Medical Factors
Guidelines for the management of low back pain at work
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At a glance: |
Clinical guidelines are evidence-based recommendations about managing medical conditions. The Occupational Health Guidelines for the Management of Low Back Pain at Work were produced by the UK Faculty of Occupational Medicine. They offer concise information about the risk-factors, prevention, diagnosis| diagnosis |  | | The process of identifying a medical condition or disease by its symptoms, the findings from a medical examination, and from the results of various diagnostic procedures. |
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Perspectives: |
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Employee |
If you have back pain you probably want to know as much about your condition as possible. It can be hard to know where to look for information. 60-80% of people experience back pain at some point so plenty of people will have experiences to share. There is a great deal of information available on the internet and your doctor will offer advice. However the information you get from some sources can be inconsistent or inaccurate. The way you personally respond to and manage your condition will have the greatest impact on your recovery, so getting the information that suits you is essential.
A discussion with your doctor is important – you might like to take this article with you as a starting point. You may need to make a longer appointment to make sure you have enough time to cover any concerns you have about your condition.
This study noted that in management of back pain:
Advice to continue ordinary activities of daily living as normally as possible despite the pain helps patients get better earlier. People who are given this advice have better outcomes than those who are given advice to rest and 'let pain be your guide'.
Communication, co-operation and common goals set between the worker and the workplace helps workers with back pain recover.
Most people with back pain are able to continue working, or to return to work within a few days or weeks, even if they still have some residual or recurrent symptoms, and they do not need to wait till they are completely pain free.
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Employer |
Employers need to understand what the workplace can do to assist people with their back pain. 60-80% of people experience back pain at some point, but back pain can be costly in terms of sick leave and lost productivity.
Preventing back pain completely might not be realistic, but there are things the workplace can do to avoid the consequences of the condition resulting from a long-term disability| disability | | | A condition or function that leaves a person unable to do tasks that most other people can do. |
Clinical guidelines are compiled by respected medical organisations, and based on hundreds of scientific studies. This article is a plain language summary of the guidelines for managing back pain, and contains information about risk factors, prevention, management, diagnosis and pre-employment screening. It focuses specifically on the role of work in the condition.
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Treater |
Clinical guidelines are a useful tool for doctors, but the information is relevant to patients too. If patients understand the causes and natural history of their condition, and the evidence base for treatment, it may improve their compliance| compliance | | | Compliance in a medical context refers to a patient adhering to their treatment program as advised by their doctor or other healthcare worker. In the context of return to work this usually means following the return to work plan. |
The role of work in low back pain is particularly important. Non-work factors appear to be more important in the aetiology of the condition, but the psychosocial| psychosocial | | | Refers to psychological and social factors. Examples of psychosocial factors that affect return to work area include: a person's beliefs about how they will cope with their condition, the attitude of the inured worker's family to their condition and return to work, the employer's return to work policy and the influence of the WorkCover system on a person. |
| intervention | | | A treatment or management program. Interventions often combine several approaches. In this field approaches include training in problem solving, adaptation of work duties, graded activity, an exercise and stretching program and pain relief. |
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Insurer |
Total prevention of low back pain is likely to be unrealistic. However, suffering and cost can still be contained by reducing sick leave and long-term disability. The right treatment and the response of the workplace are important factors in reducing disability.
It is important that all parties have the right, scientifically-based information about how to manage low back pain. The clinical guidelines below are an expert resource, discussing the risk-factors, diagnosis, treatment and the usual progression of the condition.
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Original Article, Authors & Publication Details: |
G. Waddel1 and A. K. Burton2 (2001)
Occupational health guidelines for the management of low back pain at work: evidence review. Occupational Medicine. 51(2): 124-135
1The Glasgow Nuffield Hospital, Glasgow
2Spinal Research Unit, University of Huddersfield, UK
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Background, Study Objectives, How It Was Done: |
Evidence-based guidelines are recommendations for managing medical conditions. Authorities in the field conduct extensive reviews of the scientific research, and make recommendations based on their findings.
The Occupational Health Guidelines for the Management of Low Back Pain at Work were produced by the UK Faculty of Occupational Medicine. They investigate the work-related aspects of non-specific low back pain, including prevention, assessment, treatment and return to work. Non-specific back pain is pain with no known cause. About 90% of low back pain is nonspecific.
Over 2000 scientific articles were considered when preparing these guidelines. The articles were evaluated for their relevance, quality and reliability, and 153 were included.
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Study Findings: |
Risks for low back pain
60-80% of adults experience low back pain at some point. It is one of the most common reasons why people see a doctor or take time off work. Often, the problem is recurring, with most people experiencing episodes of pain interspersed with periods of good health. Individual episodes of low back pain tend to be short and get better on their own quite quickly.
