Back pain and work

Best Practice & Research Clinical Rheumatology 24 (2010) 227–240

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Back pain and work Ka´tia M. Costa-Black, PhD, Postdoctoral researcher a, Patrick Loisel, MD, Professor a, *, Johannes R. Anema, MD, PhD, Assistant professor/ Senior researcher b, Glenn Pransky, MD, Director c a

Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada Department of Public and Occupational Health and the EMGO-Institute for Health and Care Research, VU Medical Center, Amsterdam, The Netherlands c Center for Disability Research Liberty Mutual Research Institute for Safety, Hopkinton, MA, USA b

Keywords: low back pain occupational factors return to work work disability workplace interventions

Low back pain is a leading cause of work disability and constitutes a significant socioeconomic burden worldwide. In an attempt to stem the serious consequences of long-term disability, a new approach for back pain in primary care is being disseminated. It mainly focusses on identifying the relationship between pain/ disability and work, recognising important workplace and psychosocial issues, providing patients reassuring messages about activity, facilitating the return to work process and engaging other resources as needed. This article examines current expert opinion and available evidence on work issues for effective back pain management. In general, return to work, if safe, is beneficial for recovery and well-being. Some cases might require physicians to actively communicate with employers, claims managers and others in order to achieve safe and sustained return to work, while in most instances, simple efforts to identify and discuss work issues directly with the patient can lead to better work outcomes. Ó 2009 Elsevier Ltd. All rights reserved.

Introduction In order to discuss low back pain (LBP) in relation to work issues, it is helpful to reflect on its epidemiology, presentation and typical course in primary care and rheumatology practice. LBP is a highly common health problem (about 90% of people will experience it at least once in their adult * Corresponding author. Dalla Lana School of Public Health, University of Toronto, Toronto Western Hospital, Med West Building, 2nd Floor Rm 201, 750 Dundas St. W., Toronto, Ontario M6J 3S3, Canada. Tel.: þ1 416 860 0420x2010; Fax: þ1 416 860 0634. E-mail address: [email protected] (P. Loisel). 1521-6942/$ – see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.berh.2009.11.007

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life). At most, 20% of working-age individuals experiencing LBP seek medical help and, of those, only 20% report sickness absence and 10% file a worker’s compensation claim [1,2]. Typically, medical management has little impact on the outcome of acute episodes; rapid improvement usually occurs in the short term (approximately within 1 month) for most people [1,3]. In many cases, back pain amongst primary care patients runs a recurrent course characterised by variation and change, rather than an acute, self-limiting course [4]; however, few patients have long-term limitation in daily activities, even if some pain persists [5]. The small percentage who have significant pain and work disability account for most of the healthcare costs and socioeconomic burden (lost productivity and prolonged work disability) of LBP. Within the 45- to 65-year-old age group, LBP is one of the most frequently reported medical reasons for work loss [6]. According to a large cohort study of injured workers who filed workers’ compensation claims for occupational back pain in the United States, the decision to seek care and the choice of providers was associated with injury severity, occupation and employer actions [7]. Thus, for most working patients seeking medical care, amelioration of pain is not the only outcome or treatment focus to consider. Work participation and restoring function play major roles in recovery, are beneficial to overall health and mental well-being and, are essential for the patients’ self-confidence and selfcontrol over an important life dimension[8]. The International Labour Organization (2008) recently emphasised the intrinsic importance and meaning of work in the lives of people, irrespective of whether they have a medical condition or not: ‘‘work is not just an economic issue, it provides a means to prove one’s worth and ability, gain selfconfidence and self-esteem, and participate in the life of the community’’ (International Labour Organization (ILO), 2008). Long periods out of work can cause or contribute to 2–3 times increased risk of poor general health, 2–3 times increased risk of mental health problems and even 20% excess mortality risk [9,10]. Prolonged sickness absence can result in permanent disability, even without serious illness, as patients become depressed, inactive, develop catastrophic beliefs and become fixated on their disability. First and foremost it is important to recognise that prevention of all back pain occurrence in the workplace would be optimal, but seems less feasible and less cost-effective than controlling the consequences of pain and disability [1]. Subsequently, it is when pain first appears to lead to temporary work disability that many physicians in primary care encounter work issues in their LBP patients. Working-age patients often consult their primary care physician when they need a sick note, or advice about how their health impacts work ability or vice versa [11]. In many situations, patients are legally required to obtain medical certification for work disability, or clearance to return to work (RTW) [12]. Primary care physicians thus have a secondary prevention role when making proper recommendations to patients with regard to work restrictions and participation. As first evaluators and communicators of a patient’s health and condition, they have a unique window of opportunity, early on, to prevent poor outcomes in patients at risk of experiencing prolonged pain, recurrent illness and disability [13,14]. Since attention to RTW is proven to be more important than solely focussing on treating the injury or pain, physicians need to better understand the work context in relation to the capacity and beliefs of the patient. Many do find these issues frustrating, time consuming and feel ill prepared to deal with them [15]. However, a change in approach can improve the experience for patients, providers and employers [16]. There is much variation across primary care practices in the specific role for dealing with work-related issues. However, current evidence leads to practical recommendations that are relevant for most providers. Many literature reviews, clinical guidelines and implementation studies are seeking to engage primary care physicians in simple but effective disability prevention practices in these encounters. For instance, clinical practice guidelines emphasise the idea of ‘do no harm’ by advising physicians not to prescribe unnecessary diagnostic tests in order to avoid catastrophic beliefs [17,18]. They also suggest ways to identify risk factors for disability, suggest appropriate reassurance and encourage RTW. More recent research efforts offer new knowledge on specific work-related factors related to clinical and disability outcomes, which can be translated to clinical practice [19–23]. This article discusses these recommendations in view of improving current practices for LBP management. We review work issues in the context of managing LBP, perspectives on factors that

