OCCUPATIONAL HEALTH GUIDELINES
FOR THE MANAGEMENT OF
LOW BACK PAIN AT WORK
Evidence Review and Recommendations
Published March 2000
SUGGESTED CITATIONS
Carter JT, Birrell LN (Editors) 2000. Occupational health guidelines for
the management of low back pain at work - principal recommendations. Faculty
of Occupational Medicine. London.
Occupational health guidelines for the management of low back pain at work
- leaflet for practitioners. Faculty of Occupational Medicine. London. 2000.
Waddell G, Burton AK 2000.
Occupational health guidelines for the management of low back pain at work
- evidence review. Faculty of Occupational Medicine. London.
Proposed review date: December 2005
ACKNOWLEDGEMENTS
Thanks are due to the following who made major contributions to preparing these
guidelines:
- The Working Group and Reviewers (see page ii).
- The Steering Group and Funders, in particular Mr Brian Kazer of Blue Circle
Industries plc and Mr Alan Bayley of British Occupational Health Research
Foundation.
- The Royal College of General Practitioners for leading the way with their
guidance and for permission to include their clinical guidelines as an appendix.
- Relevant Government Departments (Health and Social Security) and the Health
and Safety Executive by providing assessors to the Working Group and supporting
the initiative.
- Frances Quinn and Jananne Rahman of the Faculty of Occupational Medicine
for preparing this document for publication.
MEMBERS OF THE FACULTY WORKING
GROUP
Dr Tim Carter (Chairman) Occupational Physician
Professor Gordon Waddell (Reviewer) Orthopaedic Surgeon
Professor Kim Burton (Reviewer) Ergonomist
Dr Lisa Birrell (Scientific Secretary) Occupational Physician
Dr Cathy Amos Occupational Physician
Richard Bolton Physiotherapist
Dr John Gration Occupational Physician
Andrew Nicoll Occupational Health Nurse Manager, representing Royal College
of Nursing
Dr Keith Palmer Occupational Physician
Dr Sally Randall Occupational Physician
Dr Charles Sears General Practitioner, representing Royal College of General
Practitioners
Allason Thompson Physiotherapist
Claudia Treasure Physiotherapist representing the TUC
Dr Peter Verow Occupational Physician Assessors
Dr Andrew Auty Scientific Adviser, British Occupational Health Research Foundation
Avril Imison Head of Policy, Therapy Services, Department of Health
Dr Philip Sawney Medical Policy Manager, Department of Social Security
Dr David Snashall Occupational Physician, Health and Safety Executive
CONTENTS
1 Preface
2 Introduction
3 Principal recommendations for occupational health management
Figure 1 Diagnostic Triage including 'Red Flags'
Figure 2 Psychosocial Risk Factors - 'Yellow Flags' Figure
3 Active Rehabilitation Programme
4 Practitioners' leaflet - 'Occupational Health Guidelines for the Management
of Low Back Pain at Work'
5 Evidence review methods
6 Evidence review
A Background
B Pre-placement assessment
C Prevention
D Assessment of the worker presenting with back pain
E Management principles for the worker presenting with back pain
F Management of the worker having difficulty returning to normal occupational
duties at approximately 4-12 weeks
7 Evidence tables
Table 1a Systematic reviews
Table 1b Main conclusions of systematic reviews
Table 2 Narrative reviews
Table 3 Individual scientific studies
Table 4 Additional studies on return to work
Table 5 Previous guidelines
8 References
Appendix 1 Faculty of Occupational Medicine
Appendix 2 Clinical Guidelines for the Management of Acute Low Back Pain -
Royal College of General Practitioners 1999
1 PREFACE
Disability from back pain in people of working age is one of the most dramatic
failures of health care in recent years. Its greatest impact is on the lives
of those affected and their families. However, it also has a major effect on
industry through absenteeism and avoidable costs (the CBI estimate that back
pain costs £208 for every employee each year) and at any one time 430,000 people
in UK are receiving various social security benefits primarily for back pain.
This review and the guidelines based on it aim to reduce the toll of harm by
providing a new approach to back pain management at work which is based on the
best available scientific evidence and uses this to make practical recommendations
on how to tackle the occupational health aspects of the problem. This project
was made possible thanks to the foresight of Blue Circle Industries PLC who
funded it as their 1999 Community Project. Completion of the project was only
achieved because of the quality of the reviewers, the hard work of the multidisciplinary
working group in the Faculty of Occupational Medicine and the logistical support
provided by the British Occupational Health Research Foundation.
Evidence-based guidelines are becoming the benchmarks for practice in most
areas of health care. It is hoped that this will be the first of many for UK
occupational health practitioners. It complements existing guidelines produced
for primary care health professionals by the Royal College of General Practitioners
(RCGP) and thus should facilitate better links between the workplace and the
community for back pain management.
The process used to prepare such guidelines is well established (Royal College
of General Practitioners 1995). Six key occupational health areas were identified
and a systematic review prepared of the scientific evidence covering each of
these areas. Evidence statements were prepared and linked to that evidence.
As far as possible, recommendations for practice were based upon and linked
to these evidence statements, though there are some important areas where there
is a lack of evidence. The evidence and recommendations concentrate on interventions
and outcomes rather than on professional disciplines and so do not make any
comment on which occupational health professional should provide advice or support.
A number of evidence gaps in occupational health management of low back pain
are identified. The need to fill these gaps in knowledge is the first of several
challenges posed by the review. Revisions of the review and guidelines are envisaged
to take account of new information.
Other challenges include:
- The need for everyone to recognise that work is only one contributor
to back pain but that back pain whatever its cause can, if poorly managed, have
a devastating effect on a person's ability to work.
- The importance of planning ahead at the workplace to reduce back pain disability
by following the guidelines and involving all those concerned - because it can
be difficult to manage a case well if the ground has not been laid in advance.
- How best to encourage General Practitioners to follow the RCGP guidelines,
for instance by offers of collaboration from the workplace to maintain people
with back pain at work or to help them to return to work as soon as possible
if they have been absent.
- The need for the health care system to develop the sort of rehabilitation
measures which have been shown to be effective in other countries and to make
them available within a month of the start of an episode of back pain and before
it has become a chronic and largely irremediable problem.
Tim Carter and Lisa Birrell
Chair and Secretary of Faculty of Occupational Medicine Guidelines Working Group
Editors of Chapters 1- 4
2 INTRODUCTION
This publication presents the output from the Blue Circle Industries PLC/Faculty
of Occupational Medicine/British Occupational Health Research Foundation project
on occupational health aspects of low back pain:
1. a systematic review comprising the scientific evidence base underlying the
Occupational Health Guidelines for the Management of Low Back Pain at Work.
This provides a directory and guide to the evidence available, and links it
to individual evidence statements. (Chapter 5 onwards)
2. Occupational Health Guidelines for the Management of Low Back Pain at Word:
the full evidence statements and recommendations based on them for occupational
health practitioners. (Chapter 3)
3. a leaflet summarising the evidence based guidelines for occupational health
practitioners. (Chapter 4)
The complementary RCGP Clinical Guidelines for the Management of Acute Low
Back Pain (1999) are included as an appendix. (Appendix 2)
The development process for the guidelines began with the Faculty of Occupational
Medicine (FOM) commissioning a comprehensive review of the available scientific
literature, from which a guideline document was developed. Wherever practicable,
the methods of guideline development described by the RCGP Clinical Guidelines
Development Group were adopted (Royal College of General Practitioners 1995).
The Guidelines consist of recommendations accompanied by evidence
statements, with ratings of the strength of that evidence. The Evidence
Review expands on the evidence statements, references the associated literature
and specifically links the evidence statements to the recommendations given
in the Guidelines.
The Evidence Review was written principally by the appointed reviewers, whilst
the Guidelines and leaflets resulted from extensive debate by a multidisciplinary
development group assembled for this purpose by the FOM.
This intensive development process would not have been possible without the
support of the British Occupational Health Research Foundation (BOHRF) and funding
from Blue Circle Industries PLC (BCI).
Scope
The Guidelines are intended for health professionals undertaking the occupational
health management of low back pain (LBP). They focus on interventions that might
be considered appropriate for occupational health practitioners to implement.
They are designed to complement and to be used in conjunction with the RCGP
Clinical Guidelines for the Management of Acute Low Back Pain (Royal College
of General Practitioners 1999).
It is not intended, nor should it be taken to imply, that these guidelines
override existing legal obligations. Any duties under the Health and Safety
at Work Act 1974, the Management of Health and Safety at Work Regulations 1992,
the Manual Handling Operations Regulations 1992, the Disability Discrimination
Act 1995, or other relevant legislation must be given due consideration.
3 PRINCIPAL RECOMMENDATIONS FOR
OCCUPATIONAL HEALTH MANAGEMENT
This section lists the full evidence statements derived from the systematic
literature review. Recommendations for occupational health management based
on each set of statements are given alongside. Recommendations are also included
which are not strictly evidence-based, but considered good practice either legally
or by consensus, and these are identified by the use of italics.
The recommendations linked to evidence statements are grouped according to
occupational health context:
A. Background
B. Pre-placement assessment
C. Prevention
D. Assessment of the worker presenting with back pain
E. Management principles for the worker presenting with back pain
F. Management of the worker having difficulty returning to normal occupational
duties at approximately 4-12 weeks
The strength of evidence for each statement is classified as follows:
*** Strong evidence - provided by generally consistent findings in multiple,
high quality scientific studies.
** Moderate evidence - provided by generally consistent findings in fewer,
smaller or lower quality scientific studies.
* Limited or contradictory evidence - provided by one scientific study
or inconsistent findings in multiple scientific studies.
- No scientific evidence - based on clinical studies, theoretical considerations
and/or clinical consensus.
Notes:
1. 'LBP' within these guidelines means non-specific low back pain, unless
stated otherwise.
2. 'Worker' is used to describe all those in employment (including the self-employed,
trainees and apprentices).
