Debbie Gilbert, Anne Harriss and Siva Murugiah demonstrate how OH practitioners can assist employees with lower back pain to return to work
One of the most dramatic failures of healthcare in recent years in people of working age is the disability experienced from back pain.1 Almost 13 million working days are lost annually because of back pain, at a cost of £10bn and up to 12 million GP consultations a year.2 Lower back pain (LBP) will affect 70% of the working population at some time during their working lives.3 Sickness absence and the costs associated with back pain will, therefore, affect all employers and the productivity of the nation.
Occupational health practitioners will be involved in the assessment of fitness to work of people who have back pain either at the pre-employment stage or following a period of sickness absence.
There is strong epidemiological evidence that the physical demands of work can be associated with increased reports of back symptoms. However, disability owing to LBP depends more on the complex interplay between individual and work-related psychosocial factors, than on clinical features or on the physical demands of work.4
Although LBP is a symptom rather than a diagnosis, its presence is relevant when assessing fitness for work, along with other factors, including age, height, fitness, weight and sex.5
The impact of LBP caused by a protruding intervertebral disc with nerve root involvement with a view to assessing and facilitating the continued employment of a serving police officer, provides a good example of OH in action.
To place this in context, the pathology of a protruding intervertebral disc at L5/S1 with compression of the right S1 nerve root will be explored. Interventions available to promote the individual’s return to work, the rehabilitation process while adhering to police force policies and procedures and compliance with health and safety legislation will be highlighted.
A police sergeant working in a large city force, officer Leo (not his real name) was 43 years old at the time of the management referral and had been off work for three weeks with LBP radiating down his right leg following an injury on duty. In line with the attendance management policy, advice on the expected recovery time and general rehabilitation was sought from the OHN.
Leo joined the police force when he was 18 and has 26 years’ service. His hobbies centred on family life and sports, in particular, for the previous seven years he had been involved in youth rugby coaching. He worked as a full-time officer and his duties involved working shifts, street duty policing, custody of prisoners, public contact – which often can be confrontational in nature – and fast-response driving of police vehicles.
The city police force provides a multidisciplinary OH team which includes counsellors, physiotherapists, physicians and an OHN. Leo was referred to the OHN three weeks after sustaining an injury on duty and was off sick. He reported a back injury at rugby coaching some eight weeks earlier, but that had almost completely cleared up by the date he fell down a 60cm hole while crossing soft ground in pursuit of a suspect.
Leo described the first injury as a “trapped nerve”, which did not require time off work and that responded well to analgesia and a modified lifestyle. He felt he had made a 99% recovery prior to his fall. He did see his GP and experienced some pain in the right leg, buttock, and lower back and was walking with a limp. Despite an active past he had no other medical history or injuries of note.
After falling down the hole, Leo was unaware of the extent of his injuries as, although uncomfortable, he was able to climb out of the hole and walk around for the rest of the day. However, after a night in bed he awoke to find himself with severe pain in both legs and lower back with almost no ability to move and was unable to leave the house.
The OH nurse initially assessed Leo by telephone and thereafter either in person at the regular monthly OH clinics or by telephone. A case and medical history was taken and OH support services initiated.
Physiotherapy
The OHN immediately referred Leo to a physiotherapist for further assessment and treatment as he now reported pain in the lumbar right side, across the right buttock and down the right leg into the toes.
The full history included functionality and general health information, it was noted that Leo had a body mass index of 36 – obese class II – which is a significant risk factor for LBP.6 Analgesia was non-steroidal anti-inflammatory Ibuprofen, 400mg to be taken three times a day. Initially, this treatment had beneficial effects.
On a functional level Leo reported a sleep disturbance and an inability to sit for longer than 20 minutes before pain levels became intolerable.
A recuperative duty plan was proposed to Leo by the OHN as a way of returning to a modified work role. However, due to his worsening symptoms this was postponed for a further 10 weeks.
Subsequent reviews, along with updates received from the physiotherapist, revealed a worsening of peripheral symptoms, in particular a cold right foot with pins and needles. He also had numbness in the three lesser phalanges and lateral aspect of his right foot. Leo described the pain in his leg as “totally debilitating” and could only walk with a pronounced limp. He became less optimistic for recovery and over time his mood was subdued.
Referral by his GP to an orthopaedic consultant resulted in an MRI scan, which is especially effective for the evaluation of the intervertebral disc, neural elements, and soft-tissue elements of the spinal canal.7 This scan revealed a right-sided nerve root compression caused by a combination of a tight nerve root canal and large degenerative paracentral right disc protrusion at L5/S1. This diagnosis and his clinical presentation led to the consultant’s decision to perform a right-sided L5/S1 micro-discectomy.