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influence work disability outcomes, guidelines and recommendations for primary care physicians as well as strategies to deal with the most common challenges. While managing illness, give attention to work issues An observer of clinical medicine may state that patients suffer ‘illnesses’ while doctors tend to diagnose and treat ‘diseases’. Illnesses are experiences of discontinuities in states of being and perceived role performances [24]. Diseases, in the scientific paradigm of modern medicine, are ‘‘abnormalities in the function and/or structure of body organs and systems’’ [24]. More than three decades ago, Eisenberg [24] stressed the discrepancy between ‘disease’ as it is conceptualised by the physician and ‘illness’ as it is experienced by the patient, insofar as illness is highly influenced by cultural belief systems. In this context, the role of belief systems – and opportunities for health-care professionals to change them – is a growing focus of LBP research and practice improvements. From a health-care provider and patient viewpoint, pain is often interpreted as a sign of disease or injury. A distinction between serious spinal pathology and common back pain with unrecognised diagnosis (often referred to as non-specific back pain) clearly remains important in medical triage [25]. There is consensus in the medical community that an important role in the initial encounter with a LBP patient is to rule out potential ‘red flags’ (i.e., indicators of potentially serious pathology). If ‘red flags’ are identified – less than 5% of all acute LBP cases – prompt medical attention is necessary depending on the specific pathoanatomical diagnosis, such as fracture, tumour, severe radiculopathy or cauda equina syndrome [18]. For most patients with non-specific, persistent LBP, a specific diagnosis or injury is not present [17,26]. Despite this, patients often believe that any form of work can cause further damage, an impression reinforced by physicians or other health-care providers who may have similar beliefs [27], and send the wrong messages about the relationship between pain and activity, reinforcing pain– sickness behaviour. Because physicians can influence a patient’s belief system and generate realistic or unrealistic expectations about his/her ability to RTW, a new proposed approach which focusses on managing illness (while preventing work disability), rather than pain, appears to be ideal in generating more informed decisions regarding back pain management. Many scientists believe that, by placing a focus on health–illness rather than pain alone, physicians are able to provide higher-quality and more individualised care to back pain patients [28–31]. It is through attention to health–illness in patients presenting with LBP that the use of the biopsychosocial model has been recommended [32,33]. This model offers an opportunity of collecting objective data that are truly representative of each patient’s own and integrative experience of pain and sickness behaviour (i.e., formed by cultural, social, emotional, biological and psychological dimensions). It is important to apply this model’s perspective as early as possible, in particular, when separation from usual activities is occurring because, at that time, factors (other than biomedical) have greater impact on prognosis [12,34]. The application, in practice, of a biopsychosocial model (in terms of the adopted provider perspective) proposes a shift in focus from fixable anatomic causes and aetiology, towards a consideration of the broader aspects of patients’ lives and an understanding of health–illness relationships [30,32,33]. When taking this more comprehensive approach to design a treatment plan and communicate with patients, health-care providers are able to more effectively improve patient’s quality of life while reducing the burden of disability [8,35–37]. The model focusses on health, individual and workplace psychosocial factors, injury and recovery, as well as work capabilities and job demands as interacting to impact work-disability outcomes. Recommendations on work issues from clinical guidelines In an attempt to identify recommendations for addressing work issues in the context of primary care for back pain, four recently published clinical guidelines, several studies and published recommendations for primary care physicians were reviewed. Table 1 shows all the recommendations to physicians on RTW and work-related issues for both acute (<6 weeks) and persistent LBP (>6 weeks)