3. 'Employer' is used as a collective term for all those with managerial responsibilities,
including all types of employers, line managers, supervisors and their representatives.
A Background
| Recommendation |
Evidence |
You, as an occupational health practitioner, have
a professional duty to support the worker with LBP and should do so whether
or not occupational factors play any role in causation.
Make employers and workers aware that:
- LBP is common and frequently recurrent but acute attacks
are usually brief and self-limiting.
- Physical demands at work are one factor influencing
LBP but are often not the most important.
- Prevention and case management need to be directed
at both physical and psychosocial factors.
Establish a partnership, involving workers, employers
and health professionals in the workplace and the community, with a common
consistent approach to agreed goals, to manage back pain and prevent unnecessary
disability.
|
*** Most adults (60-80%) experience LBP at some time
and it is often persistent or recurrent. It is one of the most common
reasons for seeking health care and it is now one of the commonest health
reasons given for work loss.
*** Physical demands of work (manual materials handling,
lifting, bending, twisting, and whole body vibration) can be associated
with increased reports of back symptoms, aggravation of symptoms and 'injuries'.
* There is limited and contradictory evidence that the
length of exposure to physical stressors at work (cumulative risk) increases
reports of back symptoms or of persistent symptoms.
*** Physical demands of work (manual materials handling,
lifting, bending, twisting, and whole body vibration) are a risk factor
for the incidence (onset) of LBP, but overall it appears that the size
of the effect is less than that of other individual, non-occupational
and unidentified factors.
** Physical demands of work play only a minor role in
the development of disc degeneration.
*** Care-seeking and disability due to LBP depend more
on complex individual and work-related psychosocial factors than on clinical
features or physical demands of work.
|
B Pre-placement assessment
| Recommendation |
Evidence |
LBP is common and recurrent and is not a reason for
denying employment in most circumstances. However care should be taken
when placing individuals with a strong history of LBP in physically demanding
jobs.
Enquire about previous history of LBP as part of the
pre-placement assessment, in particular the frequency and duration of
attacks, time since last attack, radiating leg pain, previous surgery
and sickness absence due to LBP.
Do not routinely include clinical examination of the
back, lumbar x-rays, back function testing, general fitness or psychosocial
factors in the pre-placement assessment.
Placement should take account of the risk assessment
and requirements under the Disability Discrimination Act 1995 to provide
'suitable and reasonable' adjustments, but it is ultimately a question
of professional judgement.
|
*** The single, most consistent predictor of future
LBP and work loss is a previous history of LBP, including in particular
the frequency and duration of attacks, time since last attack, radiating
leg pain, previous surgery and sickness absence due to LBP.
** Examination findings, including in particular height,
weight, lumbar flexibility and straight leg raising (SLR), have little
predictive value for future LBP or disability.
** The level of general (cardio-respiratory) fitness
has no predictive value for future LBP.
* There is limited and contradictory evidence that attempting
to match physical capability to job demands may reduce future LBP and
work loss.
*** X-ray and MRI findings have no predictive value for
future LBP or disability.
*** Back-function testing machines (isometric, isokinetic
or isoinertial measurements) have no predictive value for future LBP or
disability.
*** For symptom-free people, individual psychosocial
findings are a risk factor for the incidence (onset) of LBP, but overall
the size of the effect is small.
|
C Prevention
| Recommendation |
Evidence |
Advise on current good working practices such as specified
in the Manual Handling Regulations and associated guidance.
Do not recommend lumbar belts and supports or traditional
biomedical education as methods of preventing LBP. There is insufficient
evidence to advocate general exercise or physical fitness programmes.
Advise employers that high job satisfaction and good
industrial relations are the most important organisational characteristics
associated with low disability and sickness absence rates attributed to
LBP.
Encourage employers to:
- Consider joint employer-worker initiatives to
identify and control occupational risk factors.
- Monitor back problems and sickness absence due
to LBP.
- Improve safety and develop a 'safety culture'.
|
* There is contradictory evidence that various general
exercise/physical fitness programmes may reduce future LBP and work loss;
any effect size appears to be modest.
*** Traditional biomedical education based on an injury
model does not reduce future LBP and work loss. - There is preliminary
evidence that educational interventions which specifically address beliefs
and attitudes may reduce future work loss due to LBP.
*** Lumbar belts or supports do not reduce work-related
LBP and work loss.
*** Low job satisfaction and unsatisfactory psychosocial
aspects of work are risk factors for reported LBP, health care use and
work loss, but the size of that association is modest.
* There is limited evidence but general consensus that
joint employer-worker initiatives (generally involving organisational
culture and high stakeholder commitment to identify and control occupational
risk factors and improve safety, surveillance measures and 'safety culture')
can reduce the number of reported back 'injuries' and sickness absences,
but there is no clear evidence on the optimum strategies and inconsistent
evidence on the effect size.
|
D Assessment of the worker presenting with back pain
| Recommendation |
Evidence |
Screen for serious spinal diseases and nerve root problems
(see 'Diagnostic Triage' Figure 1).
Clinical examination may aid clinical management (RCGP
1999), but is of limited value in planning occupational health management
or in predicting the vocational outcome.
Take a clinical, disability and occupational history,
concentrating on the impact of symptoms on activity and work, and any
obstacles to recovery and return to work.
Consider psychosocial 'yellow flags' to identify workers at particular
risk of developing chronic pain and disability (Figure 2). Use this assessment
to instigate active case management at an early stage.
X-rays and scans are not indicated for the occupational
health management of the patient with LBP.
Ensure that any incident of LBP which may be work-related
is investigated and advice given on remedial action. If appropriate, review
the risk assessment.
|
** Screening for 'red flags' and diagnostic triage is
important to exclude serious spinal diseases and nerve root problems.
** Examination findings, including in particular height,
weight, lumbar flexibility and SLR are of limited value in planning occupational
health management or in predicting the prognosis of non-specific LBP.
** Patients who are older (particularly >50 years), have
more prolonged and severe symptoms, have radiating leg pain, whose symptoms
impact more on activity and work, and who have responded less well to
previous therapy are likely to have slower clinical progress, poorer response
to treatment and rehabilitation, and more risk of long term disability.
*** Individual and work-related psychosocial factors
play an important role in persisting symptoms and disability, and influence
response to treatment and rehabilitation. Screening for 'yellow flags'
can help to identify those workers with LBP who are at risk of developing
chronic pain and disability. Workers' own beliefs that their LBP was caused
by their work and their own expectations about inability to return to
work are particularly important.
*** In patients with non-specific LBP, x-ray and MRI
findings do not correlate with clinical symptoms or work capacity.
|
E Management principles for the worker presenting with back pain
| Recommendation |
Evidence |
|
Clinical:
|
|
Clinical management should follow the RCGP (1999) guidelines.
Discuss expected recovery times, and the importance of continuing ordinary
activities as normally as possible despite pain.
Ensure that workers with LBP receive the key information
in a form they understand (see footnote The Back Book).
|
*** Advice to continue ordinary activities of daily
living as normally as possible despite the pain can give equivalent or
faster symptomatic recovery from the acute symptoms, and leads to shorter
periods of work loss, fewer recurrences and less work loss over the following
year than 'traditional' medical treatment (advice to rest and 'let pain
be your guide' for return to normal activity).
** The above advice can be usefully supplemented by simple
educational interventions specifically designed to overcome fear avoidance
beliefs and encourage patients to take responsibility for their own self-care.
|
|
Occupational:
|
|
Encourage the worker to remain in his or her job, or
to return at an early stage, even if there is still some LBP- do not wait
until they are completely pain-free. Consider the following steps to facilitate
this:
- Initiate communication with their primary health care
professional early in treatment and rehabilitation.
- Advise the worker to continue as normally as possible
and provide support to achieve this.
- Advise employers on the actions required, which may
include maintaining sympathetic contact with the absent worker.
- Consider temporary adaptations of the job or pattern
of work.
|
** Communication, co-operation and common agreed goals
between the worker with LBP, the occupational health team, supervisors,
management and primary health care professionals is fundamental for improvement
in clinical and occupational health management and outcomes.
*** Most workers with LBP 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.
* Advice to continue ordinary activities as normally
as possible, in principle, applies equally to work. The scientific evidence
confirms that this general approach leads to shorter periods of work loss,
fewer recurrences and less work loss over the following year, although
most of the evidence comes from intervention packages and the clinical
evidence focusing solely on advice about work is limited. *
There is general consensus but limited scientific evidence
that workplace organisational and/or management strategies (generally
involving organisational culture and high stakeholder commitment to improve
safety, provide optimum case management and encourage and support early
return to work) may reduce absenteeism and duration of work loss
|
Footnote: The Back Book is an evidence-based booklet developed
in conjunction with the RCGP clinical guidelines, for use by patients and published
by The Stationery Office.
F Management of the worker having difficulty returning to normal occupational
duties at approximately 4-12 weeks
| Recommendation |
Evidence |
Ensure that workers, employers and primary care health
professionals understand that the longer anyone is off work with LBP,
the greater the risk of chronic pain and disability, and the lower their
chances of ever returning to work.
Address the common misconception among workers and employers
of the need to be pain-free before return to work. Some pain is to be
expected and the early resumption of work activity improves the prognosis.
Encourage the employer to establish a surveillance system
to identify those off work with LBP for over 4 weeks so that appropriate
action can be taken. Intervention at this stage is more effective than
delaying and having to deal with established intractable chronic pain
and disability.
Advise employers on ways in which the physical demands
of the job can be temporarily modified to facilitate return to work.
If medical treatment fails to produce recovery and return
to work by 4-12 weeks, 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 the worker who is having difficulty
returning to normal occupational duties at 4-12 weeks to an active rehabilitation
programme. Such a rehabilitation programme needs to be carefully designed
to fit local circumstances and should consist of a multidisciplinary 'package'
of interventions (Figure 3).
|
*** The longer a worker is off work with LBP, the lower
their chances of ever returning to work. Once a worker is off work for
4-12 weeks they have a 10-40% risk (depending on the setting) of still
being off work at one year; after 1-2 years absence it is unlikely they
will return to any form of work in the foreseeable future, irrespective
of further treatment.
