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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6034_Библиотеки_им_академика_М_И_Перельмана.pdf
CHAPTER 15/ACUPUNCTURE AND REFLEXOLOGY / 163
and self-care education for chronic low back pain. Arch Intern Med
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898–906.
SECTION III
The Injured Worker
CHAPTER 16
Returning Workers to Gainful Employment
Margareta Nordin
Returning workers to gainful employment after work
absence due to low back pain has become a public
health policy problem. Being unemployed or disabled
from work due to low back pain of benign nature is a
societal problem in industrialized and industrializing
parts of the world. Compounding this problem is the
fact that the reputation of low back pain and its potential incapacitating symptoms has worsened. In industrialized countries, the public still believes that low back
pain is crippling, leading to serious disability and the
loss of gainful employment and a satisfying lifestyle.
Without great fanfare, back pain became the leading
20th century medical disaster (1), with an estimated cost
of 1% to 2% of gross national product (GNP) in Organisation for Economic Co-operation and Development
(OECD) countries (2) and a cost of about $50 billion in
the United States (or 0.5% to 0.6% of GNP based on
data from 2001) (3). Cats-Baril and Frymoyer (4) estimated that costs for back pain in the United States were
equivalent to 0.5% to 2.0% of GNP in 1991. In these
and other industrialized countries, the cost structure for
low back ailments is the same, with approximately 10%
to 30% of being spent for direct costs and 70% to 90%
on indirect costs.
It is technically difficult to estimate work loss due to
back pain, however work loss due to back pain has been
reported in several studies. For example, Guo et al. (5)
reported in 1988 that 17.6% of the respondents (n <
30,074) to the National Health Interview Survey lost an
estimated 149 million workdays in the United States. The
Office of National Statistics in the United Kingdom
reports from 1993 to 1998 approximately 5% of employed
individuals said they had taken time of f from w ork for back
pain over a 4-week period being questioned (6).
In Sweden about 2% to 6% of the working population experiences work loss from back pain (7). The differences in reported work loss may be due to different
reporting systems, national versus non-national health
systems, and various compensation systems, among
others. There are indications that sickness absence is
increasing (8) and early retirement resulting from back
pain is decreasing (7), however there are also indications that an increasing proportion of people receive
benefits for much longer time and that the amount of
benefits paid are increasing (7). This would make a
strong argument to intensify the prevention of disability and encourage work ability for individuals experiencing low back pain.
COMMONALITY OF BACK PAIN EPISODES
Prevalence of low back pain is high. International studies reveal a point prevalence (about 1 week) of 15% to
30%, a 1-month prevalence of 10% to 43%, and a lifetime
prevalence of low back pain of 51% to 81% (1,7). It is
important to note that study design and cultural differences in self-reporting, more so than actual differences of
the populations studied, may cause the variation of these
estimates (7,8). Therefore, one can reasonab l y state that it
is more common during life to have experienced back
pain than not to have experienced back pain. In fact,
when conducting a study, it is actually quite difficult to
find individuals who have never experienced or been out
of work for back pain (9,10).
BACK PAIN CLASSIFICATION
Pain in the lumbar spine can be classified as specif ic
or nonspecific pain. These terms are convenience terms
created to establish some sort of triage mechanism. Specific low back pain means that the pain originates from a
known structure, abnormality, tumor, trauma, or systemic
or established disease. All other conditions are classif ied
and diagnosed as nonspecific low back pain (NSLBP), a
diagnosis that stems from the fact that science has not yet
revealed which structure in the spine generates the pain.
167
168 /SECTION III/THE INJURED WORKER
This classification system has been very helpful for
researchers and clinicians.
One point of encouragement is that large working population cohorts using the classif ication of NSLBP have a
good prognosis for 90% of affected individuals to return
to work. Studies show that 75% of compensable back
pain resolved within 4 weeks, 90% within 3 months, and
95% within 6 months (1,11,12). The probability of an
NSLBP diagnosis developing into “chronic back pain
syndrome” (often defined as disabling pain of more than
3 to 6 months) is approximately 5% to 6%, compared to
patients presenting with a specific diagnosis of low back
pain for whom about 35% to 40% will develop a chronic
and disabling condition (13–15).
Although chronicity as defined by continuous pain or
permanent work disability affects about 3% to 5% of
patients seeking care for low back pain, recurrence of low
back pain is more frequent. For e xample: in Canada the frequency of recurrent episodes after compensable back injury
was 36% over 3 years (11). In a survey of approximately
3,800 Belgian adults, 85% of those reporting back pain at
the time of interview had experienced prior episodes (16).