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Table 1 RTW and other work-related recommendations from recently published guidelines (early management). Phase

RTW and work-related recommendations

ICSI (USA) guideline

European guidelines

Canadian guideline

NICE (UK) guideline

Acute (< 6 weeks)

Advise patients to stay active and continue normal daily activities including work/‘‘Work poses no threat and will not harm them’’

X

X

X

N/A

Be aware of psychosocial factors (such as low social support in the workplace, low job satisfaction, and review them in detail if there is no improvement). ‘‘Clinical assessment for psychosocial yellow flags’’

X

X

X

N/A

Consider using the following questions to guide your discussion about non-physical factors that can significantly impact risk for ongoing disability and return to work: - Do you enjoy the tasks involved in your job? - Do you get along with your closest or immediate supervisor?

X

Encourages the person to be physically active and continue (or take a gradual resumption of) work and physical exercise as tolerated/‘‘Remaining active leads to a more rapid recovery with less chronic pain.’’

X

X

X

X

It is important to evaluate non-clinical factors that may impact returning to work or ongoing disability (mainly psychosocial yellow flags that can be intervened such as conflict at work or poor job satisfaction.

X

X

X

X

Refer patients with persistent and disabling back pain (beyond 6 weeks), or significant limitation of function including job related activities to a comprehensive RTW/rehabilitation program.

X

X

X

Persistent or recurrent back pain (> 6 weeks but for <12 months)

Source: RTW and other work-related recommendations compiled according to: 1) The Institute for Clinical Systems Improvement (ICSI) guideline for Adult low back pain Bloomington, MN, USA 2008; 2) The European guidelines for the management of acute nonspecific low back pain in primary care, 2006 & European guidelines for the management of chronic non- specific low back pain, 2004; 3) Guideline for the evidence-informed primary care management of LBP. Guidelines management for Primary Care Practice in the Calgary Health Region, Alberta, Canada, 2009; and, 4) The National Institute for Health and Clinical Excellence (NICE). Low back pain: Early management of persistent non-specific low back pain, London, UK, 2009.

retrieved from the guidelines. Each guideline represents a combination of practical expertise and scientific evidence on effective back pain management to be implemented regionally by a specific organisation [38–41]. For those requiring medical attention due to acute pain and no specific diagnostic pathology, three guidelines recommend RTW or normal daily activities as soon as possible [38,39,42]. This recommendation is in line with several observational studies indicating that a longer duration of work absenteeism is associated with poor recovery and no health benefit [43]. Doctors can often prevent work disability at this stage simply by reassuring patients that activities can be resumed safely, even if pain is still present. These recommendations are generic in terms of various work situations patients might face and more specific work accommodations might be needed in certain circumstances in order to RTW safely. In such instances, simple communication about temporary modified work between the primary care physician and employer may be especially helpful [12,44]. One step ahead of what has been proposed by these three guidelines has been made by the Canadian Medical Association. This organisation has developed a practical guide to help physicians to better support return to the workplace after illness or injury [45]. They suggest discussing expectations