*** Various treatments for chronic LBP may produce some
clinical improvement, but most clinical interventions are quite ineffective
at returning people to work once they have been off work for a protracted
period with LBP.
** From an organisational perspective, the temporary
provision of lighter or modified duties facilitates return to work and
reduces time off work.
- Conversely, there is some suggestion that clinical
advice to return only to restricted duties may act as a barrier to return
to normal work, particularly if no lighter or modified duties are available.
** Changing the focus from purely symptomatic treatment
to an 'active rehabilitation programme' can produce faster return to work,
less chronic disability and less sickness absence. There is no clear evidence
on the optimum content or intensity of such packages, but there is generally
consistent evidence on certain basic elements. Such interventions are
more effective in an occupational setting than in a health care setting.
** A combination of optimum clinical management, a rehabilitation
programme, and organisational interventions designed to assist the worker
with LBP return to work, is more effective than single elements alone.
|
Figure 1: Diagnostic Triage including 'Red Flags'
SIMPLE BACK PAIN
Presentation between ages 20-55
Lumbosacral region, buttocks and thighs
Pain 'mechanical' in nature - Varies with physical activity and time
Patient well
Prognosis good - 90% recover from acute attack within six weeks
|
NERVE ROOT PAIN
Unilateral leg pain worse than low back pain
Pain generally radiates to foot or toes
Numbness or paraesthesia in same distribution
Nerve irritation signs - Reduced SLR which reproduces leg pain
Motor, sensory or reflex change - Limited to one nerve root
Prognosis reasonable - 50% recover from acute attack within six weeks |
RED FLAGS FOR POSSIBLE SERIOUS SPINAL PATHOLOGY
Age of onset less than 20 or greater than 55 years
Violent trauma: eg. fall from a height, RTA
Constant, progressive, non-mechanical pain
Thoracic pain
PMH carcinoma, systemic steroids, drug abuse, HIV
Systemically unwell, weight loss
Persisting severe restriction of lumbar flexion
Widespread neurology
Structural deformity |
Reproduced from: Clinical Guidelines for the Management of
Acute Low Back Pain - Royal College of General Practitioners 1999
Figure 2: Psychosocial Risk Factors - 'Yellow Flags'
When conducting an assessment, it may be useful to consider psychosocial
'yellow flags' (beliefs and behaviours on the part of the patient which
may predict poor outcomes).
The following factors are important and consistently predict poor outcomes:
=> A belief that back pain is harmful or potentially severely disabling
=> Fear-avoidance behaviour (avoiding a movement or activity due to
misplaced anticipation of pain) 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
Suggested questions to the worker with low back pain (to be phrased in
your own style):
=> Have you had time off work in the past with back pain?
=> What do you understand is the cause of your back pain?
=> What are you expecting will help you?
=> How is your employer responding to your back pain? Your co-workers?
Your family?
=> What are you doing to cope with your back pain?
=> Do you think you will return to work? When?
A worker may considered to be 'at risk' if:
=> There is a cluster of a few very salient factors
=> There is a group of several less important factors that combine
cumulatively
The presence of risk factors should alert the clinician to the possibility
of long-term problems and the need to prevent their development. Specialised
psychological referrals should only be required for those with psychopathology,
or for those who fail to respond to the management advocated in this guideline.
|
Reproduced from: Kendall et al. 1997
Figure 3: Active Rehabilitation Programme
Education:
Directed primarily at overcoming fear avoidance beliefs and encouraging
patients to learn to manage and take responsibility for their own self-care
(for example The Back Book).
Reassurance and advice:
Strong reassurance and advice to stay active.
Exercise:
An active, progressive exercise and physical fitness programme.
Pain management:
Behavioural principles of pain management
Work:
In an occupational setting and directed strongly towards return to work.
Rehabilitation:
May also include some symptomatic relief measures, but if so these should
supplement and reinforce, and must not interfere with the primary goal
of rehabilitation.
|
Footnote: The Back Book is an evidence-based
booklet developed in conjunction with the RCGP clinical guidelines, for use
by patients and published by The Stationery Office.
4 PRACTITIONERS' LEAFLET-'OCCUPATIONAL
HEALTH GUIDELINES FOR THE MANAGEMENT OF LOW BACK PAIN AT WORK'
These guidelines represent the main recommendations and evidence statements
derived from a detailed Evidence Review and developed by a multidisciplinary
group of practitioners. They concern the clinical management of workers affected
by non-specific low back pain (LBP), including advice on placement, rehabilitation
and measures for prevention. They focus on actions to be taken to assist the
individual and do not specifically cover legal issues, health and safety management,
job design and ergonomics. They assume that a risk assessment has been conducted
and used to define the control measures required, including the need for occupational
health advice.
The evidence is weighted as follows:
*** Strong evidence - generally consistent findings in multiple, high quality
scientific studies.
** Moderate evidence - generally consistent findings in fewer, smaller or
lower quality scientific studies.
* Limited or contradictory evidence
- one scientific study or inconsistent findings in multiple scientific studies.
|
These guidelines complement and should be used in conjunction
with the RCGP Clinical Guidelines for the Management of Acute Low Back Pain
1999. Available from: Royal College of General Practitioners, 14 Princes Gate,
Hyde Park, London, SW7 1PU. www.rcgp.org.uk
The Back Book is an evidence-based booklet for use by
patients, published by The Stationery Office (ISBN 011 702 0788).
A. BACKGROUND
Principal recommendations
Make employers and workers aware that:
- LBP is common and frequently recurrent but usually brief and self-limiting.
- physical demands at work are only one factor influencing LBP.
- prevention and case management need to be directed at both physical and psychosocial
factors.
Evidence
*** Physical demands at work can be associated with increased back symptoms
and 'injuries', but they do not generally produce lasting physical damage. Overall,
they are less important than other individual, non-occupational and unidentified
factors.
*** Disability due to LBP depends more on psychosocial factors.
B. PRE-PLACEMENT ASSESSMENT
Principal recommendations
LBP is not a reason for denying employment in most circumstances. Care should
be taken when placing individuals with a strong history of LBP in physically
demanding jobs.
Placement should take account of the risk assessment and requirements under
the Disability Discrimination Act 1995, but is ultimately a question of professional
judgement.
Evidence
*** A strong history of LBP is the best predictor of future problems: frequency
and duration of previous attacks, time since last attack, radiating leg pain,
back surgery and sickness absence.
*** Clinical examination, x-ray, MRI, back-function testing machines and psychosocial
screening are not reliable predictors.
C. PREVENTION
Principal recommendations
Advise on current good working practices such as specified in the Manual Handling
Regulations and associated guidance.
Encourage employers to:
- Consider joint employer-worker initiatives to identify and control occupational
risk factors.
- Monitor back problems and sickness absence due to LBP.
- Improve safety and develop a 'safety culture'.
- Recognise the importance of providing satisfying work in a climate of good
industrial relations.
Evidence
*** Traditional biomedical education and lumbar supports do not reduce future
LBP and work loss.
* There is conflicting evidence whether general exercise/physical fitness programmes
have much preventive effect.
* Joint employer-worker initiatives to monitor and improve safety can reduce
the number of reported back 'injuries' and sickness absence.
D. ASSESSMENT OF THE WORKER PRESENTING WITH BACK PAIN
Principal recommendations
Screen for serious spinal diseases and nerve root problems.
Take a detailed clinical, disability and occupational history.
Consider psychosocial risk factors for chronicity. (see 'Yellow Flags')
Evidence
** Patients aged >50 years, with more prolonged and severe symptoms or radiating
leg pain are at more risk of long term disability.
** Clinical examination, x-ray and MRI do not predict clinical symptoms or work
capacity.
*** Individual and work-related psychosocial factors play an important role
in persisting symptoms and disability.
Psychosocial 'Yellow Flags' (beliefs and behaviours on the part
of the patient which may predict poor outcomes).
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
|
E. MANAGEMENT PRINCIPLES FOR THE WORKER PRESENTING WITH BACK PAIN
Principal recommendations
Ensure that workers with LBP receive the key information in a form they understand
(The Back Book) and that their clinical management follows the RCGP Guidelines
(1999). Discuss expected recovery times.
Encourage the worker to continue as normally as possible and to remain at work,
or to return to work at an early stage, even if they still have some LBP. Consider
temporary adaptation of the job or pattern of work if necessary to achieve this.
Evidence
*** Staying active and returning to ordinary activities as early as possible
leads to faster recovery and fewer recurrences.
*** 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.
** 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.
F. MANAGEMENT OF THE WORKER HAVING DIFFICULTY RETURNING TO NORMAL OCCUPATIONAL
DUTIES AT APPROXIMATELY 4-12 WEEKS
Principal recommendations
Address the common misconception among workers and employers that you need to
be pain-free to return to work.
Advise on ways in which the job can be adjusted to facilitate return to work.
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.
Evidence
*** The longer a worker is off work with LBP, the lower their chances of ever
returning to work.
** Temporary provision of modified or lighter duties facilitates return to work
and reduces time off work.
** Changing the focus from purely symptomatic treatment to an 'active rehabilitation
programme' can produce faster return to work and less chronic disability. This
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 LBP return
to work, is more effective.
ACTIVE REHABILITATION PROGRAMME
Education - directed at managing their pain and overcoming disability
Reassurance and advice - to stay active
Exercise - an active and progressive physical fitness programme
Pain management - using behavioural principles
Work - in an occupational setting and directed strongly towards
return to work
Rehabilitation - symptomatic relief measures should support and
must not interfere with rehabilitation
|
Evidence Review
Gordon Waddell, DSc MD FRCS
Kim Burton, PhD DO Eur Erg
5 EVIDENCE REVIEW
METHODS
This review is about non-specific low back pain (abbreviated simply
as LBP) unless otherwise stated. The main target for the literature search was
evidence from occupational settings or concerning occupational outcomes. The
review methodology broadly followed that used for the Royal College of General
Practitioners (RCGP) clinical guidelines ((Waddell et al. 1996) (Waddell et
al. 1999)) and the Swedish SBU Report on back pain (Nachemson & Jonsson 2000).
