Prevention and Management of Occupational Related LBP

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Original Editors

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Search Strategy

• Databases Searched: CINAHL, PT Journal, JOSPT, Google Scholar, Cochrane, Medline
  
• Key Terms: low back pain, prevention of LBP, prevention of low back pain, management of LBP, management of low back pain, management of occupational related LBP, occupational related low back pain, occupational related LBP, work related LBP, work related low back pain
  
• Dates Searched: April 6, 2011 to April 20, 2011
  

Definition/Description

IN PROGRESS: Back pain is the second leading cause for all physician visits (Deyo, 1996) and approximately 80% of the population will experience it at some point in their lifetime (??? et al).

Work-related low back pain (WRLBP) is a major cause of work absenteeism and accounts for a high proportion of occupational disability costs (Poitras et al.).  Workers' compensation claims account for 70% of all compensation costs. Suprisingly, this percentage only accounts for 7% of all LBP cases.  Another important factor associated with WRLBP is the psychosocial element.  In people with acute WRLBP, the individual opinion on whether or not they would return to work was most predictive of who would be off work for 4 weeks after the onset (Godges et al, 2008). 

The greatest psychosocial predictor of prolonged work restrictions is the work subscale of the Fear-Avoidance Beliefs Questionnaire (FABQ) with a negative likelihood ratio (-LR) of 0.08 for scores less than 30 and positive likelihood ratio (+LR) of 3.33 for scores greater than 34 (Fritz et al 2002). The FABQ is used to quantify the level of fear of pain and beliefs about the need to change behavior to avoid pain in individuals with LBP (Fritz et. al 2002).  Acute pain is typically pain present in the first month whereas chronic pain usually presents longer than 3 months (Poitras et al).

Epidemiology /Etiology

Approximately 1/3 of American workers are at increased risk of developing back disorders secondary to their jobs (Lis et al 2007). One of the most commonly cited risk factors of occupational related LBP is sitting along with heavy physical work, heavy or frequent lifting, combined postures with rotation and flexion, pushing and pulling, and exposure to whole body vibration (WBV) such as motor vehicle driving (Lis et al 2007).

According to Shaw et. al., back disability is highly associated with 7 variable:work that involves heavy physical demand, inability to modify work, stressful work demands, lack of workplace social support, job dissatisfaction, lack of work social support, job dissatisfaction, poor expectation of recovery and return to work, and the fear of reinjury. Heavy physical demands includes bending, lifting, pushing, or pulling heavy objects for a long period of time at work. Workers that have stressful jobs involving time pressure, productivity demand and the inability to control the speed of work could associated with a prolonged recovery. The lack of a workplace social support can be a result from an isolated work environment, unusual working hours, new place of employment, a recent departmental trasfer, past conflicts with coworkers or supervisors or difficulty developing social ties in the workplace. Job dissatisfaction could be a contribution to unrewarding, few prospects for transfer or advancement and an overall discontent of the job.

Characteristics/Clinical Presentation

There are 4 typical presentations of mechanical (nonspecific) LBP

Image:Fritzclassificationchart2_(2).JPG

(Fritz et al)

Some common characteristics related to potential occupational related LBP are jobs that require:

• Manual lifting of items >25kg
• Extreme or very extreme trunk flexion very extreme trunk flexion
• Exposure to whole-body vibration
• Static work postures i.e. sitting or standing for long periods of time
• Uncomfortable working positions

(Murtezani et al 2010)

There are also psychosocial aspects that contribute such as:

• Low job satisfaction
• Unsatisfactory psychosocial aspects of work

(Waddell, 2000)

Differential Diagnosis

IN PROGRESS: The differential diagnosis of low back pain can often times be difficult. The cause of low back pain can stem from a number of conditions including cancer, spinal infection, ankylosing spondylitis, cauda equina syndrome, compression fracture, symptomatic spinal stenosis, or herniated disc with radiculopathy. It can also be caused by referred pain from several internal organs (Chou).

Examination

IN PROGRESS: According to Fritz et al., measurements of impairments, pain, disability and psychosocial measures should be assessed to determine the appropriate intervention. (Fritz, 2)

Wong et, al,. developed a screening tool to assess trunk control  while performing a simple movement to predict the chances of the occurance of LBP. The active hip abduction (AHAbd) test provides a general assessment of a n individual's ability to maintain trunk and pelvis alignment during lower extremity movement when placed in an inherently unstable position. The AHAbd test has been tested in groups without LBP and has shown to yeild measurements with some reliabitly and validity (Sp = .92, +LR = 4.59).

Medical Management (current best evidence)

IN PROGRESS:

PHARMACOLOGICAL

A systematic review by Roelofs et al. analyzing pharamacological interventions concluded that there is strong evidence that those using non-streroidal anti-inflammatory drugs (NSAIDs), especially COX-2 NSAIDs, are receiving equally as effictive of an intervention than those eceiving non-drug therapies. On the contrary, Chou stated that a medication does not exist to show results in large average benefits on pain. Evidence is also lacking on the beneficial effects of medication on functional outcomes.  He also notes that medications are beneficial for helping patients get through the acute phase, but that medication does not alter the natural course of LBP.

Physical Therapy Management (current best evidence)

The Treatment Based Classification system developed by Delitto and colleagues is used to classify those with LBP into either manipulation, stabilization, repeated exercise, or traction subgroups to better allow for homogenous subgroups based on impairments. (Fritz 2) Focusing on pain reduction, increasing range of motion, strength, reducing muscle tension, and educating the worker are all treatment focuses that should be considered for appropriate management of the patient. (Poitras et al. 8)  A PT intervention should differ from a physicians' by identifying job tasks that are problematic, thinking of ways to modify those tasks, and assessing the workplace's expectations in order to best help the client consider available alternatives or modifications that may need to be implimented (Shaw et al. 4).

Educating patients with occuputional LBP during treatment can impact the recovery time allowing patients to return to work quicker.  Participants in the Godges et. al. study were unable to return to work due to a work-related injury of low back pain had to score 50 points of higher on the Fear- Avoidance Beliefs Questionaire were alternately assigned to a comparison group or an eductional group. The educational group was given the educational booklet Back Pain: How to Control a Nagging Backache that emphasized the importance of staying active, not letting the back pain control your life, understanding the pain cycle, gettting the pain under control, and how exercise and relaxation can help control pain. According to George et. al., The Back Book is another educational pamphlet that has the potential in reduce FABQ and disability in people with actue LBP. Education and counseling regarding pain management, physical activity, and exercise can reduce the number of days off work in people with fear-avoidance beliefs and acute low back pain. (Godges et. al.).

PREVENTION

A systematic review by Ammendolia et al. provided evidence from a combination of observational studies, clinical trials, and RCT's indicated limited benefits of using a back belt unless the worker presents with a prior history of LBP. Laboratory evidence suggested that if prescribed, back belts should only be used short-term due to possible adverse effects such as cardiovascular complications.

Key Research

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Resources

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Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

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