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about healing and RTW early on, understanding the psychosocial context in relation to work, developing an understanding of workplace demands, risks and RTW options and effectively communicating an RTW plan. Similar recommendations were published in another physician guide from a Canadian workers’ compensation board; this guide (available at the following website: (http://www.wsib.on.ca) offers specific suggestions on communication with patients and employers, and identification of risk factors for prolonged disability [46]. Furthermore, recurrence of back pain is a common and, often a normal part of the course of the condition. Health-care providers can advise patients to avoid loads or positions that appear to exacerbate pain in order to prevent recurrent disability. There is some evidence supporting the value of instruction in safer work practices for lifting, carrying, pushing, pulling and sitting to help decrease or prevent disability recurrence [47]. However, patient education at any stages of pain and/or disability is a complex issue. Physicians should be attentive that educational material based on a biomechanical model (anatomical and posture-oriented information) can convey negative messages for those with back pain [38]. If LBP persists beyond 6 weeks, all guidelines encourage the patient to resume work and other activities within the limits permitted by the pain (please refer to Table 1 for work-related recommendations at that phase). Attention should be given, however, to the necessity of referral to a comprehensive RTW/rehabilitation programme, which typically are multidisciplinary and involve case management, education about keeping active, psychological or behavioural treatment and participation in an exercise programme. Finally, these guidelines suggest that an assessment of nonclinical factors, including those related to work, is essential if no improvement of function is observed. The next section presents more detailed considerations of those factors in the context of primary care. Work-related factors: considerations for primary care Which ones are important? There is good evidence demonstrating that both the course and prognosis of LBP and disability are highly influenced by a number of interplaying factors besides clinical features, including those related to work [48,49]. According to Waddell and Burton [50], care seeking and disability associated with LBP depend more on these individual and work-related psychosocial factors than on clinical features. Patient’s perceived work-related factors – often referred to as ‘yellow flags’ – include known psychosocial and behavioural barriers to RTW that have been studied in the primary and secondary care context. Most clinical practice guidelines make reference to the identification of these yellow flags in the assessment of acute and sub-acute back pain patients [38,39,42]. They recommend, for instance, to assess in patients the belief that pain and activity are harmful, social problems at work, poor job satisfaction, undesirable work hours (shift work), etc [23]. In recent years, the conceptualisation of those factors has evolved to specify two types of workplace factors: ‘blue flags’ and ‘black flags’. ‘Blue flags’ are the parameters related to work and workplaces mainly based on workers perceptions of a stressful, unsupportive, unfulfilling or highly demanding work environment [23]. ‘Black flags’ are actual workplace conditions that can affect disability and individual perceptions about work, whether accurate or inaccurate, that can affect disability. They include employer and insurance system characteristics as well as objective measures of physical demands and job characteristics [23]. The guidelines listed in Table 1 primarily focus on patient screening and how to address psychosocial yellow flags. They have not yet fully incorporated the blue and black flags classification of occupational factors. Nonetheless, this new classification of non-clinical factors may offer a closer liaison between primary care doctors and the workplace by, at a minimum, helping doctors to think logically about work-related barriers to recovery and RTW. In fact, this new flag system represents a large body of epidemiological evidence on LBP predictors for disability (Table 2), which has been classified and translated into specific assessment methods. With regard to the cumulative evidence on LBP predictors and determinants of disability, there is still some conflicting evidence, particularly in terms of the physical demands and work organisation

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Table 2 Evidence from systematic reviews on work-related factors affecting back disability. Work variables: Physical demands Heavy physical demands* Ability to modify work* High-risk industry Driving* Psychological demands Monotonous work Job stress* Lack of control* Emotional effort of work Poor work environment Social/management factors Social support/dysfunction* Short job tenure* Frequent job changes Delayed notice to employer*