Some authors claim that low back pain should be regarded
as a persistent problem with intermittent exacerbation (Fig.
16-1) (1,17,18) that may seriously affect work ability (19).
This chapter will focus on the prevention of workrelated disability in the working population with NSLBP. It
will discuss the return of workers to gainful employment
and the subsequent retention of that gainful employment.
MISUNDERST ANDINGS AND A
PHILOSOPHICAL SHIFT REGARDING BACK
PAIN
The Paris Task Force (20) best describes the philosophical and evidence-based shift from passive to active
treatment. The treatment of low back pain has not advanced beyond the outdated prescription for bed rest,
because the role of activity in its treatment has been the
object of three misunderstandings:
1. The first misunderstanding is related to the fact
that certain activities (mainly occupational) are undeniably risk factors for low back pain and there is a natural
tendency to avoid activity once an episode of back pain
has begun. Although reexposure to the conditions that
triggered the episode often causes pain, which may
sometimes be intolerable (reinforcing the idea that it is
better to avoid the conditions altogether), conditions
that cause back pain are not necessarily risk factors for
chronicity.
High
Pain
Low
A
High
Pain
Low
B
FIG. 16-1. Examples of concepts in studies including duration and pain in the lumbar spine. A: More
traditional concepts where the bouts of pain are represented with a pain-free period in between.B: More
current and debated concept in subgroups of patients where the pain over time may vary and not subside completely. (Adapted from Croft P, Papageorgiou A, McNally R. Low back pain. In: Stevens A,
Raftery J, eds. Health care needs assessment. Second series: The epidemiologically based needs
assessment reviews. Oxford: Radcliffe Medical Press, 1996:129–182.)
Time
CHAPTER 16/ RETURNING WORKERS TO GAINFUL EMPLOYMENT / 169
2. The second misunderstanding stems from the association many people make between “sciatica” (i.e., low
back pain accompanied by spinal symptoms and signs)
and low back pain unaccompanied by neurologic sequelae. However, low back pain accompanied by spinal damage only accounts for a very low percentage (approximately 5%) of all cases of low back pain, and there is no
longer any consensus on the existence of a continuum
linking the two types of conditions.
3. The third misunderstanding arises from current
approaches to pain management. While it is common to
neglect, if not disparage, specific and effective pain
relief, it is nevertheless considered important to avoid
anything that might trigger pain. In the absence of specific pain relief, rest becomes the only possible choice,
with unfortunate results.
APPROACH T O TREATMENT FOR NSLBP
Despite the time and effort spent preventing and treating NSLBP, the costs associated with NSLBP continue to
rise (1,2,8). This may, in part, be attributed to the current
management of NSLBP in which the patient is either
over- or under-treated. It is often assumed that pain is due
to either a specific underlying cause or that it is of a nonmedical origin. Both conclusions do a disservice to the
patient with NSLBP.
In the first scenario, attempting to provide a specif ic
diagnosis to a patient with NSLBP can have deleterious
consequences. For example, Abenhaim et al. (11) observed that patients given a specific spine diagnosis
faired worse than patients given a diagnosis of NSLBP.
The authors further discussed the possibility that medically “labeling” a condition of NSLBP with specific
diagnoses may convince the patient that the pain is of a
purely physical origin, suggesting that pain requires medical interventions such as medication, injections, manipulations, and even surgery. In order to relieve pain, the
patient may then engage, to no avail, in negative health
behaviors such as “doctor shopping,” avoidance of movement and activities, and an o ver -reliance on medication or
other passive treatments.
In the second scenario, attributing pain to nonmedical
factors such as psychological conditions alone inv alidates
the true nature of pain, causing serious psychological distress to the patient. Furthermore, this attribution of
NSLBP to nonphysical conditions may backfire as the
patient seeks validation of the physical pain by overfocusing on the pain in an effort to convince others that it
is “real.” The health care provider may also grow frustrated and give up on the patient prematurely.
In the best scenario, however, the successful treatment
of NSLBP requires a unique approach where the true
nature and prognosis of NSLBP are shared with the
patient. This is best accomplished proactively through an
evaluation and treatment program derived from the application of the biopsychosocial model (1,8,21).
A Proactive Approach to NSLBP
A proactive approach to NSLBP includes the follow-
ing:
1. The health care provider forms a partnership with the
patient. Together they follow evidence-based medical
practices and timelines for evaluation and treatment.
2. The health care provider must also be ab le to identify
risk factors for chronicity as they emerge and make
timely referrals when appropriate (19,22).
