Low back disorders account for more than a third of all work-related musculoskeletal disorders, and occupational health can play an important support role for employees and employers. But as Anne Harriss and Ndaba Mnkandla explain, assessing the fitness to work of an employee with lower back pain can be challenging.
Musculoskeletal disorders (MSDs), including back pain, are the most commonly reported cause of work-related ill health in the UK (Stanford & Harriss, 2012). It is estimated that work-related MSD accounts for 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 account for 35% of all work-related MSD and therefore represent a significant workplace problem affecting employees, employers and national wellbeing (Health and Safety Executive, 2017).
In the UK, it is estimated that the effects of lower back pain (LBP) cost the economy around £12.3bn annually (Whitehurst et al., 2012). LBP is very common and it is estimated 60-80% of the population will experience it at some point (Palmer and Greenough 2013). Its prevalence worldwide is comparative to UK data and is thought to be the leading cause of long term disability globally (Parson et al., 2011).
Back pain is a symptom, not a disease, with a range of triggers including; mechanical causes, degenerative and inflammatory conditions (Parson et al., 2011). It tends to be episodic, in most instances settling within a few weeks. However, it can be chronic in nature with varying severity, from mild to severe (Health and Safety Executive, 2017). The most common form of low back pain is non-specific LBP. Non-specific LBP refers to LBP where the pathophysiological cause of the pain is undetermined (Maher et al., 2017).
Ndaba Mnkandla MSc PG Dip BSc RN is an occupational health adviser and Anne Harriss MSc, BEd, RGN, OHNC, NTF(HEA), PFHEA, CMIOSH, FRCN, Hon FFOM, Queens Nurse is professor in OH and course director, London South Bank University
The spine is complex, consisting of bony structures, articulation, ligaments, muscles, blood supply, and neural structures. LBP may result from any combination of these structures. The dysfunction of the lumbar region has a pivotal role in etiology of LBP. Lumbar vertebrae consist of a weight-bearing vertebral body, and a neural arch that encircles the spinal cord in a ring of bone. Vertebrae can resist most of the compressive forces acting along the length of the spine and the neural arch protects the spinal cord (Adam, 2004). The vertebral bodies are separated and bound together by intervertebral discs that allow for small movements between vertebrae distributing compressive loading evenly on to the vertebral bodies (Adam, 2004).
Challenges of lower back pain
One of the biggest challenges occupational health (OH) practitioners face in assessing the fitness to work of an employee with back pain is the fact that there isn’t a single cause, risk factor or treatment. LBP is often a complex interaction between lifting or forceful movements; awkward and static posture, fixed or constrained body positions, continual repetition of movements (Palmer and Greenough et al., 2013). In addition to this, the employee’s individual characteristics, including age, gender, smoking habit, physical fitness, anthropometry, lumbar mobility, strength, psyche and mental well-being, other aspects of medical history, pre-existing spinal abnormalities can impact on incidences of LBP (Health and Safety Executive, 2017, Palmer and Greenough 2013).
Should an employee be referred for an OH opinion, Cooper (2017) states that the referrer must explain the purpose and procedure for the referral and obtain their consent for an assessment to be undertaken. The OH practitioner will note the impact of LBP on their activities of daily living, identify any red flags to eliminate any serious spinal pathology. The ultimate aim is confirmation of fitness to return to undertake their job requirements, with or without modifications, and if fit, expedite an early return to their contractual role. Red flags refer to a commonly-used screening tool first devised in 1924 and consist of features from the patient’s medical history and physical examination associated with a higher risk of serious pathology. They are used to indicate if more diagnostic testing is necessary before the appropriate care can be delivered (Cook et al., 2018; Williams et al., 2013).
Despite their widespread use, some authors have argued that there is scant evidence for their continued use, stating that red flags have a stronger relationship with prognosis rather than diagnosis and that the low specificity of red flags may lead to unnecessary further investigations if followed blindly (Cook et al., 2018; Balague et al., 2012). Maher et al (2017) argue that, whilst red flags are useful in identifying patients requiring further diagnostic assessment for serious disorders as part of clinical assessments, taken individually few have diagnostic accuracy. Clinical features are a more reliable method of identifying those requiring further investigation (Maher et al., 2017).