Occupational health care services frequently deal with low back pain. Although many people assume that this means low back pain is caused by work, the scientific evidence is unclear. While back pain is more common in manual jobs that require heavy physical work, many people who perform lighter duties at work, and even those who are not working, also experience back pain.
Physical work might cause specific damage in certain cases, and some jobs are riskier than others. Manual handling, lifting, twisting, bending and whole-body vibrations all increase the risk of low back problems, and aggravate existing symptoms. People who have low back pain (from whatever cause) find physical work harder to manage. Overall, however, most back pain is not caused by physical work. Even for people in physically demanding jobs, pain usually comes about while doing ordinary activities like bending or twisting. While physical work can be a factor in back pain, it is not often the most important factor. Other non-work-related factors have a stronger influence.
Most low back pain resolves quite quickly, but some people develop long-term pain or disability. It is usually hard to find visible physical damage when people experience back pain, and clinical tools like X-rays do not help doctors to judge which people will have long-term problems. Individual, psychological| psychological | | | Refers to a person's perceptions, thought processes, emotions, personality and behaviour. Psychologists can treat mental health problems. |
| chronic | | | continuing a long time or recurring frequently |
How people respond to low back pain depends on many individual, psychological, social and workplace factors. These factors influence peoples beliefs about the cause of the pain (e.g. if they believe it is caused by work). They also influence the person's decision about whether or not they seek healthcare or take time off work.
Pre-employment health checks
Pre-employment health checks aim to identify people who might be at higher risk of low back pain. The checks usually involve assessing physical strength, finding out whether the person has had back pain in the past, and assessing psychological and social factors.
Back pain is often recurrent, and a past history of low back pain indicates that a person is at higher risk of experiencing the condition again in the future. These people are at higher risk if:
the pain they experienced was more severe, more recent or longer-lasting
their problem 'flared up' more frequently
they experienced pain that radiated to their leg
they had time off work because of low back pain
they had surgery for low back pain
There is an argument that people at risk of low back pain should not be placed in a job that involves heavy physical work. People with low back pain do find physical work harder to manage. However, those at higher risk for back pain are likely to experience problems again regardless of what work they do. The research suggests that those who remain unemployed may be at the highest risk of all for chronic problems and disability.
Furthermore, low back pain is extremely common. The problem occurs in 60-80% of adults, so most applicants for any job will have experienced low back pain in the past. They may or may not report this truthfully. Avoiding employing people because they have a history of pain excludes many people who are medically fit for most work. All screening tests, meanwhile, miss many people who later go on to develop the problem. Finally, refusing to employ people on the basis of their past history of back pain has significant personal, societal and legal consequences, and the Disability Discrimination Act may need to be considered.
In most circumstances, low back pain is not a reason to deny a person employment. However care needs to be taken when placing people with a particularly strong history of back pain in physically demanding jobs.
Apart from the person's history of back pain, there are no other tests or screens that can identify people at higher risk of back problems. Flexibility, strength, fitness, height, weight, X-ray results, MRIs, back-testing machines and straight-leg raising tests do not predict whether a person will have back pain. Psychological and social tests indicate risk factors for back pain, but people identified as “at risk' are only slightly more likely to develop the condition.
Prevention
Back pain has many causes, not all of which are known. Personal, psychological and social issues all influence back symptoms. Therefore, preventing low back pain might not be a realistic goal. Preventing the possible consequences of low back pain, such as long-term disability and time lost from work, may be more achievable.
It is hard to tell the extent to which workplace changes can reduce the risk of low back pain. Previous studies have shown inconsistent results linking physical demands of work with reports of back pain.
Some prevention strategies do not work. There is strong evidence that education based on the medical aspects of low back pain is not effective in preventing low back pain. In contrast, education that focuses on beliefs and attitudes about back pain might reduce the time lost from work after back pain has occurred, although the evidence for this approach is still limited. Back belts or supports do not prevent back pain, and general fitness/exercise programs in the workplace do not seem to be very effective.
There are steps that can be taken to reduce the consequences of low back pain, however. There is strong evidence that low job satisfaction and psychological or social issues increase the risk of low back pain, use of the healthcare system and lost time from work. Job satisfaction and good industrial relations are the most important organizational characteristics when it comes to preventing disability and sickness absence.
A cooperative approach to preventing low back pain, with strong involvement from both workers and management, can effectively reduce injury reports and time lost from work. This strategy can involve joint efforts to identify and control risks, monitor the occurrence of low back problems and sick leave and develop a “safety culture' in the workplace.