The clinical management aspects of these guidelines were based
on the most recent review of the current evidence in the Swedish SBU report
(1999) on back pain and the recommendations of the RCGP clinical guidelines
(1999), whilst the key areas of concern to occupational health practitioners
were addressed by the present literature search.
The scientific evidence on LBP is now so extensive that it is
impossible to carry out a complete systematic review of every aspect of management
de novo to an acceptable high standard within an acceptable time scale and using
reasonable resources. The present evidence review therefore started with a search
for all published, methodologically sound, systematic reviews. These were supplemented
by narrative reviews in key areas of interest or where systematic reviews were
unavailable. These narrative reviews were variously selected according to the
following additional criteria: appropriateness to the management of occupational
LBP; comprehensive and/or structured coverage of topic; basic aspects of the
management of occupational LBP. Selection inevitably involved judgements of
quality: the narrative reviews were selected by each of the two reviewers independently
with a high level of agreement and any disagreements resolved by discussion.
Further literature searches were made for original scientific studies covering
key issues not covered by existing reviews, along with searches for more recent
studies that might confirm, modify or expand upon the conclusions of the published
systematic reviews. In addition, recent guidelines from various countries relevant
to occupational health management were obtained and assessed. The resulting
guidance is evidence-linked, in that sources supporting each evidence statement
in this document are specifically identified.
In view of the occupational health focus of the guidelines and
the present review, the following areas were excluded from the review, except
where they impact directly on the guideline recommendations:
- chronic intractable pain, long-term disability and pain management programmes
- spinal surgery and post-operative states
- primary ergonomic interventions
- methods of disability evaluation
- workers compensation issues
Literature searches
The literature was searched systematically to September 1999, using a variety
of standard methods.
MEDLINE was searched for articles published in English from 1966,
using a number of search terms including:
- back pain or back injury
- work or occupational
- return to work
- clinical trial or intervention or prospective study
- appropriate MESH terms were also used
- (some of the systematic reviews did also include studies in other languages)
EMBASE was searched from 1980 based on a number of search terms
including:
- back, low back or lumbar
- occupation, work or working
- prevention, screening, pre-employment, rehabilitation or return to work
Additional searching included:
- selected Internet searches
- personal bibliographies and personal communications
- citation tracking
- scanning of relevant journals in the field up to late 1999
- papers known to be 'in press' at the end of 1999
More than 2000 titles and abstracts were considered. Thirty-four
systematic reviews were identified dealing with various aspects of management
relevant to occupational health guidelines (Table 1a). The main conclusions
of these systematic reviews are in Table 1b. Twenty-eight narrative reviews
were selected and their main conclusions are in Table 2. Fifty two additional
scientific studies (randomised controlled trials and other high quality scientific
studies) are listed in Table 3. Two crucial areas in which there is limited
scientific evidence are: 1) the advice that occupational health practitioners
(and other health professionals responsible for clinical management) should
give to patients with LBP about work and return to work; and 2) the effectiveness
of return to work interventions which attempt to promote increased activities
and early return to work. Twenty two additional, relevant but scientifically
weaker, studies on work retention and return to work issues are in Table 4.
Most of these are descriptive, retrospective or uncontrolled clinical studies
and even when they are controlled they are not randomised controlled trials
(RCT). Seventeen previous guidelines and one systematic review of guidelines
are in Table 5. A single reference list includes all citations in the Evidence
Statements and the text: although some papers in the tables are not directly
cited in the Evidence Statements, all of this material is retained as a literature
resource for any future work in this field. The evidence is presented under
the same logical sequence of occupational health situations as in the Guidelines.
The evidence statements for each situation are preceded by an introduction to
the relevant issues, and some important areas are given additional discussion.
The methodology of the review may be best summarised as systematic
searching plus rating of the strength of the evidence plus a narrative overview,
by agreement between two experienced and independently minded reviewers. There
was no attempt at blinded double review or quality scoring.
Separate tables are provided for: T1:
systematic reviews (Tables 1a & 1b)
T2: narrative reviews (Table 2)
T3: individual high quality scientific studies (Table 3)
T4: other scientifically weaker but relevant studies (Table 4)
T5: previous guidelines relevant to occupational health management (Table 5)
Evidence rating
Although the present review was based largely upon existing reviews, it was
considered important in principle, and the reviews provided sufficient information
to make it possible, to rate the strength of the evidence on the original scientific
studies in these reviews. We used the RCGP three-star system as modified in
the SBU report for scientific studies, but added a fourth category to accommodate
additional clinical studies and modified the wording of the definitions slightly
to allow for this.
*** Strong evidence - provided by generally consistent findings
in multiple, high quality scientific studies.
** Moderate evidence - provided by generally consistent findings in fewer, smaller
or lower quality scientific studies.
* Limited or contradictory evidence - provided by one scientific study or inconsistent
findings in multiple scientific studies.
- No scientific evidence - based on clinical studies, theoretical considerations
and/or clinical consensus.
For interventions, scientific studies were taken to be
RCTs. However, RCTs are not applicable to some important areas such as the epidemiology
of LBP, assessment and prognosis. In these areas, scientific studies were taken
to be high quality basic science studies, major epidemiological surveys and
prospective cohort studies of acute/recurrent LBP in primary care or occupational
health settings. Other, scientifically weaker, clinical studies included
retrospective, cross-sectional, uncontrolled cohort and descriptive studies.
RCTs are in principle appropriate for workplace interventions but in that setting
they are generally impractical and certainly rare, thus the evidence in this
area consists mainly of weaker, clinical studies (Zwerling et al. 1997).
Evidence linking is to the most comprehensive and most recent
source available. Where possible this is to systematic review(s) which should
include all of the earlier, original studies in that area. Direct reference
to original studies is only made where there is no adequate review, where they
are not included in the review(s), or where they are necessary to support an
important point. Rating the evidence on the original studies, however, may occasionally
produce the paradoxical outcome that T3 evidence based on multiple RCTs can
be stronger than T1 or T2 evidence based on reviews in which most of the original
studies are of lower scientific quality.
Clinical judgement is necessary when using the evidence statements
to guide decision making, but it is also important to consider the relative
strength of the evidence. Moreover, weak evidence statements on a particular
relationship or effect does not necessarily mean that it is untrue or unimportant
but may simply reflect insufficient evidence or the limitations of current scientific
investigations.
6 EVIDENCE REVIEW
A Background
Non-specific low back pain (LBP) can be occupational in the sense that it is
common in adults of working age, frequently affects capacity for work, and often
presents for occupational health care. It is commonly assumed this means that
LBP is caused by work but the relationship between the physical demands of work
and LBP is complex and inconsistent. A clear distinction should be made between
the presence of symptoms, the reporting of LBP, attributing symptoms to work,
reporting 'injury', seeking health care, loss of time from work and long term
damage. LBP in the occupational setting must be seen against the high background
prevalence and recurrence rates of low back symptoms, and to a lesser extent
disability, among the adult population. Workers in heavy manual jobs do report
rather more low back symptoms, but most people in lighter jobs or even those
who are not working have similar symptoms. Jobs with greater physical demands
commonly have a higher rate of reported low back injuries, but most of these
'injuries' are related to normal everyday activities such as bending and lifting,
there is usually little if any objective evidence of tissue damage (though clinical
examination and current in vivo investigations may be insensitive tools to detect
this), and the relationship between job demands and symptoms or injury rates
is inconsistent. Physical stressors may overload certain structures in individual
cases but, in general, there is little evidence that physical loading in modern
work causes permanent damage. Whether low back symptoms are attributed to work,
are reported as 'injuries', lead to health care seeking and/or result in time
off work depends on complex individual psychosocial and work organisational
factors. The development of chronic pain and disability depends more on individual
and work-related psychosocial issues than on physical or clinical features.
People with physically or psychologically demanding jobs may have more difficulty
working when they have LBP, and so lose more time from work, but that can be
the effect rather than the cause of their LBP.
In summary, physical demands of work can precipitate individual
attacks of LBP, certain individuals may be more susceptible and certain jobs
may be higher risk but, viewed overall, physical demands of work only account
for a modest proportion of the total impact of LBP occurring in workers.
T1:(Ferguson & Marras 1997) (Bigos et al. 1998)
(Burdorf & Sorock 1997)
T2: (Garg & Moore 1992a) (Andersson 1997) (Burton 1997) (Hadler 1997) (Dionne
1999) (Waddell 1998)
T3: (Brinckmann et al. 1998)
A1 *** Most adults (60-80%) experience LBP at some time, and it
is often persistent or recurrent. It is one of the most common reasons for seeking
health care, and it is now one of the commonest health reasons given for work
loss.
T2: (Garg & Moore 1992a) (Andersson 1997) (Waddell
1998)
(Jones et al. 1998) (Croft et al. 1998) (Department of Health 1999)
A2 *** There is strong epidemiological evidence that physical
demands of work (manual materials handling, lifting, bending, twisting, and
whole body vibration) can be associated with increased reports of back symptoms,
aggravation of symptoms and 'injuries'.
T1: (NIOSH 1997) (Vingard & Nachemson 2000)
(Ferguson & Marras 1997)
T1: (Burdorf & Sorock 1997) (Bovenzi & Hulshof 1999) T2: (Andersson 1997) (Burton
1997) (Dionne 1999) (National Research Council 1999) (Wilder & Pope 1996)
T3: (Marras et al. 1993)
A3 * There is limited and contradictory evidence that the length
of exposure to physical stressors at work (cumulative risk) increases reports
of back symptoms or of persistent symptoms.