At the initial referral appointment, the client’s identity, personal details and consent to participate in the referral should be confirmed (Palmer, K.T and Greenough, (2013). The purpose of the consultation, the role of OH in the referral process and boundaries of confidentiality should be explained. The client’s occupational, current and past medical history should be recorded including any past history of back pain or spinal pathology. Recent investigations, physical and pharmacological treatment and the impact of current pathology should be recorded.
National Institute for Health and Care Excellence (NICE) guidelines recommend non-steroidal anti-inflammatory drugs as the first choice of analgesia for LBP with only weak opioids prescribed should non-steroidal anti-inflammatory medication be ineffective, contraindicated or poorly tolerated (NICE, 2016).
When taking a medical history, it is appropriate to note:
- factors provoking/reducing pain, particularly whether pain is worse on movement;
- the features of the pain and whether the pain is localised to the lower back or radiates into the buttocks and/or leg; or
- whether current analgesia provides adequate pain control noting any side effects problematic for those undertaking safety critical roles.
The initial assessment should identify serious spinal pathology requiring urgent medical referral. The purpose of the assessment is confirmation that the client can undertake his contractual role safely without posing risks to themselves and/or others.
The Murugiah et al (2002) framework considers four elements: personal aspects, work characteristics, work environment and legal aspects. It integrates the variables to be considered when making a fit to work assessment in a systematic and logical manner. This allows for a consistent and transparent method of assessment, decision-making and documentation, taking into account the needs of both the employer and employee.
The impact of LBP on activities of daily living and work tasks should be noted. Findings from a meta-analysis concluded that obese individuals have an increased risk of LBP (Balague et al., 2012). Furthermore, physical inactivity and deconditioning contribute to ongoing intolerance of physical activities, which in turn results in functional limitations (Verbunt et al., 2010). Teichtal et al (2015) showed that physical inactivity is associated structural abnormalities in the lumbosacral spine, including narrow intervertebral disc height and an increased risk for high multifidus fat content. They conclude that low levels of physical activity may result in inadequate mechanical stimulation, a factor important in maintaining intervertebral disc integrity.
The additional weight that obese people carry places a greater mechanical load on weight-bearing joints and structures, potentially increasing the rate of degeneration through excessive wear-and-tear. Obese people are advised to lose weight to decrease the mechanical load on the affected weight-bearing spinal structures and moderate the obesity-induced lordotic curvature of the lumbar spine (Roffey et al., 2013).
Work-related psychosocial risk factors
Yellow flags relating to attitudes and beliefs about the LBP and long-term outcomes, may cloud assessment and treatment (Samanta et al., 2003). There is strong evidence that individual and work-related psychosocial risk factors, including fears about pain or injury and/or unhelpful beliefs regarding recovery, play an important role in persistent symptoms and disability (Waddell & Burton, 2001). Workers’ own beliefs that their LBP was caused by their work and their own expectations about inability to perform certain tasks or return to work are particularly important considerations (Carter & Birrell, 2000).
Clients may believe that investigations including imaging are essential. Maher et al (2017) believe clinicians should educate patients why routine imaging is unhelpful in identifying causes of non-specific LBP, and OH professionals may play an important role in this. MRI imaging may pick up degenerative changes of the lumbar spine that are part of the normal ageing process and may not be related to the present episode of back pain, a high level of skill is required to determine clinically relevant changes (Walker, 2012).
Clinicians are well placed to provide education and information on the causes, likely outcomes and explain that, for most patients suffering non-specific LBP, little to no medical attention is required. Educating those suffering from LBP about their condition may alleviate anxiety and stress (Adams et al., 2006) and promote recovery (Maher et al., 2017).
Clients should remain active and continue ordinary activities of daily living as normal, despite the pain as such an approach is associated with a faster recovery, shorter periods of work loss and fewer occurrences/re-occurrences of LBP. Clients and their managers may express concerns regarding returning to work with residual problems, especially if LBP is attributed to work as they may anticipate a risk of re-injury. Most workers continue/return to work with symptoms still present. Studies indicate such employees have reduced recurrences and sickness absences in the year after they first experienced LBP (Waddell & Burton, 2001). Providing information regarding back pain is an important OH role. The randomised trial of Burton et al (1999) showed that carefully selected and presented information and advice about back pain can have a positive effect on patients’ beliefs and clinical outcomes.
