Screening for the psychological causes of back and neck pain can speed recovery

A questionnaire that looks beyond the physical causes of back and neck is proving useful in aiding return to work
A questionnaire that looks beyond the physical causes of back and neck is proving useful in aiding return to work

GP Nick Summerton suggests how the Orebro questionnaire is a basis for referring employees to forms of support and could tackle the underlying causes of back pain.

Latest statistics show that back and neck pain is given more often as the reason for sickness absence than any other condition.

For GPs, back problems are a straightforward job. We normally look for a “red flag”, checking for more serious physical health issues, a fracture, infection, or inflammation. Once they have been ruled out, we can prescribe painkillers and provide a sick note.

It is a black-and-white approach that is most practical within the limits of a publicly funded service. But a number of complicated and unresolved issues can be left behind.

Employers need to be thinking again about whether or not they can just accept a sick note for back pain. It is not a case of browbeating absentees, but taking a more active approach that helps both the employee and the organisation get to the root cause of problems.

Of the 131 million days of sickness absence in the UK (according to the most recent study carried out by the Office for National Statistics), 31 million were for back and neck pain – more than any other reason given.

Many cases progress from being a single, acute incident to a long-term issue. Figures suggest that between 3% and 10% of cases of low back pain, for example, will become chronic. Up to 62% of people still experience the pain after one year.

The sheer level of absence, as well as the potentially crippling impact of back pain on people’s lives outside of work, means that musculoskeletal disorders (MSDs) have a huge financial and social cost.

Occupational health provides an essential service in checking on the working environment, the basics of lighting, layouts and training, and minimising the risks from any kind of physical activity in the workplace, whether it is lifting, standing or days of sitting in front of a screen. But where is the resulting reduction in back pain problems and lower levels of absence?

Looking beyond physical reasons

What is needed is more of a “yellow flag” system, which goes beyond the more obvious physical health issues to look at the whole person and the context of the back pain. Psychology – people’s attitudes to themselves and to their health – can play a significant role in conditions like chronic back pain, and identifying issues of anxiety and/or depression are critical in terms of providing the right kind of help and allowing people to return to work.

The yellow flag approach is one beginning to be made available to employers through the Orebro Musculoskeletal Pain questionnaire (named after the town in Sweden where the tool was developed). The original questionnaire covers five relevant areas: function; pain; psychological; fear-avoidance;
and miscellaneous.

There are 25 standard questions, most on a 0 to 10 scale. Questions explore an individual’s attitudes and feelings about levels of pain recently experienced, its effect on their ability to work, experiences of anxiety or depression and any impact on sleeping.

Research into the questionnaire has shown it to be effective in predicting future issues and identifying which employees are most likely to be long-term absent. This kind of biopsychosocial approach picks up on negative attitudes, fears and concerns that exacerbate and encourage the experience of chronic pain.

Data from the Orebro questionnaire is a basis for referring employees to other forms of support that tackle the underlying root causes – often through Cognitive Behavioural Therapy (CBT), which has been shown to be effective in encouraging more positive attitudes and therefore a better ability to cope with the types of pain associated with MSDs.

One research study looked at the impact of a number of programmes offering a combination of physical therapy (exercise supervised by a physical therapist), along with psychological therapy (counselling or CBT). The progress of chronic back pain sufferers was tracked over at least a year, and showed that including a psychological element of treatment was more likely to lead to a better recovery than exercise alone.

There is also good evidence from a programme undertaken in New South Wales in Australia under the Work Cover initiative, which saw successful results in terms of helping speed up recovery times and getting more people back to work.

Employers should also be looking beyond the traditional route of physiotherapy and the benefits of osteopathy, acupuncture and chiropractics. In the NHS, we have had a difficult relationship with these kinds of methods, which have appeared gimmicky, and contrary to the accepted norms of physiotherapy.

But we have the evidence that they are methods that work, often more effectively than physiotherapy, and need to be taken seriously as part of a response to MSDs.

The scale of the back pain issue for employees and employers means new thinking and approaches are needed. The more we can break out of the standard routines of treatment and understand the whole picture, the closer we will come to helping people stay in work, avoiding what can become a vicious circle of physical and mental illness.

The Orebro questionnaire is now being used by Bluecrest Wellness in the UK as part of a standard health screening process, where organisations are providing screens across whole staff populations.

About Dr Nick Summerton

Dr Nick Summerton is a GP, cancer adviser to the Department of Health, and medical director at Bluecrest Wellness.
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