Shaw [23]

Crook [76]

X X

X

Waddell [43] X

Steenstra [57] X (no effect) X

X

(no effect) X

X X

X X

(no effect)

X

X

Lack of vocational direction Inflexible work schedule Night shift/unsociable hours No gradual RTW pathways Absence of employer interest Negative employer response Small firm size Overtime work Workplace beliefs Job satisfaction* Belief work is dangerous Expectations for RTW* Fears of re-injury* Worries about work absence Barriers/facilitators for RTW

Hartvigsen [77]

(no effect) (no effect) X

X

X

X X

(no effect)

* Evidence on work factor supported by at least one systematic review. Source: Shaw et al. [23] (Reproduced by courtesy of publisher).

structure (Table 2) [23]. Factors such as heavy physical demands, ability to modify work, social support, short job tenure, job satisfaction and fears of re-injury are supported by more than one systematic review and thus have a higher level of evidence. Other work factors analysed in the five review studies, presented in Table 2, either were not associated with back disability or had little or no effect. Some studies provide inconclusive answers due to methodological issues related to evaluating workplace factors in a fragmented manner without accounting for social organisation dynamics that have not been consistently included in systematic reviews of the quantitative literature on risk factors [51]. Work-related determinants of back pain and disability have been translated into several assess¨ rebro Musculoskeletal Pain Questionment methods. Yellow and blue flags are addressed in the O naire (OMPQ), the Psychosocial Risk for Occupational Disability Instrument (PRODI), the Back Disability Risk Questionnaire, the Work Disability Diagnosis Interview (WoDDI) and the Obstacles to Return-to-Work Questionnaire (ORQ) [23]. The usefulness of these tools in clinical practice is still not fully established; for example, screening results have not yet been empirically linked to proven early intervention strategies, although researchers have suggested ways that this might occur early on in the course of LBP [52]. Clinicians, especially in primary care, may feel unprepared to interpret the results [23]. However, these instruments are excellent sources of evidence-based questions for patients in order to uncover key work-related information impacting a patient’s recovery process and return to function/work.

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In summary, because RTW is a complex inter-related social and behavioural subject, it is difficult for any professional group involved with this problem to agree on which factors should or not be considered within their domain and practices [53]. Furthermore, it is widely recognised the methodological complexity of studying work factors can limit how well they can be studied. These factors are not easily distinguished by occurrence of ‘disease’ or injury, but rather in relation to ‘illness’ representation and behaviour or in relation to ‘sickness’ duration, claims and social dimensions of the problem [26,54]. In addition, the changing nature of the workplace system (due mainly to introduction of new technologies and business cycles) makes it very difficult for researchers to step into such a complex system with its own particular determinants and incentives [20,55]. Independent of research methodological barriers, the cumulative knowledge that exists today on a number of work factors (as showed in Table 2) provides an opportunity to health-care providers to propose patientcentred interventions which are more inclusive of an individual’s working-life dimension. For instance, if a patient perceives low workplace support for RTW, the treating physician needs to connect with workplace actors (or, in some instances, with a case manager) in order to discuss viable solutions for quickly retuning the patient to work. When do they need to be considered? Patients can experience persistent or recurrent pain with fluctuating symptoms and, in each episode, different or additional disability determinants (mainly of a non-medical nature) might play a role in disability duration [56]. Thus, primary care physicians need to develop a clear understanding of changes in work issues at various times during an episode of care. There are methodological difficulties in studying an episodic and highly variable illness such as non-specific LBP [57]. However, most experts agree that early identification is ideal. The RTW process can be quite complex and there is as yet insufficient scientific evidence – although enough practical knowledge has been built – on when factors should be considered in clinical decision making. A common agreement among experts in the field is that the longer the patient with back pain has been away from work, the more difficult it will become for him/her resume work [31,50]. This is clearly observed on the classical RTW curve in relation to time away from work as depicted in Fig. 1 [58]. Accordingly, identification of work factors at an early stage of work absence seems plausible. At 4 weeks away from work (less than 40 days in the curve), there is still a good chance that a large proportion of individuals will RTW. Thus, the implicit rationale is to remove RTW barriers as early as possible and understand the needs and situations patients face when reassuming work. For making timely and proper referrals on an individual and needed basis, the reviewed clinical guidelines suggest that the physician should be attentive to patient-oriented outcomes, such as daily

Fig. 1. Proportion of people returning to work with back pain (adapted from CSAG/Reports on back pain [58]).