3. The patient is monitored on a regular basis so that
changes in treatment needs may be assessed and
implemented in a timely manner. For example,
NSLBP may sometimes become specific as when
true sciatica or a discitis develop. This can only be
detected if the patient is monitored properly.
A proactive approach to NSLPB works best in the context of a biopsychosocial paradigm (8). A biopsychosocial perspective takes into consideration psychological
and social factors related to pain, as well as physical factors and has been proven successful for the treatment of
NSLBP. By definition, NSLBP has no identifiable known
medical cause and therefore traditional medical approaches often fail. In the context of failed medical treatment approaches, as time goes on, psychological and
social factors become increasingly important in determining pain and its subsequent disability. These factors
must be acknowledged for successful outcomes in treating NSLBP (19,22–25).
WORKER’S CHOICE:TO SEEK OR NOT TO
SEEK TREA TMENT
Pain developing in the lumbar spine may be or may not
be attributed to work functions; however, the pain may
still affect the work capacity and be aggravated during
working hours. An individual may or may not seek help
for the condition (26). The dif ference in action taken transpires in the predicament of the worker/employee and the
system in which that individual works. Hadler described
the process of predicament (27). The indi vidual considers
the pain, the restriction in function, and the options for
action. There may or may not be an event that ignited the
pain. All these factors influence the idiosyncratic decision to seek help based on prior experience, education,
environment, and possible fear for the seriousness of the
condition. Three obvious choices are relevant at this
point:
1. Endure the pain and continue to work, which is not
uncommon. How ever, few studies have focused on the
individual who continues to work with low back pain.
170 /SECTION III/THE INJURED WORKER
2. Seek professional medical advice and be considered
a person with an illness (i.e., a patient under medical
or other care). Most studies of low back pain have
focused on this group of individuals.
3. Report an occupational injury or illness and f ile a
claim. The individual who reports a claim becomes a
claimant with an injury or illness. Fewer studies have
focused on treatment of work-related low back pain
and claimants.
The choice an individual makes may affect the outcome
of the condition. Because the environment in which the
condition is treated or left untreated varies, the health care
and reimbursement provided may be different. As well, the
external perception of the individual with low back pain
differs. For example, a person who chooses to continue to
work with moderate NSLBP will probably do f ine except
in very physically demanding jobs such a construction,
firefighting or rescue work, nursing, or jobs with exposure
to whole body vibration (i.e., driving a truck) (28). An individual who seeks medical care for acute or subacute
NSLBP should be advised by their health care provider to
keep active and to return to w ork as soon as possible based
on the international scientific guidelines for low back pain
(19,23,29,30). The outcome for these patients, which is
measured as return to work and well-being, will be far
more successful than those undergoing a long-term bed
rest or passive modality treatment. Finally, a claimant
experiencing NSLBP who is told by the employer’s physician to return to work as soon as possible will usuall y start
to negotiate about the date to return to work. The outcome
is usually very favorable if the health care provider takes
the time to explain the condition and establishes trust with
the claimant, and recommends continued activity, short
course of active treatment, and light work duty during the
next 1 to 4 weeks. The recommendation to return to the
regular work is usually negotiated based on type of work,
exposures to hazardous or unsafe working conditions, and
tasks to be performed.
Health care providers must acknowledge and understand the options and predicaments of choice for the individual with back pain. None of the choices are wrong or
right, however, they are personal and choices that are not
always well understood in the scientific and medical
environment. The health care provider who chooses to
manage the working/employed patient should reinforce
the distinction between impairment and disability, hurt
and harm (1,23), and should recognize that work disability is a multidimensional problem of which clinicians and
researchers have only just begun to unravel the complexity (8).
RULING OUT RED FLAGS
The evaluation of low back pain should involve ruling
out specific signs, referred to as “red flags” (23) and
identifying risk factors for chronicity, referred to as “yellow flags” (22). A diagnostic triage has been suggested
by the Clinical Guidelines for the Management of Acute
Low Back Pain from the Royal College of General Practitioners (19). Diagnostic imaging tests are not routinely
indicated (31).
Red flags are signs and symptoms detected by the clinician that may indicate possible serious spinal pathology
and require referral to a specialist (23). A standardized
physical examination is necessary to exclude possible
specific conditions. The examination must consist of a
patient history that includes trauma, systemic diseases,
cancer, infection, or major neurologic compromise (red
flags). The patient history is followed by a physical evaluation that includes posture, gait, toe and heel walk, palpation, range of motion, the effect of trunk sagittal flexion/extension and lateral flexion on lo w back pain and leg
pain, and a neurologic examination of the lower extremities to test motor, sensory, and reflexes (32,33). The presence of red flags or neurologic signs and symptoms (such
as back pain with radiation to a leg below the knee level
or sensory-motor dysfunction) will classify low back pain
as specific and may require a referral to a specialist for
treatment (19,23). All other patients can be classified as
having NSLBP.
