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first_img Previous Article Next Article Related posts:No related photos. Comments are closed. With back pain costing employers £5bn a year in absenteeism, managing theproblem is of fundamental importance. Recognising this, a research team has setout new guidelines on dealing with inflicted staff.  By Lisa Birrell and Tim Carter Disability from back pain in people of working age is one of the mostdramatic failures of healthcare in recent years. Its greatest impact is on thelives of those affected and their families. However, it also has a major impacton industry through absenteeism and avoidable costs: every year 40 per cent ofthe population is affected by back pain and 50 million working days are lost ata cost of about £5bn – or £200 per employee1. New approach A multidisciplinary working group, including occupational health nurses, forthe Faculty of Occupational Medicine (FOM), has produced guidelines for themanagement of low back pain at work2. It aims to reduce the toll by providing anew approach, based on the best available scientific evidence, and using thisto make practical recommendations on how to tackle the occupational healthaspects of the problem3. A number of key messages and challenges for occupational healthpractitioners managing low back pain at work are identified in the guidelines.Work is only one contributor to back pain, but whatever its cause, if poorlymanaged, back pain can have a devastating effect on a person’s ability to dotheir job. There are no valid methods of pre-placement screening to detect those atrisk, but a history of back pain should not generally be a reason for refusingemployment. For people with back pain, inactivity and bed rest increase the chance ofdisability – an active approach to treatment and return to work brings benefitsto everyone. And insisting on freedom from pain before someone resumes normalwork may delay recovery. OH professionals should discuss whether the inflictedperson’s job needs to be adapted to help them return quickly to fullactivities. Solutions such as rest pauses, task rotation, handling aids andextra help should be considered. Joint initiatives OH advisers should involve employer, employees and trade unions whendeveloping measures to combat back pain. This joint approach has provedeffective in reducing the impact of back pain at work. Encourage employers toset up systems to deal promptly with reports of back pain and review thesereports to see if the prevention measures can be improved. OH nurses should collaborate with GPs, for instance, to help people withback pain to return to work as soon as possible if they have been absent. Andemphasise the need for active rehabilitation within a month of the start of anepisode of back pain and before it has become a chronic and largelyirremediable problem. If such services are not available locally through theNHS, it may be possible to make arrangements through employers’ liability orprivate medical insurance. Leaflets summarising the guidelines have been produced for occupationalhealth practitioners, employers and people at work (see box of principlerecommendations overleaf). These complement existing guidelines produced forprimary care health professionals by the Royal College of General Practitioners(RCGP), and should facilitate better links between the workplace and thecommunity for back pain management4. The process used to develop such guidelines is well established: asystematic review of the scientific evidence was prepared covering each of sixkey occupational health areas. Evidence statements, with weighting according to strength, were linked tothat evidence. As far as possible, recommendations for practice were based on and linked tothese evidence statements, though there are some important areas where there isa lack of evidence. The evidence and recommendations concentrate oninterventions and outcomes rather than on professional disciplines and so donot make any comment on which occupational health professional should provideadvice or support. The guidelines concern the clinical management of employees affected bynon-specific low back pain (LBP), including advice on placement, rehabilitationand measures for prevention. They focus on actions to be taken to assist theindividual and do not specifically cover legal issues, health and safetymanagement, job design and ergonomics. The guidance assumes that a riskassessment has been conducted and used to define the control measures required,including the need for occupational health advice. It is not intended, norshould it be taken to imply, that these guidelines override existing legalobligations. Any duties under the Health and Safety at Work Act 1974, the Management ofHealth and Safety at Work Regulations 1992, the Manual Handling OperationsRegulations 1992, the Disability Discrimination Act 1995, or other relevantlegislation must be given due consideration. Lisa Birrell is secretary and Tim Carter is chairman of the Faculty ofOccupational Medicine Guidelines Working Group The report was sponsored by Blue Circle Industries, through the BritishOccupational Health Research Foundation and the Faculty of OccupationalMedicine. Copies of the full evidence review and guidelines available (at £15 acopy) from: Faculty of Occupational Medicine, 6 St Andrew’s Place, Regent’sPark, London NW1 4LB. 1 Clinical Standards Advisory Group (1994) Epidemiology Review: TheEpidemiology and Cost of Back Pain. London, HMSO: 1-72. 