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functioning, work status, patients’ expectations as well as to the yellow flags. These are very important to distinguish for who and when a referral will be appropriate during the course of treatment. Based largely on epidemiological data, a number of prediction models have been developed. Heymans et al. [59] recently developed a clinical prediction rule based on a comprehensive workdisability model for LBP patients. They confirmed the importance of demographics, work, pain and psychosocial-related factors on the course of disabling back pain (i.e., early prediction – at 2–6 weeks after start of sick leave – of long-term sick-leave at 6 months). To better evaluate the feasibility in clinical practice, further research considering the time required for the patient and/or clinician to determine the final risk score and probability of outcome is needed. During the acute and sub-acute phases, several authors recommend that the workplace undergo an ergonomic evaluation in order that changes may be implemented to help some patients quickly and safely RTW [60–62]. Although the prognosis appears positive for the majority of non-specific LBP cases even without medical intervention, a few cases will progress to chronicity or long-term work disability. These cases are not as easy to predict as once was expected. Ideally, after ruling out serious pathology, patients should be initially screened in terms of risk for developing chronicity and work disability to facilitate early intervention. This is not just a ‘simple’ question of screening predictors of pain and disability. It requires individualised attention to the interacting factors associated with disability and RTW. According to the European Guidelines [42], if at the stage of sub-acute episodes (between 6 and 12 weeks of persistent pain and significant functional limitations) the outcome is not favourable (e.g., long work absence) the physician should consider referring the patient for a multidisciplinary programme in an occupational setting. For the chronic phase or persistent back pain/disability for more than 4 months, once the patient steps into a complex phenomenon of conflicting opinions and advice, failed treatment, pain-related distress, ‘sick certification’ and work incapacity, preventing further work disability is very difficult [8]. It is not known, however, if in a stage of prolonged incapacity and chronic pain, addressing work issues in liaison with clinical management would be effective and cost-effective in diminishing the harmful effects of lifetime back pain disability [63]. Several studies have shown the potential impact of intensive, prolonged multidisciplinary approaches on work-disability outcomes [8,64]. To understand these more challenging disability cases, it is necessary to situate the LBP problem within an ecological and multifaceted paradigm in which personal, social and environmental factors evolve and interact to create (or prevent) prolonged work disability. Practically, this means taking into account the fact that the actions and decisions of a diverse array of stakeholders are involved. The different groups of stakeholders are represented in Fig. 2. At large, they are influenced by cultural and political arrangements that govern our society as a whole [54]. Four main inter-related systems form the basis of the work-disability-prevention arena, namely workplace system, personal system, health-care system, legislative/compensation system and personal system. All systems are intertwined to generate or prevent work disability; however, too often, there are practical and conceptual discrepancies between systems (represented by groups of stakeholders), leading to misunderstandings in what to act on and how to act. To confront this problem, a unified view of low back disability (or disablement related to back pain) must be promoted between and amongst each group of stakeholders.

Work-related strategies: considerations for primary care In a recent scientific review, Krismer and van Tulder [65] recommended that the most important targets in the management of LBP are reduction of pain, and improvement of activity/participation, which includes strategies for maintenance of work capacity. With regard to work participation, what is known today about LBP has led to the development of a number of workplace interventions aimed at addressing factors (or barriers) that are modifiable. Many of them, if implemented in a timely fashion and integrated with primary care, have been shown to be effective [36,47,66,67]. Most of them are based on a biopsychosocial and ecological view of LBP.

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Fig. 2. The arena in work disability prevention (Reproduced by courtesy of publisher from Loisel et al. [54]).