PHYSICAL AND PSYCHOSOCIAL RISK
FACTORS ASSOCIA TED WITH DELA YED
RECOVERY
A number of physical, personal, psychosocial, and
environmental factors have been associated with the outcome of NSLBP. Physical signs that have been found to
be predictors of delayed return to work in patients with
acute (up to 4 weeks of duration of pain) NSLBP are
altered gait and pain below the knee in a nondermatomic
topography (32,34–37). Since these signs are present in
both specific LBP and NSLBP, their meaning for NSLBP
is still unclear. It is possible that they may reflect aspects
of fear of pain and behaviors intended to communicate
suffering to the health care provider rather than actual
physical abnormality (38). Personal factors, such as age,
affect recovery and therefore work ability (39–41). For
example, it takes a person about twice as long to return to
work at age 50 compared to age 30. Clinical factors such
as the duration of back pain have also been associated
with poor prognosis in that the likelihood of recovery
diminishes steadily after as early as 4 weeks (39).
Most significantly, studies have revealed a number of
psychological risk factors. For example, strong associations between delayed recovery in acute NSLBP and psychological distress have been found (38,42–44); depressive mood and somatization are consistently observed in
the transition from acute to chronic low back pain (21);
and high self-perceived disability and short-term changes
in perceived disability ha ve been associated with return to
CHAPTER 16/ RETURNING WORKERS TO GAINFUL EMPLOYMENT / 171
work outcomes such that higher perceptions of disability
are related to poorer outcome (19,38,39,41,42,44,45).
Other factors have been associated with poor outcome,
including the belief that back pain is harmful or potentially sev erel y disab ling; fear a v oidance beliefs (the belief
that certain movements or acti vities will exacerbate pain);
perceived inability to return to work; and the belief that
passive treatment is preferable to active participation in
care (19,22).
These psychosocial factors can be summarized as negative beliefs about low back pain and its consequences
and negative emotional states. They may be considered
“yellow flags” (22) or “early predictors” (38,36) because,
while they do not indicate the same urgency of treatment
as red flags, there is enough evidence to recommend that
they receive attention when present. Guidelines from
New Zealand stress the importance of assessing psychological and psychosocial risk factors as early as 2 weeks
after the onset of NSLBP (22).
In an occupational health setting, psychosocial factors
such as work-related perceptions constitute additional
risk factors (46). Job dissatisfaction, monotony, poor
social support, high perceived stress, and high perceived
job demands have all shown a strong association with
NSLBP (47). Therefore, it is reasonable to evaluate these
perceptions in patients with NSLBP and discuss with the
patient how these factors may influence the perceived
back pain.
Physical characteristics of the job (such as excessive
overtime or heavy workload) may also contribute to stress
(28,43,48–50). Physical characteristics may be assessed
subjectively and objectively. It is less understood what
impact reducing perceived or actual physical stressors at
work may have on psychological distress, NSLBP, and
disability.
THE IMPACT OF COMORBIDITY ON
DISABILITY IN NSLBP
There is recent information in the literature about the
relationship between comorbidity and work disability
from back pain. In a prospective, randomized case-controlled study Seferlis et al. (41) compared somatic and
personality characteristics of acute LBP patients with
healthy matched controls and found a fourfold increase in
sick leave episodes in LBP patients for reasons other than
spine morbidity. Fanuele et al. (51), in their prospective
observational study on spine center patients, demonstrated that comorbidity affects the physical function,
showing that the more comorbidities a patient has, the
lower the physical functional status.
Nordin et al. (12) examined the relationship between
comorbidity and the initial return to work following first
episodes of work-disabling NSLBP. An inception cohort
of workers with new episodes of NSLBP was identif ied
from administratively maintained occupational health
records. A comparison of 6-month return to work rates
between workers with one or more comorbid conditions
to those without documented comorbidity was conducted. Workers with comorbidity were 1.3 times more
likely to remain work-disabled than those with uncomplicated NSLBP, after adjusting for age, gender, lifting
demands, and type of work (adjusted hazard ratio 1.31,
95% confidence interval 1.12 to 1.52). Concurrent injury
(i.e., sprains or strains of the neck, upper and lower
extremity, and contusions and lacerations) had the
strongest association with delayed return to work
(adjusted hazard ratio 1.49, 95% confidence interval 1.21
to 1.83). The authors concluded that occupational health
professionals should routinely evaluate comorbidities at
the first, as well as subsequent visits to better manage disability associated with NSLBP.