There is a strong correlation with the period of time off work and the probability of returning. In general, the longer a person is off the lower their chance of an eventual return; after six months this probability falls to 50% (Palmer and Greenough, 2013). This trend could be attributed to the natural selection of those with severely limiting condition, however it could be associated with reduced mobility, lethargy, and passivity affecting muscle strength and tone (Palmer and Greenough 2013).
Rates of LBP vary by industry and occupation. In general, jobs involving heavy manual handling suffered more from LBP and took more time off than work. Prevalence rates for back disorders are statistically significantly higher in construction industries in comparison to other industries. This is unsurprising because of the physical nature of the job tasks that require the use of hand and power tools, entailing the use of multiple body regions, constant movement in awkward positions, and repetitive, forceful, use of the back and upper and lower extremities (Health and Safety Executive, 2017).
NICE advocates a proactive approach in which employers and clinicians are encouraged to consider referral to a physiotherapist (Palmer & Greenough, 2013). A systematic review by van Middelkoop et al (2011) indicated that exercise therapy improved LBP pain intensity and disability, and long-term function when compared to other forms of treatment. Several studies have shown a significant association between LBP and degeneration of the lumbar vertebral discs and, since disc degeneration is more prevalent with age progression, it is possible that in some instances non-specific LBP can be due to natural changes that occur with age (Walker, 2012; Adam, 2004).
There is evidence that some adults aged over 60 years’ experience LBP and concurrent radicular leg pain resulting from lumbar spinal stenosis caused by degenerative narrowing of the spinal canal (Hicks et al., 2008). Adams (2004) argues that changes due to ageing are unlikely to cause pain. The patho-physiology of non-specific back pain is poorly understood. There is a strong association between back pain and disc degeneration which occurs earlier than other musculoskeletal tissues.
Planning return to work
Degenerative changes can occur early; lumbar disc degeneration has been identified in 11-16-year-olds. It is therefore unsurprising that up to 60% of 70-year-olds have inter-vertebral discs that are severely degenerated (Urban & Roberts, 2003). This could be an issue in the workplace as changes to the age at which workers qualify to take their state pension will result in an ever-ageing workforce. Biochemical changes occur in ageing articular cartilage and intervertebral discs; large proteoglycan molecules that bind water into the intervertebral discs become increasingly fragmented and some fragments are lost, resulting in disc reduced ability to equalise loading on the vertebrae. This leads to decompressed nucleus, and stress concentrations in the annulus that causes the LBP (Adam, 2004).
It is important to consider the person’s expectations and preferences when considering available treatments (Walker, 2013). When planning a return to work, any work processes, tasks and sub-tasks that may put their recovery at risk should be risk assessed. Restricted duties may incorporate limiting manual handling tasks and there may be occasions when sedentary tasks are preferable to those undertaken from a standing position. Workers should still be encouraged to mobilise at least every 30 minutes, performing warm-up stretches and exercises. Health education is an integral part of an OHN role (World Health Organization, 2001). “Tool box” talks focusing on common causes of LBP and self-help techniques to manage back pain are helpful in providing advice and information on the prevention and self-management of LBP. OHNs can advise on correct manual handling techniques, maintaining good postural positions and the importance of keeping active and avoiding bed rest and on basic stretches and exercises to strengthen back muscles (Walker, 2012).
Important legal aspects as advocated by Murugiah et al., 2012 include 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. Regulation 3 of the Management of Health and Safety at Work Regulations 1999 places an absolute duty on the employer to make a ‘suitable and sufficient’ health and safety assessment of the risks that employees are exposed to at work (Management of Health and Safety at Work Regulations, 1999). Other key legislation pertinent to back pain in the work place includes: 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 who use computers as part of their work tasks.
As non-specific LBP generally improves regardless of treatment or management (Walker 2012), OH care should focus on linking health to risk assessment and providing clients and their managers with education, advice and information that promotes self-management facilitating a return to normal activities, with work considered to be an important health outcome. OH professionals are particularly well placed to facilitate such an eventuality.
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