Psychological factors are significant in the onset of LBP and the transition from acute to chronic pain and disability. Depression, distress and cognitive factors, such as passive coping and catastrophising, have been closely linked with perceived pain and associated disability.12
Leo displayed the classic symptoms of a nerve root compression with pain experienced in the distribution of the nerve. Typically this occurs down the back of the leg, side of the calf and into the lateral aspect of the foot. For this reason a herniated lumbar disc characteristically causes sciatica but not necessarily back pain, however Leo experienced both. If sensory function of the nerve root is impaired, numbness will result, and if motor function is impaired, weakness will result.
Leo was prevented from working normally as the result of limited movement, pain, and muscle weakness. He did not make a spontaneous recovery from the injury, possibly because of the tight nerve root canal noted on the MRI scan. He also reported difficulty in sleeping, which added to his distress. These symptoms were incompatible with the demands of his normal role, but a phased return to work was achieved.
Assessment of fitness to work
Developing a return to work programme following a period of incapacity can be one of the most challenging aspects of the role of the OHN. Care must be taken that the assessment does not only focus on the functional and anatomical attributes without attempting to fit the individual to the role.13
The primary purpose of a medical assessment of fitness for work is to ensure the employee is fit to perform work tasks safely and effectively without risks to themselves or others. To do this, the OHN requires knowledge and understanding of the job role and job description and has to be able to link these to risk assessments.
Leo’s health assessment was triggered because of the attendance management policy, rather than any regular in-service assessment required for his role. Indeed, he had very limited health records as apart from his pre-employment form some 26 years earlier and he had not undergone any role-specific health assessments other than visual acuity for police driving. Thus there was very little to benchmark him against.
Police fitness standards are not prescriptive for existing uniformed officers, but are so for new recruits and specialist operational staff. It was, therefore, only possible to measure Leo’s level of fitness against the subjective history of how he was prior to the injuries and also by the minimum fitness levels required to pass the bi-annual officer safety training sessions. For this, the ability to cope with a 10-minute warm-up routine, participate in group practice of baton and handcuff procedures and observe best practice techniques are necessary.
Officer safety training sessions teach officers non-threatening but assertive public order control measures. And throughout this, public contact is discouraged and is only deemed acceptable as a last resort to maintain law and order.
However, in reality, police service staff are regularly involved in potentially hazardous work. An additional factor is an expectation both on the part of the public and the police, of acceptance of risk by police, during their work for the public.13
Job specification and health
For Leo the job specification as an operational sergeant became an increasingly difficult role for him to be phased back into as he did not make the progress expected after his injury, despite the expectation that 90% of LBP will resolve spontaneously within 6 to 12 weeks14 and most workers with LBP are able to continue working and do not need to wait until they are pain-free to return to work if off sick.15
Four weeks after the injury and in line with the above predicted progress, the OHN advised management that Leo should be able to return, full-time to an office-based non-confrontational role. This was to include no face-to-face public contact, heavy lifting or police driving, with time off to continue to attend physiotherapy. But severe disabling symptoms and mobility difficulties, including driving his own vehicle, resulted in Leo only returning to work 12 weeks after the injury. A phased return to work programme was devised by the OHN which incorporated reduced hours allowing him to adjust without overstretching and risking further damage to health.16
A risk assessment for the role was undertaken ensuring that the duty of care to the employee was upheld and Leo returned to a modified work role inside the police station. This was deemed suitable and involved computer input and telephone intelligence gathering in a non-pressurised environment with frequent opportunities for rest breaks to carry out the exercise and stretching regime recommended by the physiotherapist.
Physiotherapy continued in both the pre- and post-operative phase and Leo reported that he found the active care reassuring, he felt supported by the organisation assisting him towards recovery. Additionally, Leo stayed at the Police Residential Rehabilitation Centre three times in total, twice prior to his micro-discectomy and once afterwards. The philosophy of the centre is to provide short-term intensive rehabilitation and psychological support. Each visit involved a 10-day stay and focused on daily treatments, a combination of:
- massage and hydrotherapy
- core stability and abdominal strengthening exercises
- Back strengthening exercises – four-point stabilisation17
- balance work
- muscle spasm relief and relaxation techniques.
Following recovery from surgery the OHN recommended a return to recuperative duties in an office-based role. Leo stated that he found the recuperative duties placement unfulfilling and he aspired to get back to his old role.
However, it could not be argued that in this case risk was minimal or unforeseen and it remained inappropriate to sign him back as fit for his original duties.
Continuing symptoms of leg pain and numbness in his toes meant it took him four months to build his hours back to full time.
There is strong evidence that individual and work-related psychosocial factors play an important part in persisting symptoms and disability, and that they influence treatment and rehabilitation response times.18 Additionally, long-term results after discectomy are only slightly better than non-surgical intervention.19
New dimension
The case management was progressive but unremarkable until six months after surgery when Leo expressed an interest in applying for a new position at work. It seemed to motivate him and added a new dimension to his recovery. He requested an OH assessment of the job prior to his application and the specification of the role was suitable for him. It was an ideal use of an experienced officer who had not made a full recovery from his injuries and surgery. Residual limitations to his physical capacity were insignificant in the new role and the decision was made with personnel and the OH physician that long-term redeployment from operational duties on health grounds to this non-operational post was appropriate.
