up and reduces unnecessary
investigations.

Physical treatments

OH departments do not normally provide physical treatment services, but some
use in-house physiotherapists, or osteopaths. It is important to target this
service where it is most likely to be effective for the patient and
economically viable for the organisation.

For example, after 12 weeks’ sickness absence, figures show that 25 per cent
of workers with low back pain will never return and this figure increases to 50
per cent by 26 weeks off.

When the goal is to reduce long-term sickness absence, it therefore appears
that the group of workers to whom available resources are best targeted are
those who are off work for between four and 12 weeks. Interventions provided to
those who are at work but struggling are arguably no less important to help
them remain functioning. Those at work and coping with nuisance symptoms not
interfering with their ability to work are a low priority. Some form of
priority has to be given when resources are insufficient to meet demand.

Whatever the course of treatment for low back pain, or any other regional
pain problem, it is worth remembering that if it is not beginning to make any
useful difference to the patient, as shown by improved function, by, at the
most, six treatments, it is not working. Reassess, review the obstacles to
recovery and do something different. Prolonging ineffective treatments is very
damaging to the psychological well-being of the patient.

Much can be done and begins at the first consultation. Some important points
are:

– Encourage a return to work as soon as possible; there is no need to wait
until all the pain has gone

– Make a return to normal work the goal: this reinforces the belief in the
patient that normality can be achieved. It also, and vitally, reduces
fear-avoidance beliefs and behaviour

– Use a fixed period for return to work, with a gradual increase in activity
and responsibility to help achieve a return to normal activities. This must be
time-limited, with goals set and reviews arranged. Some form of temporary
restrictions may be helpful, but must be time-limited. It is a mistake to allow
restrictions to depend on ‘how the patient feels': this encourages pain and
illness behaviour and only creates more problems in the future, which are even
more difficult to solve

– Use treatments that facilitate active rehabilitation and that do not
interfere with it

– Consider short spells in functional restoration programmes for those who
have demonstrated a commitment to work hard to improve their functional
capacity, but are having difficulty. These excellent (but expensive) programmes
should not be used, however, in the hope that they can magically motivate a
person who has learned helplessness, is depressed, is focused on compensation
issues of whatever nature or who has no belief that their quality of life or
occupational status can be improved

– Support and encourage the person through the difficulties and setbacks
that will inevitably occur. OH professionals are in an ideal position to do
this

– Consider redeployment or severance only when all reasonable attempts have
been made to rehabilitate to normal work. Healthcare professionals not trained
in OH frequently advise patients, who mention during a consultation that they
are experiencing difficulties at work with back pain, to give up or find
alternative work. The consequences are not discussed and are often devastating
to the individual, especially those with limited transferable skills

– Liaise with all health care professionals involved in the case. Be
prepared to take a lead in case management. Seek other opinions if you believe the
patient will benefit

Summary

The causes of low back pain are multifactoral, and management is multimodal.
Psychosocial factors strongly influence presentation and outcome at all stages
and are no less important, even in the presence of clearly identifiable spinal
pathology.

These psychosocial factors, particularly, are amenable to intervention in
the occupational setting. Excellent communication and consulting skills must be
a goal for all healthcare professionals. Learning the skills of brief, solution-focused
counselling will improve your outcomes and job satisfaction.

References

1. Waddell G (1998) The Back Pain Revolution. Churchill Livingstone, London

2. Occupational Health Guidelines for the Management of Low Back Pain at
Work: Evidence review and recommendations. (2000) Faculty of Occupational
Medicine, London.

3. Buchbinder R, Jolley D, Wyatt M (2001) Population-based intervention to
change back pain beliefs and disability: Three part evaluation. BMJ,
322:1516-1520.

4. Symonds TL, Burton AK, Tillotson KM, Main CJ (1995) Absence resulting
from low back trouble can be reduced by psychosocial interventions at the
workplace. Spine, 20: 2738-2745.

5. Roland M, Waddell G, Moffett JK, Burton AK, Main CJ, Cantrell E, (1997)
The Back Book. The Stationary Office, Norwich.

Further information

Musculoskeletal (orthopaedic) physicians:

The British Institute of Musculoskeletal Medicine, 34 The Avenue, Watford,
Herts, WD17 4AH
01923 220999, www.bimm.org.uk

Physiotherapists and doctors

The Society of Orthopaedic Medicine, 6 Court View Close, Lower Almondsbury,
Bristol, BS32 4DW
01454 610255, www.soc-ortho-med.org

Workshops, seminars and courses on brief, solution-focused effective
counselling and communication skills: suitable for all healthcare
professionals:

MindFields College, Church Farm, Chalvington, East Sussex, BN27 3TD

01323 811440 www.mindfields.org.uk/humangivens

Dr Grahame Brown BSc MRCGP DipSportsMed AFOM HGdip FFSEM(RCSI)is a
musculoskeletal (orthopaedic) and sports physician and specialist in
occupational and psychological medicine at the Royal Orthopaedic Hospital NHS
Trust, Birmingham.

He is hon. senior clinical lecturer at The Institute of Occupational
Health, the University of Birmingham, and consultant to the occupational health
team at Land Rover vehicles and to a number of professional sports teams and
musicians.