Workplace-centred interventions for disability prevention have been developed in the context of integrated case management for musculoskeletal disorders and have drawn from successful strategies used in mental health and other problems [37,68]. They include employer-based initiatives to reduce sickness absence, clinically based programmes and multidisciplinary biopsychosocial interventions offered by occupational rehabilitation services. The central feature that makes them attractive from the perspective of various stakeholders, including workers, is that early management is offered in close collaboration with the real work environment [69]. This approach generates pragmatic methods for health-care providers to intervene in a way that addresses workers’ expectations, fears and beliefs about the relationships between work and health. In addition, workplace-centred interventions can positively influence relationships at work in a broader sense, perhaps leading to more successful RTW outcomes [70]. Table 3 presents a brief description of a number of possible workplace interventions, displaying a range of possible interventions and their potential to prevent work disability. This information was extracted from two reviews; one which examined the content of workplace interventions specific for back pain [71] and another which examined the effectiveness of workplace interventions and strategies for musculoskeletal or other pain-related conditions [72]. Only information on interventions and strategies specificly for back pain patients was extracted from the latter. All interventions listed in Table 3 have been investigated in back pain patients experiencing between 2 and 12 weeks of sick leave. The interventions vary in their forms and objectives, and thus many findings have not been replicated and will require adaptation to individual clinical settings. Furthermore, some programmes are not yet widely available [73]. Despite the limitations cited, it is nonetheless important to clarify the role workplace interventions may play in the early management of back pain, particularly as part of an attempt to identify possible links between primary care and secondary care actions (given that most workplace interventions centred in the workplace have been designed for the latter only). For some recommendations for early intervention (e.g., reassurance to quickly return to ordinary activities, getting the right support from

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Table 3 Workplace interventions for back pain management. Interventions and strategies closer to the workplace

Main characteristic/description (if available)

Health care provider contact with workplace Ergonomic worksite visits Early contact with worker by workplace Work accommodation offers (e.g temporary modified work) Supernumerary replacements

It often includes a worksite visit by a physiotherapist or occupational therapist. It involves an ergonomic evaluation and recommendations Self-explanatory They are usually presented by the employer and depend on fundamental employment policies and practice. It occurs when financial support is available to cover the cost of an additional person to replace the injured or ill worker, while the worker is doing modified work. It includes an exercise programme and measurements taken at baseline. A workplace visit is done with the patient, the physiotherapist and supervisor to: 1) enable the supervisor become involved in the treatment process; and 2) help the physiotherapist to obtain an overview of the work demands. Known types: - Multimodal cognitive behavioral treatment. It includes a series of coordinated treatments focus on the functional level patients can achieve and not on pain. If necessary, work modifications are also discussed with the patient and directly negotiated with the work supervisor; - Care management by insurance carriers; - Work hardening; - Occupational rehabilitation and participatory ergonomics. The later involves a consensus building between union members, worker and supervisors for implementing ergonomics solutions.

Graded activity

RTW coordination

Source: Workplace interventions and their respective descriptions compiled according to Staal et al. [71] and Franche et al. [72], with slightly modified descriptions.

the employer for appropriate work accommodations), the evidence across multiple studies is quite good. For other interventions targeting more specific RTW issues, the evidence is still insufficient and they have not become part of recommendations in existing clinical practice guidelines (following stateof-the-art evidence-based principles of clinical guidelines). However, primary care physicians need to become aware of their potential role in reducing disability duration and in increasing patient’s chances for successful work resumption. A recent European report on musculoskeletal disorders that affect working life concluded that, for back pain, a combination of optimal clinical management, a rehabilitation programme and a number of workplace interventions is more effective than single elements alone [74]. This report also highlights that temporarily modified work (a type of workplace-centred intervention) is an effective RTW strategy for LBP patients in sick leave, but only if it is embedded in a programme of occupational health management [74]. This argument is mainly based on the idea 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. Working in collaboration with the employer to create work-accommodation options is an important feature of all well co-ordinated clinical management programs for back pain with long sickness absence (>12 weeks) [33]. New studies on RTW co-ordination (an approach that proposes the coordination to be done by one highly qualified individual) bring new hope for cost-effective RTW for sub-acute and chronic back pain patients. The RTW co-ordinator is a key player in keeping a focus on the workplace and mobilising the necessary resources that can facilitate RTW [75]. This new approach has been implemented mainly in Canada, the USA and Australia with great success so far. Further research is needed across different jurisdictions and to better define how coordinators can work in close partnership with primary care physicians. Summary The rise in the cost and volume of worker compensation claims, associated litigation measures and indices of poor quality of working life associated with persistent or recurrent back pain all suggest