Despite active OHN and multidisciplinary team involvement from an early stage the client did not make a full and uncomplicated recovery from his injury.
Leo’s progress and care was co-ordinated by the OHN. Regular updates were exchanged between members of the multi-disciplinary team and the OHN passed the outcomes of these on to HR. Ongoing pain in both the leg and back has continued to be problematic, in-house physiotherapy was stopped after 14 months as the practitioner considered further active treatment inappropriate. Exercises and rehabilitation work were continued by the client.
Some 20 months after the surgery and 27 months after the injury, Leo’s condition is stable, his work role is ideal and rewarding and he can expect to complete his 30 years’ service in this role. He is able to walk four miles a day, run up to one mile in distance with several breaks and has returned to manage, rather than coach, the local youth rugby team.
He is now reviewed annually to see if he can return to operational duties or whether he should remain on restricted non-operational duties for the remainder of his service.
Pathological effects of a protruding intervertebral disc
The spinal column forms the major part of the skeleton and contains 33 vertebrae. The bodies of adjacent vertebra are bound together by intervertebral discs. Each disc features a central core of soft gelatinous material (the nucleus pulposus) and an outer rim of fibrocartilage, the (annulus fibrosis).8
A herniated intervertebral disc secondary to trauma results from extreme flexion of the trunk.9
A prolapse at L5 often results in the disc material compressing the S1 nerve root which produces lower back pain and sciatica.10 The herniated or ruptured nucleus pulposus can be caused by the posterior longitudinal ligament, lying on the forward side of the neural canal, giving way or allowing passage of some of the substance of the cartilage between the vertebrae into the canal, causing great pain.11
About the authors
Debbie Gilbert is an OHN working with the police, Anne Harriss is a reader in educational development and course director of the BSc (Hons) Occupational Health Nursing at London South Bank University, and Siva Murugiah is senior lecturer BSc (Hons) Occupational Health Nursing at London South Bank University.
References
1. Carter T and Birrell L (2000) Occupational Health Guidelines for the Management of Low Back Pain at Work – Principal Recommendations, Faculty of Occupational Medicine, London.
2. Kaye J (2003) ‘Fast track back to work’, Occupational Health Journal May pp 24-25
3. MacDonald E and Haslock I (2000) ‘Spinal disorders’ in Cox R A F, Edwards F C and Palmer K Fitness for Work. The Medical Aspects, 3rd edition, Oxford Press, pp 210-234
4. Waddell G and Burton K (2000) Occupational Health Guidelines for the Management of Low Back Pain at Work – Evidence Review Faculty of Occupational Medicine, London
5. Cox R A F, Edwards F C and Palmer K (2000) Fitness for Work. The Medical Aspects 3rd edition, Oxford Press, pp 210-234
6. Winter-Griffith H (1995) Symptoms, Illness & Surgery – The Complete Guide Diamond Books, London
7. Chen A L and Spivak J M 2003 ‘Degenerative lumbar spinal stenosis options for aging backs’ The Physician and Sports Medicine Vol 31, No 8 August
8. Wilson K J W (1987) Anatomy and Physiology in Health and Illness
9. Paradiso C (1999) Pathophysiology 2nd edition Lippincott Williams & Wilkins, Philadelphia.
10. Grainger A (2004) Prolapse of intervertebral disc, Cyberanatomy Tutorials http://anatome.ncl.ac.uk/tutorials/clinical/disc/text/index.html
11. Shafer K, Sawyer J, McClusky A, Beck E and Phipps W (1975) Medical-Surgical Nursing (6th edition) Saint Louis, Mosby
12. Drezner J A and Herring S A (2001) ‘Managing low-back pain’, Physician and Sportsmedicine, Vol 29 No 8 August
13. HSE Public Services (2004) Police homepage http://www.hse.gov.uk/services/police/index.htm
14. Murugiah S, Thornbory G and Harriss A (2002) ‘Assessment of fitness’, Occupational Health, April Vol 54 No 4 pp26-29
15. Walter S (2001) ‘Rehabilitation is good for business, say engineering employers’ Health & Safety at Work Vol July p 6-7 6th edition, Churchill Livingstone
16. Ballard J (2002) ‘Rehabilitation at Work. Part two: Rehabilitation in Practice’ Occupational Health Review. Nov/Dec, pp19-28
18. Waddell G and Burton K, see 4. above
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19. Samanta A and Beardsley J (1999) ‘Sciatica: Which intervention?’ British Medical Journal; Vol 319 31 July pp 302-303