2 Carter JT, Birrell LN (2000). Occupational Health Guidelines for theManagement of Low Back Pain at Work – Principal Recommendations. Faculty ofOccupational Medicine, London ( 3 Waddell G, Burton AK (2000). Occupational Health Guidelines for theManagement of Low Back Pain at Work- Evidence Review. Faculty of OccupationalMedicine, London ( 4 Royal College of General Practitioners 1999. Clinical Guidelines for theManagement of Acute Low Back Pain. Royal College of General Practitioners,London ( 5 Kendall NAS, Linton SJ, Main CJ (1997). Guide to Assessing PsychosocialYellow Flags in Acute Low Back Pain: Risk Factors for Long-term Disability andWork Loss. 1-22. Wellington, NZ. Accident Rehabilitation and CompensationInsurance Corporation of New Zealand and the National Health Committee. 6. The Back Book (1997). The Stationery Office (ISBN 0 1170 2078 8). Principle RecommendationsEvidence * * * Strong * * Moderate * Limited or contradictoryBackgroundMake 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 andpsychosocial factors* * * Physical demands at work can be associated with increased backsymptoms and ‘injuries’, but they do not generally produce lasting physical damage.Overall, they are less important than other individual, non-occupational andunidentified factors* * * Disability due to LBP depends more on psychosocial factorsPre-placement assessment– LBP is not a reason for denying employment in most circumstances. Careshould be taken when placing individuals with a strong history of LBP inphysically demanding jobs– Placement should take account of the risk assessment and requirementsunder the Disability Discrimination Act 1995, but is ultimately a question ofprofessional judgement* * * A strong history of LBP is the best predictor of future problems:frequency and duration of previous attacks, time since last attack, radiatingleg pain, back surgery and sickness absence* * Clinical examination, x-ray, MRI, back-function testing machines andpsychosocial screening are not reliable predictorsPrevention– Advise on current good working practices such as specified in the ManualHandling Regulations and associated guidanceEncourage employers to:– Consider joint employer-worker initiatives to identify and controloccupational 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 goodindustrial relations* * * Traditional biomedical education and lumbar supports do not reducefuture LBP and work loss* There is conflicting evidence whether general exercise/physical fitnessprogrammes have much preventive effect* Joint employer-worker initiatives to monitor and improve safety can reducethe number of reported back “injuries” and sickness absenceAssessment of the worker with back pain– Screen for serious spinal diseases and nerve root problems– Take a detailed clinical, disability and occupational history – Consider psychosocial risk factors for chronicity (see “YellowFlags” box).* * Patients over 50, with prolonged and severe symptoms or radiating legpain are at more risk of long-term disability* * Clinical examination, x-ray and MRI do not predict clinical symptoms orwork capacity* * * Individual and work-related psychosocial factors play an importantrole in persisting symptoms and disabilityManagement principles for the worker with back pain– Ensure that workers with LBP receive the key information in a form theyunderstand (The Back Book6) and that their clinical management follows the RCGPGuidelines 4. Discuss expected recovery times– Encourage the worker to continue as normally as possible and to remain atwork, 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 necessaryto achieve this* * * Staying active and returning to ordinary activities as early aspossible leads to faster recovery and fewer recurrences * * * Most workers with LBP are able to continue working or to return towork within a few days or weeks: they do not need to wait until they arecompletely pain free* * Joint employer-worker initiatives to provide optimum management and tofacilitate and support workers remaining at work or returning to work as earlyas possible may reduce sickness absenceManagement of the worker having difficulty returning to normal workduties at 4-12 weeks– Address the common misconception among workers and employers that you needto be pain-free to return to work – Advise on ways in which the job can be adjusted to facilitate return towork– Communicate and collaborate with primary healthcare professionals to shiftthe emphasis from dependence on symptomatic treatment to rehabilitation andself-management strategies. Where practicable refer to an active rehabilitationprogramme* * * The longer a worker is off work with LBP, the lower their chances ofever returning to work* * Temporary provision of modified or lighter duties facilitates return to workand reduces time off work* * Changing the focus from purely symptomatic treatment to an activerehabilitation programme can produce faster return to work and less chronicdisability. This is more effective in an occupational than in a healthcare setting* * A combination of optimum clinical management, a rehabilitationprogramme, and organisational interventions designed to assist the worker withLBP return to work, is more effectivePsychosocial ‘Yellow Flags’ Patient beliefs and behaviours which may 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 activeparticipation will help Back statementsOn 1 Jun 2000 in Personnel Todaylast_img read more