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a need for a radical shift in perspective and approach to its clinical management. Medical practices rely on a collaborative and direct relationship between doctor and patient in terms of health–illness and well-being issues. However, when the patient is temporarily unable to work, doctors need to consider the role of other parties in the picture, especially the employer. In some cases, prompt RTW may depend on close collaboration with employers and with other stakeholders, including insurance representatives. The optimal clinical approach includes reassurance about activity and work, a more individualised understanding of the patient’s work context and, when necessary, closer contact with the workplace in order to facilitate the RTW process. These actions can be part of an integrated effort that appropriately focuses more on preventing work disability, rather than focussing on mitigating the causes of pain. Unfortunately, some practice guidelines – the main reference doctors have for best practice – still place their central focus on pain management and have only incorporated generic recommendations on reassurance, managing illness and preventing work disability. Other resources suggest specific ways to broaden the primary care physician perspective and role, while acknowledging that many of the barriers to effective disability prevention practice lie outside of the clinical realm. These barriers can only be addressed through broader systemic changes – in the workplace, health insurance system and medico-legal systems [31,67]. Prevention of work incapacity associated with back pain is challenging due to the fluid interplay of personal and environmental factors and dynamics between systems, but there are extensive opportunities to promote healthy and productive work life, and to reduce the burden of back pain. What we know today about work influences and workplace interventions might not provide all the necessary answers for effective prevention of back disability. Nonetheless, it is now reasonable to suggest that primary care physicians and other health-care providers can begin to support workplace-related preventive strategies – if properly considered at an early stage of the disablement process – and develop a closer liaison with the workplace when necessary. This might be more feasible than it seems at first glance, as more workplaces are themselves starting to welcome this new clinical approach to reduce the burden of work disability [44,62].

Practice points  Addressing issues of work disability is a central role of the treating physician in many illnesses, including LBP. Therefore, physicians should become familiar with the issues involved in RTW and disability prevention.  Providing positive reassurance regarding staying active and resuming work is an important work disability prevention strategy.  Well-designed and tested questionnaires are available to help identify-early on-work-related factors for preventing prolonged work disability. Even if physicians are not familiar with them, these instruments can suggest interview questions (well supported by scientific evidence) in clinical encounters.  Physicians can make better judgements about RTW when they obtain information from the workplace on actual job demands, including available accommodations.  Physicians need to become familiar with the benefits of a clinical approach that addresses workplace-related issues, and should refer patients to programmes offering workplace interventions as early as possible, especially when there is an increased risk for work disability or when work absences are prolonged.  Despite cumulative knowledge on a number of workplace predictors, a patient’s own expectations of RTW constitute the most important predictor of work-disability outcomes, and the rationale behind these expectations can be an excellent starting point for discussions about facilitating RTW.

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Research agenda  The existing evidence-based recommendations for clinical management today are limited in terms of presenting informed recommendations to physicians on work issues and helping them to create a closer liaison with the workplace.  There is a need for high-quality studies (including randomised controlled trials (RCTs)) to further evaluate the effectiveness of specific workplace interventions for prolonged work disability (>12 weeks) due to chronic or recurrent back pain.  Determinants of work disability are often not evaluated early on; they can change over time and can be influenced by actions and belief systems of the involved stakeholders. More research is needed to clarify how to best evaluate these factors and how to intervene to improve outcomes.

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