Assessing the condition of a worker who presents with low back pain
A simple interview and assessment can identify whether back pain is ordinary or requires treatment from a specialist. When patients visit a doctor because of back pain, the doctor looks for “red flags', which are signs that the symptoms are caused by a specific problem such as a prolapsed disc| disc | | A 'cushion' between vertebrae in the spine. Each disc helps form a joint to allow movement between the vertebrae. Disks| disk | | | A 'cushion' between vertebrae in the spine. Each disc helps form a joint to allow movement between the vertebrae. Disks have a fibrous outer layer surrounding a jelly-like core, which functions to absorb impact in the spine. Alternative spelling: disc. |
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Only about 10% of low back pain is caused by a specific problem. For the 90% with non-specific pain, X-rays, MRIs and other diagnostic| diagnostic | | | Used to identify a medical condition or disease by its symptoms, the findings from a medical examination, and from the results of X-rays, scans, or other tests. |
| straight leg raising | | A procedure of stretching the sciatic nerve| sciatic nerve | | | A large nerve that starts in the lower back and runs down the leg. It is the longest and largest single nerve in the body. |
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Treatment for non-specific low back pain focuses on avoiding a long-term problem. Most people recover from low back pain quite quickly, but those who develop a chronic problem (one that lasts more than 12 weeks) experience significant suffering, have a much lower chance of ever returning to work and face heavy financial costs.
It is important to identify people who might be at risk of becoming disabled. Again, tests and X-rays cant help, and measurements of height, weight, flexibility of the back and straight leg raising tests are also ineffective. Instead, doctors look for 'yellow flags' that are risk-factors. These include:
older age
prolonged or severe pain
job dissatisfaction
significant problems with daily activities and work due to pain
distress
depression
beliefs that back pain is harmful or potentially severely disabling
avoidance of activities for fear of pain
expectations of passive treatments (e.g. ultrasounds, medications) rather than belief in active participation
Research has found that the severity of the condition is not the main factor in whether back pain will become a long-term problem. There is strong evidence that psychological and social factors influence a person's recovery and their chance of developing long-term disability. The employee's beliefs about their ability to return to work and whether they attribute blame to the workplace are particularly important. Poor relationships at work can also be obstacles to recovery.
Management of low back pain
Treatment for low back pain should focus on advice to stay active and return to work as quickly as possible. It is essential that general practitioners, occupational health specialists and other healthcare workers, managers, supervisors, workers and union representatives communicate regularly and work together cooperatively to achieve these aims.
Advice to continue ordinary activities despite the pain is much a more effective treatment than advice to rest or to 'let pain be your guide'. There is strong evidence that the active approach results in:
Equivalent or faster relief from short-term symptoms
Shorter periods of time off work
Fewer reoccurrences of the pain
Less time lost from work over the next year
Education to help patients overcome fear and pain avoidance, and encouraging them to be responsible for their own care, may also be effective.
Continuing normal activities includes getting back to work as quickly as possible. There is strong evidence that most workers with low back pain are able to continue working, or return to work within a few days or weeks, even if they still have some remaining symptoms.
Workers, supervisors and even doctors often worry about returning to work too soon, thinking they might “cause a re-injury'. In fact, returning to work as quickly as possible is the best approach. People with low back pain are likely to experience a recurrence of their condition regardless of whether they return to work or not, and this risk is actually reduced by returning to work more quickly. The longer someone stays off work with back pain, the less likely they are to ever return.
Sometimes employers refuse to allow their workers to return before they are 100% symptom-free, fearing that they will be legally liable in case of a 're-injury'. In reality, they are actually increasing the workers chance of a developing a long-term problem (which would drastically increase the cost of their compensation claim). Offering support and modified duties while the employee recovers not only improves outcomes for the employee, but also reduces the employer's legal liability.
Overall, workplace strategies such as a commitment to safety, case-management and support are likely to reduce time lost from work. Again, good communication is essential.
Workers who have difficulty returning to work after 4-12 weeks
The longer someone stays off work with low back pain, the more disabling the condition becomes. Treatment becomes less effective and long-term sickness absence is more likely. After a person has been off work for 1-2 years it is unlikely that they will return to any form of work in the future.
People who have subacute pain (pain that has lasted 4-12 weeks) are already at greater risk of a long-term problem. However, treating subacute pain is more effective than treating pain once it has become a long-term disability. There is strong evidence that intervening at the subacute phase can improve the long-term outcomes of low back pain and reduce costs. An intense effort to get employees back to work should be made.
Offering modified duties is an effective way for workplaces to help employees back to work. A combination of clinical treatment, rehabilitation| rehabilitation | | | The process of helping a person back to their former abilities and quality of life (or as close as possible) after injury or a medical condition. |
Some multidisciplinary| multidisciplinary | | | Utilizing multiple treatment approaches at the same time. e.g. combined treatement with psychology, physiotherapy and hydrotherapy |
Education about the medical aspects of back pain is ineffective as a treatment for low back pain. Education that helps patients overcome their fears, reduce negative expectations and become more active, however, reduces disability.
