Authors: Brian Anderson DC, CCN, MPH and David Radford DC, MSc
In the first article of this series, we discussed the huge impact Occupational Low Back Pain (OLBP) has on both employers and employees. The statistics on prevalence and disability due to OLBP cannot be ignored. In part two, strategies that employers can take which may prove effective in reducing the burden of OLBP were discussed. Now, in the final article of this series, we will discuss the all-important topic of treatment options for those suffering from OLBP.
There are a few variables related to the treatment low back pain (LBP) that make it particularly challenging. First, it is estimated that approximately 80% of LBP is non-specific, which means there is no well-defined cause. Second, imaging studies (x-ray, MRI) are not particularly helpful in determining those with LBP vs. those who are asymptomatic. A 1994 study in the New England Journal of Medicine concluded, “Given the high prevalence of these findings and of back pain, the discovery by MRI of disc bulges or protrusions in people with low back pain may frequently be coincidental.” Another source states that “The false positive rate for identifying clinically significant herniated discs or degenerative conditions with imaging is so high as to make the tests clinically inappropriate as screening procedures”. Unfortunately, the “biomedical model” employed by the majority of the medical community is dependent on diagnosing an abnormality on an imaging study, and treating this abnormality with medications, rest, injections and surgery. (WCxKit)
What we are recommending, and what the current literature is supporting, is a “bio psychosocial” approach to treating LBP. This model recognizes that the experience of pain has many components, and that all these components must be addressed for long term healing. Patients with LBP experience what is called fear-avoidance behaviors; they anticipate worsening of symptoms with certain activities or movements. This anticipation sets up a vicious cycle, which goes something like this
fear of painàactivity avoidanceàdeconditioningàacute tissue overloadà chronic sensitization to pain
Those LBP sufferers with “yellow flags” must get involved in a bio psychosocial program very early on, or are at high risk for developing chronic pain syndromes. These yellow flags are included.
- · radiating (travelling) pain
- · poor self-rated general health
- · anxiety/depression
- · self-perceived inability to control symptoms
- · self-perceived inability to perform normal activities
People with LBP must be educated that hurt does not equal harm; in other words, they should continue to participate in normal daily activities even if there is some pain during these activities. Patients with acute LBP may experience some benefits in pain relief and functional improvement from advice to stay active compared to advice to rest in bed.
In an ideal situation, a treatment team would be developed to deal with OLBP. This team would consist of: a return to work coordinator; an occupational health provider (MD or nurse); a health psychologist; a Chiropractic Physician; a Physical Therapist; and a Physiatrist/Neurosurgeon/Orthopedic surgeon for possible consultation. We are suggesting that all cases of OLBP be triaged by the occupational health provider and automatically referred for consultation with a Chiropractic Physician, due to their unique expertise dealing with this particular condition. This scenario would no doubt save countless healthcare dollars by preventing unnecessary imaging studies, medication use and interventional procedures such as injections and surgery.
Regarding conservative treatment of LBP, very high quality evidence exists that supports various treatment modalities. Below is a review of some of this research.
- · There is good evidence that cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation are all moderately effective for chronic or sub acute (>4 weeks’ duration) LBP
- · Fair evidence that acupuncture, massage, yoga, and functional restoration are also effective for chronic LBP
- · For acute LBP (<4 weeks’ duration), the only non-pharmacologic therapies with evidence of efficacy are superficial heat and spinal manipulation
- · There is moderate quality evidence that post-treatment exercises can reduce both the rate and the number of recurrences of back pain.
- There is moderate scientific evidence showing that multidisciplinary rehabilitation, which includes a workplace visit or more comprehensive occupational health care intervention, helps patients to return to work faster, results in fewer sick leaves and alleviates subjective disability.
- Spinal manipulation was more effective in reducing pain and improving the ability to perform everyday activities than sham (fake) therapy and therapies already known to be unhelpful. It was no more or less effective (but no doubt less costly) than medication for pain, physical therapy, exercises, back school or the care given by a general practitioner.
Significant evidence also exists suggesting that invasive treatments, such as injections and surgery, are questionable treatment options for most patients. (WCxKit)
- There is no strong evidence for or against the use of any type of injection therapy for individuals with sub acute or chronic low- back pain.
- There is serious lack of scientific evidence supporting surgical management for spinal arthritis
- There is no acceptable evidence of the efficacy of any form of fusion for spinal arthritis, back pain or instability
- 38% of surgeries performed in two university based neurosurgical units were prospectively evaluated and were determine to be inappropriate
As mentioned in the opening of part I of this series, employers are unlikely to find another issue that leads to more absenteeism and detracts from productivity in the workplace more than OLBP. We hope that, after this three part series, readers are more educated as to how to prevent and treat this serious issue. We encourage safety managers and coordinators of care to consider a comprehensive approach to dealing with OLBP. For further information or questions, please contact the authors.
Dr. Anderson works as a supervising clinician and instructor at National University of Health Sciences in Lombard IL. He has been in private practice, as well as part of a team in a University based Integrative Medicine setting. In addition, Dr. Anderson has experience in the medico-legal field, serving as an expert for various insurance companies and legal firms. He earned a Masters Degree in Public Health, as well as a Certified Clinical Nutritionist designation. He is currently working toward a specialty diplomate in Functional Rehabilitation. Contact Dr. Anderson for more information at banderson@nuhs.edu
Dr. Radford is in private practice. He is a third generation Doctor of Chiropractic Medicine. He earned a Master’s Degree in Advanced Clinical Practice and he provides conservative primary care. He has treated work related injuries for more than 30 years. Dr. Radford has found that treating the co-morbidities that often accompany injured workers like obesity, medication overuse, and addiction lead to a more complete recovery. He was a founding member of the Cleveland Orthopaedic and Spine Hospital, Cleveland, Ohio. Contact for more information at DCR8888@aol.com or phone: (440)-248-8888.
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