T1: (NIOSH 1997) (Burdorf & Sorock 1997)
T2: (National Research Council 1999)
T3: (Marras et al. 1993) (Macfarlane et al. 1997) (Norman et al. 1998) (Burton
et al. 1996)
A4 *** There is strong evidence that physical demands of work
(manual materials handling, lifting, bending, twisting, and whole body vibration)
are a risk factor for the incidence (onset) of LBP, but overall it appears that
the size of the effect is less than that of other individual, non-occupational
and unidentified factors.
T1: (Vingard & Nachemson 2000) (Ferguson & Marras
1997)
T2: (Burton 1997) (Dionne 1999)
T3: (Adams et al. 1999) (Macfarlane et al. 1997)
[Note: A2 and A4 are not incompatible. Whilst the epidemiological
evidence shows that low back symptoms are commonly linked to physical demands
of work, that does not necessarily mean that LBP is caused by work. Although
there is strong scientific evidence that physical demands of work can cause
individual attacks of LBP, overall that only accounts for a modest proportion
of all LBP occurring in workers.]
A5 ** There is moderate scientific evidence that physical demands
of work play only a minor role in the development of disc degeneration.
T2: (Videman & Battié 1999)
T3: (Battié et al. 1995)
A6 *** There is strong epidemiological and clinical evidence that
care seeking and disability due to LBP depend more on complex individual and
work-related psychosocial factors than on clinical features or physical demands
of work.
T2: (Burton 1997) (Waddell 1998) (Dionne 1999)
T3: (Papageorgiou et al. 1997)
B Pre-placement assessment
Individual health, fitness and strength can affect the ability to perform tasks.
Pre-placement assessment aims to identify those who may be at higher risk for
LBP in a given occupational setting. The main factors that have been investigated
include clinical and historical features, physical strength parameters and psychosocial
factors. The recurrent nature of LBP means that previous history is the best
predictor of future LBP, and all other pre-placement measures have no predictive
value at all, or only a weak and unreliable predictive value.
T1: (Bigos et al. 1998) (Burdorf & Sorock 1997)
T2: (Dionne 1999) (Andersson 1997)
B1 *** There is strong evidence that the single, most consistent,
predictor of future LBP and work loss is a previous history of LBP, including
in particular the frequency and duration of attacks, time since last attack,
radiating leg pain, previous surgery and sickness absence due to LBP.
T2: (Dionne 1999) (Andersson & Deyo 1997)
B2 ** There is moderate evidence that examination findings, including
in particular height, weight, lumbar flexibility and straight leg raising (SLR),
have little predictive value for future LBP or disability.
T2: (Andersson 1997) (Frank et al. 1996a)
B3 ** There is now moderate evidence that the level of general
(cardio-respiratory) fitness has no predictive value for future LBP.
T2: (Andersson 1997)
B4 * There is limited and contradictory evidence that attempting
to match physical capability to job demands may reduce future LBP and work loss.
T2: (Garg & Moore 1992a) (Garg & Moore 1992b)
(Andersson 1997) (Andersson & Deyo 1997)
B5 *** There is strong evidence that x-ray and MRI findings have
no predictive value for future LBP or disability.
T1: (van Tulder et al. 1997)
T2: (Bigos et al. 1992)
T3: (Savage et al. 1997) (Boos et al. 2000) (Borenstein et al. 1998) (Riihimaki
et al. 1989)
T3: (Symmons et al. 1991a;Symmons et al. 1991b)
B6 *** There is strong evidence that back-function testing-machines
(isometric, isokinetic or isoinertial measurements) have no predictive value
for future LBP or disability.
T2: (Szpalski & Gunzburg 1998) (Newton & Waddell
1993)
T3: (Mostardi et al. 1992) (Masset et al. 1998)
B7 *** For symptom-free people, there is strong evidence that
individual psychosocial findings are a risk factor for the incidence (onset)
of LBP, but overall the size of the effect is small.
T2: (Waddell 1998)
T3: (Adams et al. 1999) (Croft et al. 1995)
High risk patients/physically demanding jobs
There is a pragmatic argument that individuals at highest risk of LBP should
not be placed in jobs that impose the greatest physical demands. The basic concern
is that workers with physically (or psychologically) demanding work report rather
more low back symptoms, have more work-related back 'injuries' and lose more
time off work with LBP. Even if physical demands of work may be a relatively
modest factor in the primary causation of LBP (see Background above), people
who have LBP (for whatever cause) do have more difficulty managing physically
demanding work (T3: (Muller et al. 1999) T2: (Waddell 1998)). It may be argued,
therefore, that avoiding putting people at highest risk of recurrent LBP and
sickness absence into more physically demanding work would be in the interests
of the individual worker, the employer and the total societal burden of LBP.
The problem is, a previous history of LBP simply identifies people
who are more likely to have recurrent problems, but that has little to do with
the job: they are probably likely to have such problems irrespective of which
job they are recruited for - and even if they are not recruited (T2: (Garg &
Moore 1992a) (Andersson & Deyo 1997) (Dionne 1999)). Indeed, those who remain
unemployed may be at highest risk of all for chronic LBP and disability (Waddell
& Waddell 2000). Because a previous history of LBP is so common, it could exclude
many people who are medically fit for most work. At the same time, all pre-placement
assessment methods miss many people who may later develop LBP (T1: (Andersson
1997)). There is no clear evidence for a threshold of what constitutes a strong
history of LBP or excessive job demands (T4: (Garcy et al. 1996)). Most of the
evidence is from a population-based perspective whilst pre-placement assessment
must try to predict future risks for the individual, which is a different matter.
It may be concluded that the present evidence base is insufficient for reliable
selection of individuals for particular types of work (HSE 1998). Attempts to
match individual susceptibility for LBP against a risk assessment of the job
(and reduction of the risk of injury to the lowest level 'reasonably practicable')
are therefore very much a question of judgement, and there is limited empirical
evidence on their effectiveness (B4). Refusal of employment on the basis of
such judgements carries substantial personal, societal, legal and political
implications, and may need to take into account the requirement under the Disability
Discrimination Act 1995 to provide 'suitable and reasonable' adjustments.
C Prevention
Employers have a statutory and moral responsibility to safeguard the health,
safety and welfare of workers, and to take reasonably practicable steps to prevent
avoidable injuries. Over the last 50 years, there have been considerable reductions
in the physical demands of most work and much effort has gone into ergonomic
improvements: that has reduced many serious occupational health risks, but there
is inconsistent evidence on whether or to what extent it has reduced occupational
LBP. Low back symptoms are common and non-specific, physical demands of work
are only one causal factor, and non-occupational and psychosocial issues are
important, so it may be questionable to what extent occupational interventions
can realistically be expected to reduce the societal impact of LBP. It seems
reasonable in principle to attempt to reduce the incidence and prevalence of
LBP by interventions designed to reduce known occupational 'risk factors', but
the fundamental limitation of this approach may be the lack of any clear causal
link (see Background). Much depends on whether the target is reduction of symptoms,
'injuries', sickness absence or long term disability: different interventions
may well have differing effects. There is a lack of convincing evidence that
it is possible substantially to reduce the incidence or prevalence of the symptom
of LBP. Interventions to reduce physical workload have generally had an inconsistent
impact on occupational LBP - when there has been an effect it remains unclear
if the interventions actually reduced 'symptoms' or 'injuries', or simply modified
reporting patterns and altered what workers do about their LBP. Organisational
change interventions, directed to improving job satisfaction and psychosocial
aspects of work, are difficult to implement and there is conflicting evidence
that they have any significant effect on health outcomes (though little of that
evidence is specifically about LBP).
T1: (Ferguson & Marras 1997) (Polyani et al.
1998)
T2: (Frank et al. 1996a) (Volinn 1999)
C1 * There is contradictory evidence that various general exercise/physical
fitness programmes may reduce future LBP and work loss; any effect size appears
to be modest.
T1: (Lahad et al. 1994) (Gebhardt 1994)
T1: (van Poppel et al. 1997) (Dishman et al. 1998)
T2: (Kaplansky 1998) (Volinn 1999)
C2 *** There is strong evidence that traditional biomedical education
based on an injury model does not reduce future LBP and work loss.
T1: (Lahad et al. 1994) (van Poppel et al. 1997)
(Dishman et al. 1998)
T2: (Frank et al. 1996a) (Kaplansky 1998)
T3: (Daltroy et al. 1997)
C3 - There is preliminary evidence that educational interventions
which specifically address beliefs and attitudes may reduce future work loss
due to LBP.
T3: (Symonds et al. 1995)
C4 *** There is strong evidence that lumbar belts or supports
do not reduce work-related LBP and work loss.
T1: (Lahad et al. 1994) (van Poppel et al. 1997)
T3: (van Poppel et al. 1998)
C5 *** There is strong evidence that low job satisfaction and
unsatisfactory psychosocial aspects of work are risk factors for reported LBP,
health care use and work loss, but the size of that association is modest.
T1: (Bongers et al. 1993) (NIOSH 1997) (Vingard
& Nachemson 2000) (Davis & Heaney 2000)
C6 * There is limited evidence but general consensus that joint
employer-worker initiatives (generally involving organisational culture and
high stakeholder commitment to identify and control occupational risk factors
and improve safety, surveillance measures and 'safety culture') can reduce the
number of reported back 'injuries' and sickness absences, but there is no clear
evidence on the optimum strategies and inconsistent evidence on the effect size.
T1: (Westgaard & Winkel 1997) (Ferguson & Marras
1997) (Dishman et al. 1998) (Polyani et al. 1998)
T3: (Hunt & Habeck 1993) (Shannon et al. 1996) (Ostry et al. 1999)
T5: (Kazimirski 1997)
D Assessment of the worker presenting with back pain
There is general consensus that a simple clinical interview and examination
can distinguish between simple back pain manageable at the primary care level
and those pathological conditions requiring specialist referral ('red flags'
- see Figure 1). However, conventional clinical tests of spinal and neurological
function are of limited value in determining appropriate clinical or occupational
management of non-specific LBP. Furthermore, 'diagnostic labelling' may have
detrimental effects on outcome. X-rays and MRI are primarily directed to the
investigation of nerve root problems and serious spinal pathology. Much more
relevant to occupational health management is the identification of individual
and work-related psychosocial issues which form risk factors for chronicity
('yellow flags' - see Figure 2). General disaffection with the work situation,
attribution of blame, beliefs and attitudes about the relationship between work
and symptoms, job dissatisfaction and poor employer-employee relationships may
also constitute 'obstacles to recovery'.