EST ABLISHING AN EVIDENCE-BASED
TREATMENT PLAN
Researchers and clinicians have used an additional categorization of NSLBP based on the onset and duration of
pain in the lumbar spine to develop evidence-based
guidelines of treatment (20). Clinical and accepted categorizations for duration of NSLBP are:
1. Acute: Pain with a duration ≤ 4 weeks.
2. Subacute: Pain with a duration ≥ 4 weeks but ≤ 12
weeks.
3. Chronic: Unremitting pain with a duration ≥ 12
weeks
For many individuals, however, NSLBP is not a onetime event but tends to recur (18,52). Therefore, an additional classification, recurrent NSLBP, signifies intermit-
tent pain with a pain-free period in between in which the
individual could resume work (7,20). Recur rent NSLBP
may be acute or subacute, but since chronic pain signifies
unremitting pain of more than 12 weeks, by definition, it
cannot be chronic (53).
Considering the socioeconomic impact of NSLBP
there is an obvious need for effective interventions, especially in occupational health care. The ultimate goal of
such interventions for workers is return to work, either to
a preinjury or modif ied work capacity. Given the favorable natural course in the acute phase of NSLBP of return
to work, the challenge becomes returning an employee to
work who is in the subacute or chronic phase.
A variety of treatment interventions are typically used
for individuals presenting with NSLBP (54,55). Several
authors have pub lished systematic re views of the efficacy
of these interventions (19,20,53,56–58). Studies show
that for subacute NSLBP exercise therapy, behavioral
therapy, and intensive multidisciplinary rehabilitation
with functional restoration all reduce pain and improve
function in workers (20,32,59,60). Graded activity leads
to earlier return to work and reduced long-term sick leave
172 /SECTION III/THE INJURED WORKER
in workers with subacute low back pain. Lindström et al.
(60) described the goal of the graded activity approach as
being return of an individual to the previous nonmodified
workplace. Positive reinforcement to return to work is an
important aspect of graded activity as well as continuous
encouragement to resume work. Multidisciplinary treatment consisting of a combination of exercises, education,
and a behavioral approach seems the most effective intervention in the subacute phase of NSLBP. Lindström et al.
(60) conducted a randomized control trial aimed at restoring occupational function in workers in an automobile
plant. The multidisciplinary intervention team included a
physician, a physical therapist, and a social worker. All
workers (n < 103) participating in the study had been out
of work for more than 8 weeks for NSLBP. Half of the
participants were randomized to an intervention including an operant-behavioral conditioning program and the
other half received what is considered “usual care.” The
intervention program consisted of four parts: measurements of functional physical capacity, a workplace visit,
“back-to-school” education, and an individual, submaximal, gradually increased exercise program. The individually tailored exercise program was based on an operantconditioning behavioral approach and the result of the
tests and the demands of the patient’s work. No
ergonomic or other changes in the work situation were
needed in the study. The results were significant and positive.
The rate of return to work was significantly faster in
the intervention group than in the control group (κ2 <
4.7, p < .03) (Fig. 16-2). The intervention group had 7
weeks’ less sick leave in the follow-up period of 1 year
than the control group receiving “usual care.” Four
patients in the control group went on permanent disability versus one patient in the intervention group. The study
did not have an independent evaluator, causing a methodologic weakness, however it was the first randomized
control trial in the industry that emphasized the importance of activity and exercise, a behavioral approach, and
an individual tailored program to resume work demands.
It was also a program that demonstrated the importance
of full support from the employer.
One approach to augment return to work for chronic
NSLBP patients is functional restoration (61–63), the
goal being to restore a patient’s function. This approach
leads to the decrease of and control of pain through the
combination of exercise with functional work simulation
and behavioral support. The exercise program uses a
100%
Control group, n = 52
Intervention group, n = 51
0%
0
FIG. 16-2. Proportion returning to regular work. Randomized control trial from Sweden showing results
from active intervention including exercise, behavioral approach and workplace visit versus usual care.
(Adapted from Lindström I, Öhlund C, Eek C, et al.The effect of graded activity on patients with subacute low back pain: a randomized prospective clinical study with an operant-conditioning behavioral
approach. Phys Ther 1992;72:279–290.)
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