He integrates a variety of orthodox and selected complementary treatments
and therapies into patient management.

grahame.brown@talk21.com

Box 1: Psychosocial key points

– Psychological factors have a
considerable influence on pain and disability, and a stronger influence on
outcome than biomedical factors

– The shift from medical to bio-psychosocial models of illness
highlights the major importance of psychological factors

– Important factors are distress, beliefs and attitudes, pain
behaviour and pain-coping strategies

– Psychological factors in response to acute pain are
predictive of chronic incapacity

– There needs to be a redirection from investigations into the
nature of pain towards obstacles to recovery

– Distress at and confusion about previous treatments have a
powerful influence on a patient’s reaction to pain and disability

– There is an urgent need to develop the integration of
psychological perspectives into the clinical practice of all health care
professionals

– Better management of psychological reactions at early stages
of treatment has the potential to reduce distress and prevent unnecessary
chronicity

Box 2: Psychosocial warning signs

Attitudes and beliefs about pain

– Pain is always harmful

– Pain must be abolished before return to activity

– Catastrophising, ie, thinking the worst, misinterpreting
bodily symptoms

– Belief that pain is uncontrollable

– Passive attitude to rehabilitation

Behaviours

– Withdrawal from normal activities, substituted with
non-productive time

– Poor compliance with exercise. All-or-nothing approach to
exercise

– Reliance on aids or appliances

– Substance abuse, especially smoking and alcohol

Emotion

– Fear of pain

– Depression

– Anxiety, irritability, distress, post-traumatic stress

– Fear of moving (kinaesiophobia)

– Learned helplessness and hopelessness

– Anger

– All of the above are states of high emotional arousal and
will manifest with sleep disturbance, cognitive impairment (typically
black-or-white, all-or-nothing thinking patterns) and physiological symptoms

Diagnosis and treatment

– Health professionals sanctioning disability

– Conflicting opinions and advice, accepting opinions as fact

– Behaviour of health professionals, dependency on treatments,
over-controlling therapists

– Prolonged courses of passive treatments that clearly are not
working

– Advice to give up work

– Over-reliance on investigations, dramatisation and medical
labelling: ‘arthritis in the spine’, ‘crushed discs’, ‘trapped nerves’, ‘give
up work or you will end up in a wheelchair’

Family

– Over-protective partner, emphasising fear avoidance and
catastrophising

– Solicitous behaviour from spouse

– Socially punitive responses from spouse, eg, ignoring

– Lack of support

– Cultural beliefs and behaviours

Compensation issues

– Lack of incentive to return to work

– History of claims for other health problems

– Disputes over eligibility – "How can you get better if
you have to prove you are ill?"

– Persistent focus on ‘diagnosis’ and cause rather restoration
of function and health

– Ill health retirement benefit issues

– Previous experience of ineffective case management

Work

– Poor job satisfaction, feels unsupported, frequent job changes

– Poor relationship with managers, supervisors, co-workers

– Belief that work is harmful

– Minimal availability of selected or alternative duties, or a
graduated return to work, "Don’t come back until you are totally better"

– Low socio-economic status

– Job involves significant biomechanical demands

– Stress at work: eg, relationships, perceptions, bullying

Case history

Alison, a 50-year old lady, had been
presenting to health care professionals with back pain and a variety of
disturbed sensations for the best part of two years. She had had some trouble
with her back for many years, but was feeling much more pain now and the pain
was gradually getting worse.

She was starting to take off a significant amount of time from
her job as a secretary in a large organisation. Spells of absence up to four
weeks at a time were accumulating, totalling 11 weeks during the previous year.

She had no symptoms of serious pathology and no nerve root
pain. She had gained weight in the past year. Various courses of physiotherapy
had failed to make any difference to the pain or disability, and blood tests,
including thyroid function, arranged by her GP, were negative. The GP did not
know what to do next and asked for an opinion. Importantly, the patient had not
come to the attention of occupational health staff.

The patient had been told in the past that she had arthritis in
her spine and had been advised to give up swimming, as breast stroke can only
make this worse (another of the nonsense myths circulating about back pain).
Her sleep pattern was very disrupted and she was feeling low in her mood. Her
employer was supportive, but she sensed that this might not always be the case.
There did not appear to be any obvious problems at work or at home.

I was curious to find out what life events had occurred two
years ago at the time when she started to present with back pain. It did not
take long to discover that her mother her died. Non-verbal cues indicated that
she was still grieving and her sleep disturbance had started at the time of her
bereavement. Physical examination revealed nothing more than segmental
stiffness in the upper lumbar region.

I explained to her that heightened emotional arousal, reflected
in the poor sleep quality, had served to raise her sense of somatic awareness
and lower her tolerance to pain and discomfort. A simple explanation of the
mind-body system was sufficient to reassure her. I acknowledged her grief and
encouraged her to talk more about her feelings with her husband over the coming
weeks. Advice to stop exercising and instilling fears of disease had only made
matters worse. Her X-rays had merely shown age-related changes. Her back was
hurting because of excessive muscle tension crimping joints tight and her back
was out of condition. Simple and brief solution-focused counselling on that one
visit was sufficient to break the cycle of pain and depression. I advised her
to return to the physical activities that gave her pleasure. I did not think that
any further physical treatments would serve any useful purpose in this case.
The whole consultation took no more than 45 minutes.

At review six weeks later her depressed mood had lifted, her
sleep was refreshing, she was enjoying swimming and her weight was coming off.
She was much more positive about her work. And coincidentally, the back pain
was now only an ache she could manage with. All her other distressing symptoms
had vanished. She felt confident enough to request no further follow up or
treatment.  

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