T2: (Hadler 1997)
T3: (Abenhaim et al. 1995)
T5: (Royal College of General Practitioners 1999) (Kendall et al. 1997)
T5: (Agency for Health Care Policy and Research. 1994)
D1 ** There is moderate evidence that screening for 'red flags'
and diagnostic triage is important to exclude serious spinal diseases and nerve
root problems.
T5: (Royal College of General Practitioners 1999)
D2 ** There is moderate evidence that patients who are older (particularly
> 50 years), have more prolonged and severe symptoms, have radiating leg pain,
whose symptoms impact more on activity and work, and who have responded less
well to previous therapy are likely to have slower clinical progress, poorer
response to treatment and rehabilitation, and more risk of long term disability.
T2: (Andersson 1997)
T3: (Cheadle et al. 1994) (Oleinick et al. 1996) (Baldwin et al. 1996)
T3: (Infante-Rivarde & Lortie 1997) (Hazard et al. 1997) (Haldorsen et al. 1998)
T4: (Lancourt & Kettelhut 1992)
D3 ** There is moderate evidence that examination findings, including
in particular height, weight, lumbar flexibility and SLR are of limited value
in planning occupational health management or in predicting the prognosis of
non-specific LBP.
T1: (van den Hoogen et al. 1995)
T2: (Andersson 1997)
D4 *** There is strong evidence that individual and work-related
psychosocial factors play an important role in persisting symptoms and disability,
and influence response to treatment and rehabilitation. Screening for 'yellow
flags' can help to identify those workers with LBP who are at risk of developing
chronic pain and disability. Workers' own beliefs that their LBP was caused
by their work and their own expectations about inability to return to work are
particularly important.
T1: (Ferguson & Marras 1997)
T2: (Garg & Moore 1992a) (Waddell 1998) (Burton & Main 2000)
T4: (Sandstrom & Esbjornsson 1986) (Lancourt & Kettelhut 1992)
T4: (Carosella et al. 1994) (Fishbain et al. 1997) (Nordin et al. 1997)
T5: (Kendall et al. 1997)
D5 *** There is strong evidence that in patients with non-specific
LBP, x-ray and MRI findings do not correlate with clinical symptoms or work
capacity.
T1: (van Tulder et al. 1997) (Nachemson & Vingard
2000)
E Management principles for the worker presenting with back
pain
Clinical aspects of management should follow the RCGP clinical guidelines (1999).
Occupational health management should focus on supporting the worker with LBP
and facilitating remaining at work or returning to work as rapidly as possible,
and should deal with any occupational issues that may form obstacles to achieving
these goals. Occupational health practitioners should liase closely with primary
care. All stakeholders (i.e. the worker with LBP, supervisor(s) and management,
union and health & safety representatives, the occupational health team and
other health professionals undertaking clinical management) need to work closely
together with a common, consistent approach to agreed goals.
T2: (Frank et al. 1996b) (Snook & Webster 1998)
(Nadler et al. 1999)
T5: (Kazimirski 1997)
Clinical:
E1 *** There is strong evidence that advice to continue ordinary activities
of daily living as normally as possible despite the pain can give equivalent
or faster symptomatic recovery from the acute symptoms, and leads to shorter
periods of work loss, fewer recurrences and less work loss over the following
year than 'traditional' medical treatment (advice to rest and 'let pain be your
guide' for return to normal activity).
T1: (Waddell et al. 1997) (Abenhaim et al. 2000)
E2 ** There is moderate evidence that the above advice can be
usefully supplemented by simple educational interventions specifically designed
to overcome fear avoidance beliefs and encourage patients to take responsibility
for their own self-care.
T3: (Burton et al. 1999) (Moore et al. 2000)
(Pfingsten et al. 2000)
Occupational:
E3 ** There is moderate evidence that communication, co-operation, and common
agreed goals between the worker with LBP, the occupational health team, supervisors,
management, and primary health care professionals is fundamental for improvement
in clinical and occupational health management and outcomes.
T2: (Frank et al. 1996b) (Frank et al. 1998)
T2: (Snook & Webster 1998) (Nadler et al. 1999)
T3: (Hunt & Habeck 1993) (Shannon et al. 1996) (Ostry et al. 1999) (Loisel et
al. 1997)
T4: (Wood 1987) (van Doorn 1995)
T5: (Kazimirski 1997) (van der Weide et al. 1997a)
E4 *** There is strong epidemiological evidence that most workers
with LBP 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 that
they do not need to wait till they are completely pain free.
T2: (Andersson 1997) (Dionne 1999) (Burton &
Main 2000) (Hartigan 1996) (Hadler 1997)
E5 * Advice to continue ordinary activities as normally as possible,
in principle, applies equally to work. The scientific evidence confirms that
this general approach leads to shorter periods of work loss, fewer recurrences
and less work loss over the following year, although most of the evidence comes
from intervention packages and the clinical evidence focusing solely on advice
about work is limited.
T1: (Waddell et al. 1997) (Abenhaim et al. 2000)
T2: (Hartigan 1996)
T4: (Catchlove & Cohen 1982) (Hiebert et al. 2000) (Hall et al. 1994)
E6 * There is general consensus but limited scientific evidence
that workplace organisational and/or management strategies (generally involving
organisational culture and high stakeholder commitment to improve safety, provide
optimum case management and encourage and support early return to work) may
reduce absenteeism and duration of work loss.
T1: (Westgaard & Winkel 1997) (Ferguson & Marras
1997) (Dishman et al. 1998)
T2: (Frank et al. 1996b) (Frank et al. 1998) (Snook & Webster 1998) (Nadler
et al. 1999) (Hadler 1997)
T3: (Hunt & Habeck 1993) (Shannon et al. 1996)
T4: (Wiesel et al. 1994) (Nassau 1999) (van der Weide et al. 1999)
Return to work with back pain
Concern about return to work with residual symptoms is often expressed by workers
themselves, their representatives, primary care health professionals, and occupational
health professionals as well as supervisors and management, particularly if
the LBP is attributed to work and if there is thought to be a risk of 're-injury'.
This concern is natural but illogical. A recent study has highlighted the variability
in physician advice on return to work and that recommendations often reflect
personal attitudes of the physicians and their perception of the severity of
symptoms (Rainville et al. 2000). Studies of the natural history show that LBP
is commonly a persistent or recurrent problem, and most workers do continue
working or return to work while symptoms are still present (Carey et al. 2000):
if nobody returned to work till they were 100% symptom free only a minority
would ever return to work (E4). Epidemiological and clinical follow-up studies
show that early return to work (or continuing to work) with some persisting
symptoms does not increase the risk of 're-injury' but actually reduces recurrences
and sickness absence over the following year (E1). Conversely, the longer someone
is off work the lower the chance of recovery (F1). Undue caution will form an
obstacle to return to work and lead to protracted sickness absence, which then
aggravates and perpetuates chronic pain and disability, and actually increases
the risk of a poor long term outcome: this clearly is not in the interest of
either the worker or the employer. Concerns are also sometimes expressed about
legal liability for 're-injury' if the worker returns to work before they are
completely 'cured' which is also illogical. Again, the natural history shows
that LBP is commonly a persistent or recurrent problem, so expectations of 'cure'
are unrealistic and recurrences are likely irrespective of work status. Refusing
to allow a worker to return to work because they still have some LBP increases
the likelihood of a break-down in worker-employer relationships and of the worker
making a claim; and the longer the sickness absence the higher the cost of any
claim. Helping and supporting the worker to remain at work, or in early return
to work, is in principle the most promising means of reducing future symptoms,
sickness absence and claims (E1, E5). Reducing any legal liability is best achieved
not by forcing the worker into protracted sickness absence and possibly an adversarial
situation, but by addressing the issues of job reassessment ('newly assessed
duties'), the provision of modified work with adequate support, and good worker-employer
relationships. All of these goals may best be achieved by the proposed active
rehabilitation programme and organisational interventions (F3, Figure 3). That
is also more in keeping with the spirit and the requirements of the Disability
Discrimination Act.
T1: (Krause et al. 1998)
T2: (Frank et al. 1998) (Johanning 2000)
T4: (Garcy et al. 1996) (Sinclair et al. 1997) (Tate et al. 1999)
T5: (Harris 1997) (Kazimirski 1997)
F Management of the worker having difficulty returning to normal
occupational duties at approximately 4-12 weeks
In general, the longer a worker is off work with LBP the more disabling the
condition becomes, the less successful any form of treatment, and the greater
the probability of long term sickness absence (F1). This could be explained
to some extent by selection bias in that those who are off work longer are simply
those with a more severe problem. However, the clinical evidence suggests that
there is little if any physical difference in their backs and intervention studies
show that there is usually no insurmountable physical barrier to rehabilitation
(F3). There are strong logical and humanitarian arguments, and strong empirical
evidence, that treatment at the sub-acute stage (approximately 4-12 weeks) is
more effective at preventing chronic pain and disability than attempts to treat
chronic, intractable pain and disability once it is established (F2). There
is strong evidence that intervention packages at the sub-acute stage can produce
desirable occupational outcomes (F3), and these efforts are likely to be more
cost-effective (though there is only limited empirical evidence on costs and
cost-effectiveness). There is therefore a convincing argument for intense efforts
to get workers with LBP back to work before disability and sickness absence
become protracted.
T1: (van Tulder & Waddell 2000) (van Tulder et
al. 2000a)
T5: (Royal College of General Practitioners 1999) (INSERM 2000)
T5: (Aulman et al. 1999)
F1 *** There is strong evidence that the longer a worker is off
work with LBP, the lower their chances of ever returning to work. Once a worker
is off work for 4-12 weeks they have a 10-40% risk (depending on the setting)
of still being off work at one year; after 1-2 years absence it is unlikely
they will return to any form of work in the foreseeable future, irrespective
of further treatment.