An exercise or physical fitness program can improve pain and disability in the short term for people with subacute or chronic pain.
It is important that patients with subacute pain understand that their risk of long-term disability increases if they remain off work, and that they should not wait to be completely pain-free before returning. Employers should monitor workers on sick leave to identify those off work for more than 4 weeks, and help them to return to work.
Summary of Practitioners Leaflet as part of the Occupational Back Pain Guidelines
Principles of management of back pain
Make employers and workers aware that:
Low back pain is common and frequently recurrent but episodes of pain are usually brief and self-limiting.
Physical demands at work are only one factor influencing low back pain.
Prevention and case management need to be directed at both physical and psychosocial factors.
Physical demands at work can be associated with increased back symptoms and ‘injuries, but they do not generally cause lasting physical damage. Overall, they are less important than other individual, non-occupational and unidentified factors. Disability due to low back depends more on psychosocial factors than physical work demands.
Assessing and managing patients with back pain
Consider 'red flags' for potentially serious problems. Screen for serious spinal diseases and nerve root problems.
Take a detailed clinical, disability and occupational history.
Consider psychosocial risk factors (‘yellow flags') for chronicity. These are patient beliefs and behaviours which may predict poor outcomes. Individual and work-related psychosocial factors play an important role in persisting symptoms and disability. The following factors are important and consistently predict poor outcomes:
A belief that back pain is harmful or potentially severely disabling
Fear-avoidance behaviour and reduced activity levels
Tendency to low mood and withdrawal from social interaction
Expectation of passive treatment(s) rather than a belief that active participation will help
Patients aged >50 years, with more prolonged and severe symptoms, or radiating leg pain, are at higher risk of long term disability.
Clinical examination, X-ray and MRI| MRI | | | Magnetic resonance imaging (MRI) is used in medical imaging and works by applying a magnetic field to the body and observing how the atoms behave in the field in order to create an image. Whilst an X-ray shows bones, MRI scans can show soft tissues and are used to examine tissues such as discs in the back, cartilage lining a joint, muscles and tendons. |
do not predict clinical symptoms or work capacity.
Encourage the worker to continue as normally as possible and to remain at work, or to return to work early, even if they still have some pain. Most workers with LBP are able to continue working or to return to work within a few days or weeks: they do not need to wait until they are completely pain free. Temporary provision of modified or lighter duties facilitates return to work and reduces time off work. Consider temporary adaptation of the job or pattern of work if necessary. Staying active and returning to ordinary activities as early as possible leads to faster recovery and fewer recurrences. In contrast, the longer a worker is off work with low back pain, the lower their chances of ever returning to work.
Joint employer-worker initiatives to provide optimum management and to facilitate and support workers remaining at work or returning to work as early as possible may reduce sickness absence.
Communicate and collaborate with primary health care professionals to shift the emphasis from dependence on symptomatic treatment to rehabilitation and self-management strategies. Where practicable refer to an active rehabilitation programme. Rehabilitation is more effective in an occupational than in a health care setting.
A combination of optimum clinical management, a rehabilitation programme, and organisational interventions designed to assist the worker with back pain return to work, is most effective.
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Conclusions: |
Clinical guidelines are evidence-based recommendations for managing medical conditions. The Occupational Health Guidelines for the Management of Low Back Pain at Work were produced by the UK Faculty of Occupational Medicine. Their main findings include the following:
Risks for low back pain
Low back pain is common problem that affects 60-80% of adults.
Low back pain is often a recurring problem.
Physical work may be a factor in developing low back pain, but it is not the most important factor.
The only strong indicator that a person is at risk of low back pain is if they have experienced it before in the past.
Excluding people from employment because they have a history of low back pain is not a logical or effective strategy.
Diagnosis and management of low back pain
About 90% low-back pain is non-specific, meaning the cause is unknown.
Doctors look for 'red flags' to identify specific problems like spinal diseases or tumours.
If the patient doesn't show any red flags, X-rays and other tests do not help to determine the cause of the pain.
Most episodes of low back pain get better on their own quite quickly, but a minority of people have a long-term problem.
The longer the problem persists, the worse the outlook.
The severity of the condition is not the most important factor in predicting who will develop a long-term problem.
Psychological and social issues are important risk-factors for developing a long-term problem.
Staying active despite the pain and returning to work as quickly as possible is the best approach to treatment.
Patients should not wait until they are completely pain-free before returning to work.
When a person has experienced low back pain for 4-12 weeks they are at risk of a chronic disability. An intense effort should be made to help them return to work.
Workplaces can help employees return to work more quickly by offering support and modified duties.
Multidisciplinary rehabilitation programs may be effective in treating low back pain.
A cooperative approach between employers, employees, health professionals and others is required to minimize the consequences of low back pain.
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References: |
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