T2: (Andersson 1997) (Waddell 1998)
F2 *** Various treatments for chronic LBP may produce some clinical
improvement, but there is strong evidence that most clinical interventions are
quite ineffective at returning people to work once they have been off work for
a protracted period with LBP.
T1: (van der Weide et al. 1997b) (van Tulder
et al. 2000a) (Scheer et al. 1997)
F3 ** There is moderate evidence that for the patient who is having
difficulty returning to normal activities at 4-12 weeks, changing the focus
from purely symptomatic treatment to a 'back school' type of rehabilitation
programme can produce faster return to work, less chronic disability and less
sickness absence. There is no clear evidence on the optimum content or intensity
of such packages, but there is generally consistent evidence on certain basic
elements (Figure 3). There is moderate evidence that such interventions are
more effective in an occupational setting than in a health care setting.
T1: (van Tulder et al. 1999) (Di Fabio 1995)
(Karjalainen et al. 1999)
F4 ** From an organisational perspective, there is moderate evidence
that the temporary provision of lighter or modified duties facilitates return
to work and reduces time off work.
T1: (Krause et al. 1998)
T2: (Frank et al. 1998)
F5 - Conversely, there is some suggestion that clinical advice
to return only to restricted duties may act as a barrier to return to normal
work, particularly if no lighter or modified duties are available.
T4: (Hiebert et al. 2000) (Hall et al. 1994)
[Note: These two evidence statements are not incompatible. The
agreed goal should be to return to as near normal duties as possible as rapidly
as possible, and clinical advice and management must not undermine that, but
the best means of achieving this goal may be by the provision of modified or
lighter duties for a limited period.]
F6 ** There is moderate evidence that a combination of optimum
clinical management, a rehabilitation programme, and organisational interventions
designed to assist the worker with LBP return to work, is more effective than
single elements alone.
T1: (van Tulder et al. 1999) (Di Fabio 1995)
T2: (Frank et al. 1996b) (Frank et al. 1998) (Snook & Webster 1998) (Nadler
et al. 1999)
T3: (Loisel et al. 1997)
T4: (Haig et al. 1990) (Ryan et al. 1995) (van Doorn 1995) (Yassi et al. 1995)
(Tate et al. 1999)
T5: (Kazimirski 1997) (van der Weide et al. 1997a)
Rehabilitation Programmes
Most of the above principles could be combined in an active rehabilitation programme
(see Figure 3), although there is wide variation, lack of clear definition and
considerable confusion about exactly what constitutes an effective programme.
Some forms of 'back school' or 'multidisciplinary rehabilitation' at the sub-acute
stage have produced faster recovery of pain and disability, faster return to
work and fewer recurrences over the following year than other treatments to
which they have been compared (E1, F3). However, the results are inconsistent,
probably because most studies are of packages of interventions of widely varying
content and intensity. There is no clear evidence on the optimum content or
intensity of such packages, although there is generally consistent evidence
on certain basic elements.
Education alone is a relatively weak intervention. Traditional
biomedical information and advice based on spinal anatomy, biomechanics and
an injury model is largely ineffective (T3: (Roland & Dixon 1989) (Cherkin et
al. 1996)) but completely different information and advice, designed to overcome
fear avoidance beliefs and promote self-responsibility and self-care, can produce
positive shifts in beliefs and reduce disability (T3: (Burton et al. 1999) (Moore
et al. 2000)) (Snook et al. 1998).
All of the effective rehabilitation programmes have included a
progressive active exercise and physical fitness element (T1: (Di Fabio 1995)
(van Tulder et al. 1999)). Such exercise programmes can produce short-term improvement
in pain and disability for sub-acute and chronic LBP, although there is no clear
evidence that any specific type of exercise has any specific physical effect
(T1: (van Tulder et al. 2000b)).
There are theoretical considerations and empirical evidence that
most of the effective programmes are based on behavioural principles of pain
management (T1: (van Tulder et al. 1999) T2: (Waddell 1998)), but there are
few studies which look at this approach in isolation ((Fordyce et al. 1986)
(Turner 1996)). There is moderate evidence that these programmes are more effective
in an occupational setting (T1: (van Tulder et al. 1999)).
The interventions, resources and costs should be strictly controlled.
There is insufficient evidence to justify intensive and expensive programmes
and they are likely to be less cost effective. The rehabilitation programme
should be closely audited and evaluated to check that it is effective and not
having any unplanned adverse effects.
Previous guidelines
A number of guidelines (Table 5) were identified that are relevant to the occupational
health management of LBP; though some focus mainly on clinical management. They
adopted differing methods for locating and assessing the evidence base, which
vary from highly systematic, through consensus appraisal to personal interpretation,
and they have been published in varying forms through various media.
Despite the differing methodologies and target audiences, the
guidance on LBP has come to broadly similar conclusions in a number of important
respects (Burton & Waddell 1998). The clinical guidelines consistently advocate
some sort of diagnostic triage to distinguish between non-specific LBP and back
pain due to an identifiable pathology (see Figure 1). For non-specific LBP,
the guidance stresses the fundamental importance of prevention of chronicity,
and advocates an early, active management approach involving consideration of
psychosocial factors. In general terms, for primary care management at the acute
stage, patients are advised to remain active and then at the sub-acute stage
progressive exercise is encouraged, but there is some inconsistency as to where
the dividing line should be drawn. The most recent of these guidelines is the
1999 revision of the 1996 RCGP guidelines in UK (Royal College of General Practitioners
1999). The earlier CSAG report (Clinical Standards Advisory Group. 1994) also
addressed the provision of NHS and rehabilitation services in UK.
Most primary care guidelines mention occupational issues, in particular
the question of early return to work, as part of general advice on activity
but they do not fully address the issues facing the worker with LBP or the occupational
health practitioner. A few do address occupational issues slightly more fully,
but they come from development groups with differing perspectives and none of
them are evidence-linked. In general, the guidelines simply follow the primary
care approach of early active management as a strategy to prevent undue disability,
whilst the work-related guidance follows a broadly consistent pattern, focusing
particularly on workplace factors. There is a general tendency to address obstacles
to recovery rather than primary prevention, and job modification is seen as
an appropriate aid to remaining at work or early resumption of work. A major
feature of the occupational (as opposed to clinical) guidance is the concept
that work organisation and communication between workers and supervisors/management
are important elements of occupational health management; education both of
workers and employers is seen as important.
There is now extensive scientific evidence and general agreement
in the guidelines about how the clinical and occupational management of non-specific
LBP can and should be improved. There is at present very little empirical evidence
on whether such guidelines are implemented or change practice, or if the recommended
practice does actually deliver improved clinical and occupational outcomes.
T2: (Volinn 1999)
T5: (Westgaard & Winkel 1996) (van der Weide et al. 1997a)
Evidence gaps in occupational health management of LBP
This review has found considerably more scientific evidence on the occupational
health management of LBP than originally anticipated, despite the methodological
problems in a workplace setting (Zwerling et al. 1997). There is sufficient
evidence to permit a number of strong and moderate evidence statements and recommendations
for occupational health management, but this review, however, has also identified
inadequacies in the evidence in some important areas.
There is a need for further rigorously designed and carefully
controlled studies (where appropriate by RCTs and with sub-categorisation of
patients) on:
· Pre-placement assessment, particularly matching (strong) previous history
of LBP, physical capabilities and job demands.
· 'Innovative' education approaches to prevention and management specifically
designed to overcome psychosocial issues (eg fear avoidance beliefs) and encourage
patients to take responsibility for their own self-care.
· Company policies on accident prevention, 'safety culture', surveillance and
monitoring to reduce reported back 'injuries' and claims.
· The relative benefits and costs of prescribing sick certification for LBP.
· Early interventions to overcome obstacles to recovery (e.g. focused clinical
interventions targeting individual 'yellow flags' for chronicity).
· The optimum combination and relative importance of individual components in
an active rehabilitation programme.
· The optimum organisation, content and combination of case management, active
rehabilitation and return to work programmes.
When possible, cost-effectiveness analysis should be included in future studies.
Acknowledgements
The reviewers would like to express their appreciation and thanks to Serena
Bartys, BSc for her assistance with the literature searches and for securing
copies of the selected papers. Thanks are also expressed to Debbie Brown for
her administrative and secretarial contribution.
7 EVIDENCE TABLES
Table 1a - Systematic
reviews
| Authors |
Date
|
Subject |
Occup.
setting
|
Occup. outcomes
|
Number of studies |
Additional Comments |
| (Bongers et al. 1993) |
1993
|
Psychosocial risk factors at work |
+/-
|
-
|
30 |
30 |
| (NIOSH 1997) |
1997
|
Risk factors |
+
|
+
|
49 physical
13 psychosocial |
|
| (Burdorf & Sorock 1997) |
1997
|
Occupational and individual risk factors |
+
|
-
|
35 |
Estimates strength of association |
| (Bigos et al. 1998) |
1998
|
Risk factors & primary prevention |
+
|
+
|
17 prospective cohort & case control studies
risk factors |
+ 3 RCTs prevention |
| (Vingard & Nachemson 2000) |
1999
|
Occupational risk factors |
+
|
-
|
41 Physical 27 psychosocial |
Largely symptoms |
| (Hoogendoorn et al. 1999) |
1999
|
Physical load during work and leisure time
as risk factors for LBP |
+
|
-
|
28 cohort 3 case-referent |
Largely symptoms |
| (Bovenzi & Hulshof 1999) |
1999
|
Whole body vibration |
+
|
-
|
17 cross-sectional, longitudinal and case
control |
Meta-analysis |
| (Davis & Heaney 2000) |
2000
|
Psychosocial work characteristics |
+
|
-
|
66 psychosocial |
Symptoms only. Methodological critique |
| (Lahad et al. 1994) |
1994
|
Primary prevention |
+
|
-
|
62 studies with original data |
Back exercises Educational strategies Lumbar
supports |
| (Gebhardt 1994) |
1994
|
Training |
+
|
+
|
6 |
Meta-analysis |
| (Westgaard & Winkel 1997) |
1997
|
Ergonomic and workplace interventions |
+
|
+
|
20 ergonomic modification 32 production system
39 secondary prevention |
'Musculoskeletal health' |
| (van Poppel et al. 1997) |
1997
|
Primary prevention in industry |
+
|
+
|
11 controlled trials |
Back exercises Educational strategies Lumbar
supports |
| (Ferguson & Marras 1997) |
1997
|
Surveillance measures and risk factors |
+
|
+
|
57 |
|
| (Dishman et al. 1998) |
1998
|
Worksite physical activity interventions |
+
|
-
|
26 |
Outcome: activity level or physical fitness.
Not specifically LBP |
| (Polyani et al. 1998) |
1998
|
Workplace organisational changes |
+
|
+
|
21 case studies |
Health outcomes. Not specifically LBP |
| Assessment of the worker presenting with back pain |
| (van den Hoogen et al. 1995) |
1995
|
Accuracy of history & physical examination |
-
|
-
|
36 (cohort studies) |
Meta-analysis of sensitivity and specificity |
| (van Tulder et al. 1997) |
1997
|
X-rays |
-
|
-
|
35 |
Meta-analysis |
| (Nachemson & Vingard 2000) |
1999
|
MRI |
-
|
-
|
14 studies |
|
| Management principles for the worker presenting with
back pain |
| (van Tulder & Waddell 2000) |
1999 |
Clinical treatment Acute & subacute LBP |
- |
+/- |
98 RCTs |
SBU In press |
| (Waddell et al. 1997) |
1997 |
Bed rest Advice to stay active |
-
+/-
|
+/-
+/- |
10 RCTs
8 RCTs |
|
| (Abenhaim et al. 2000) |
1999 |
Activity |
+/- |
+/- |
|
Systematic review and guideline. Paris Task
Force In press |
| (van Tulder et al. 1999) |
1999 |
Back schools |
+/- |
+/- |
15 RCTs |
Cochrane review |
| (Faas 1996) |
1996 |
Specific back exercises |
- |
- |
11 RCTs |
4 acute
1 sub-acute
6 chronic |
| (van Tulder et al. 2000b) |
1999b |
Exercise therapy |
- |
- |
39 RCTs |
No conclusions about occupational outcomes |
| (Scheer et al. 1995) |
1995 |
Occupational outcomes acute LBP |
+ |
+ |
10 RCTs |
<4 weeks duration conservative interventions |
| (van der Weide et al. 1997b) |
1997 |
Occupational outcomes |
+ |
+ |
40 RCTs |
|
| Management of the worker having difficulty returning
to normal occupational duties at approximately 4-12 weeks |
| (van Tulder et al. 2000a) |
1999c
|
Clinical treatment chronic LBP |
-
|
-
|
96 RCTs |
SBU In press |
| (Scheer et al. 1997) |
1997
|
Occupational outcomes sub-acute & chronic
LBP |
+
|
+
|
12 RCTs |
Non-surgical interventions |
| (Cutler et al. 1994) |
1994
|
Pain centre treatment |
+/-
|
+
|
37 cohort studies |
Employment outcomes + meta-analysis |
| (Di Fabio 1995) |
1995
|
Comprehensive rehabilitation programmes |
+/-
|
+
|
19 RCTs |
Meta-analysis |
| (Faucett 1999) |
1999
|
Early interventions Acute and
sub-chronic LBP |
+/-
|
+
|
16 quantitative 6 qualitative
10 RCTs |
|
| (Feuerstein & Zastowny 1999) |
1999
|
Multidisciplinary occupational rehabilitation |
+
|
+
|
7 controlled studies(1 RCT) |
Chronic LBP |
| (Karjalainen et al. 1999) |
1999
|
Multidisciplinary rehabilitation |
+
|
+
|
12 |
Musculoskeletal disorders |
| (Krause et al. 1998) |
1998
|
Modified work & return to work |
+
|
+
|
29 empirical studies |
Few RCTs |
Table 1b - Main conclusions
of systematic reviews
*
Original authors' main conclusions from Abstract, Results and Discussion. (Present
reviewers' comments in brackets and italics)
| Systematic review |
Subject |
Original authors' main conclusions * |
(Bongers et al. 1993)
|
Psychosocial risk factors at work
|
The high correlation between psychosocial
factors and mechanical loading makes it difficult to draw firm conclusions.
Nevertheless, there is evidence that monotonous work, high perceived workload
and time pressure, and suggestive evidence that low control on the job and
lack of social support are associated with musculoskeletal symptoms. Stress
may be an intermediary. |
(NIOSH 1997)
|
Risk factors
|
A large, systematic review considering the
epidemiological evidence on risk factors for a wide variety of work-related
musculoskeletal disorders, including LBP. It concluded that there is strong
evidence for a causal relationship between lifting/forceful movements and
whole body vibration and LBP; there is evidence for a causal relationship
between awkward postures and heavy physical work and LBP; there is insufficient
evidence to assume a causal relationship between static work posture and
LBP. It is noted that the association applies when exposures are intense,
prolonged and multiple, but it is accepted that the multifactorial origins
of LBP may be associated with both work and non-work-related factors. There
is increasing evidence that psychosocial aspects of work play a role in
the development of LBP, and seem to be independent of physical factors.
(This review does not clearly distinguish between incidence, prevalence,
injury, chronicity, and work loss, and simply assumes that statistical associations
represent a causal relationship. Because of the focus on risk factors as
opposed to outcomes, it provides little information on work retention or
return-to-work issues where some of these factors may actually be more important.)
See also Table 2: National Research Council 1999 |
(Burdorf & Sorock 1997)
|
Occupational and individual risk factors
|
This review aimed to identify important risk
factors for work-related back disorders, to present information on the strength
of association and estimate their relative contribution to the occurrence
of back disorders in occupational populations. Considers physical and psychological
factors + certain individual factors. Lifting or carrying loads, whole-body
vibration and frequent bending and twisting were found to be consistently
associated with back disorders. There were contradictory and generally negative
findings on static work postures and repetitive movements. Job dissatisfaction
and low decision latitude found to be important, but somewhat inconsistent
(though this review only included a small number of studies on psychosocial
aspects of work). Age, smoking and education are confounding factors in
epidemiological studies. Gender, height, weight, exercise and marital status
were found not to be associated with back disorders in occupational populations. |
| (Bigos et al. 1998) |
Risk factors & primary prevention |
This (methodologically very rigorous) review
only accepted a limited number of high quality studies: 3 on prevention,
12 retrospective cohort studies and 5 case control studies. The authors
concluded that there is insufficient evidence to assess the outcome of specific
interventions to prevent back injury or back complaints at work. |
(Vingard & Nachemson 2000)
|
Occupational risk factors
|
Most studies are cross-sectional and concern
reports of pain. Nevertheless, the authors concluded that there is a constant
but weak relationship between physical work load factors and reports of
LBP. The impact of occupation on LBP is modest except for extreme working
conditions for prolonged periods without the possibility of changing work
tasks. Whole body vibration is a particular risk. Certain psychosocial factors
at work also appear to be related to reporting LBP, but most of the studies
are cross-sectional, there is confounding with physical work load, and the
effect is probably weak. There are theoretical arguments that improving
psychosocial aspects of work has the potential for reducing back complaints
at work, but at present there is little or no empirical evidence. |
(Hoogendoorn et al. 1999)
|
Physical load during work and leisure time as risk factors
for LBP
|
(This is the most up-to-date and comprehensive
review of the effect of physical demands of work.) There is strong evidence
for manual materials handling (lifting, moving, carrying and holding loads),
bending and twisting, and whole-body vibration as risk factors for reporting
LBP; moderate evidence for patient handling and heavy physical work; contradictory
evidence for standing or walking, sitting, sports, and total leisure-time
physical activity. |
(Bovenzi & Hulshof 1999)
|
Whole body vibration
|
Occupational exposure to whole body vibration
is associated with an increased risk for LBP, sciatic pain and degenerative
changes, but the cross-sectional nature of most of the evidence is insufficient
to establish a clear exposure-response relationship. |
(Davis & Heaney 2000)
|
Psychosocial work characteristics
|
(This is the most comprehensive and methodologically
critical review of psychosocial aspects of work.) There are considerable
methodological weaknesses to most studies. Controlling for physical work
load significantly weakens the association between psychosocial aspects
of work and LBP. In view of the methodological weaknesses it is difficult
to draw firm conclusions. Nevertheless, there is strong evidence for a weak
relationship between certain psychosocial aspects of work and reported LBP.
Workers' reactions to psychosocial aspects of work (e.g. job dissatisfaction
and job stress) are more consistently related to reported LBP than psychosocial
aspects of work themselves (e.g. work overload, lack of control over work,
quality of relationship with co-workers). |
(Lahad et al. 1994)
|
Primary prevention
|
Review of four specific interventions. The authors concluded
that there is limited evidence that exercises to strengthen back and abdominal
muscles and improve physical fitness can reduce the incidence and duration
of LBP episodes. They found minimal evidence for educational strategies
and insufficient evidence about lumbar supports. There is no evidence
for any specific effects from stopping smoking and reducing weight.
|
(Gebhardt 1994)
|
Training
|
Meta-analysis of six experimental studies
showed that training programmes including education and physical fitness
had a statistically significant but modest effect on the incidence and duration
of work loss due to LBP. |
(Westgaard & Winkel 1997)
|
Ergonomic and workplace interventions
|
Although this review included 92 studies,
they were not strictly ergonomic and very few were RCTs. The most effective
interventions were 1) 'organisational culture' using multiple interventions
with high stakeholder commitment to reduce identified risk factors, and
2) modifier interventions focussing on workers a |
|
