Prevention and Management of Occupational Related LBP
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Search Strategy[edit | edit source]
- Databases Searched: CINAHL, PT Journal, JOSPT, Google Scholar, Cochrane, Medline, NIOSH
- Key Terms: 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, occupational health physician
- Dates Searched: April 6, 2011 to May 1, 2011
Definition/Description[edit | edit source]
IN PROGRESS: In 2009, the United States Department of Labor reported that the back was injured in nearly 50% of all musculoskeletal disorder cases and required a median of 7 days to return to work. It is also reported that in the United States approximately 100 million days are lost from work per year because of low back pain (Makhsous et al 2003). Acute pain is typically pain present in the first month whereas chronic pain usually presents longer than 3 months (Poitras 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).
Epidemiology /Etiology[edit | edit source]
Approximately one-third of American workers are at increased risk of developing back disorders secondary to their jobs (Lis et al 2007). The United States Department of Labor reported back pain to be the leading event or exposure to those working as nursing aides, orderlies, attendants, laborers and freight, janitors, cleaners, and most all trunk drivers ranging from 44.9 to 59.2% of total injuries of all musculoskeletal diseases (Osha). According to Chou et al., (2007) approximately 2% of the U.S. work force compensated for back injuries each year resulted in tremendous indirect costs related to time lost from work.
One of the most commonly cited risk factors of occupational related LBP is sitting. Other risk factors may include 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, Murtezani).
According to Shaw et al., back disability is highly associated with seven variables:
1. Work that involves heavy physical demand
- Bending, lifting, pushing, or pulling heavy objects for a long period of time at work
2. Inability to modify work
3. Stressful work demands
- Time pressure, productivity demand, and inability to control the speed of work
4. Lack of workplace social support
- Isolated work environment, unusual working hours, new place of employment, recent departmental transfer, past conflicts with coworkers/supervisors, or difficulty developing social ties in the workplace
5. Job dissatisfaction
- Unrewarding few prospects for transfer or advancement
- Overall discontent for the job
6. Poor expectation of recovery and return to work
7. The fear of re-injury
Characteristics 4 and 5 have also been confirmed by Waddell et al. as psychosocial aspects that contribute to increased time off work.
Characteristics/Clinical Presentation[edit | edit source]
There are four typical presentations of mechanical (nonspecific) LBP, which are defined by the Treatment-based Classification (TBC) system.
(Fritz et al.)
Differential Diagnosis[edit | edit source]
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). Other factors that are less severe, such as those who are pregnant, have fibromyalgia or myofascial pain syndromes, osteoporosis, or use steroids, may be at risk for experiencing LBP (Chou et al. 2007). Therefore, it is important for clinicians to determine if the patients' pain is mechanical or resulting from an underlying cause.
Examination[edit | edit source]
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) Impairments can be measured in the history and physical examination. Pain is measured with Visual Analog Scale, disability is measured with the Oswestry Disibility Index (ODI), and psychosocial factors is measured with Fear Avoidance Believe Questionnaire (FABQ).
Impairments :
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 an 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 yield measurements with some reliabitly and validity (Sp = .92, +LR = 4.59).
Medical Management (current best evidence)[edit | edit source]
IN PROGRESS:
A multidisciplinary team of occupational health professionals exists in order to provide the best care possible for patients experiencing illness and/or injury related to their work. The role of occupational physicians is of importance because they have to be able to manage patients with occupational-related low back pain in order to return them to work in a timely manner. However, this remains a challenge for these physicians. (Verbeek JH)
According to the Occupational Safety & Health Administration (OSHA), occupational health care physicians work closely with employers in order to assist in achieving a safe and healthy work environment. They also work collaboratively with labor and management to reduce/prevent hazardous situations as well as create training programs to implement workplace health and safety.
PHARMACOLOGICAL
Chou stated that a medication does not exist to show results in large average benefits on low back pain.
Physical Therapy Management (current best evidence)[edit | edit source]
Educating patients with occuputional LBP during treatment can impact the recovery time allowing patients to return to work within a reasonable time frame. Participants in the Godges et. al. study were unable to return to work due to a work-related injury of low back pain and had to score 50 points or 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 assist in reducing FABQ and disability in those with actue LBP. Education and counseling regarding pain management, physical activity, and exercise can reduce the number of days off work in this population with elevated fear-avoidance beliefs and acute low back pain. (Godges et. al.).
PREVENTION
The National Institute for Occupational Safety and Health (NIOSH) compiled a review of scientific literature and concluded a lack of evidence for supporting or recommending use of back belts to prevent injuries. A systematic review by Ammendolia et al. provided additional 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.
Sitting has become the most common posture in the workplace in the United States and approximately three-quarters of all workers in industrialized countries have jobs that require sitting for long periods (Lis et al 2006). Many biomechanical studies have been performed to determine the effects on the low back in sitting. Though there is some debate, one common finding is that intrathecal pressure is increased in the seated posture and aggravates discogenic LBP (Lis et al 2006 and Makhsous et al 2003). Another finding reported is during sitting high pressure is found at the ischial tuberosities which is associated with high load to the spine (Makhsous et al 2003). OSHA suggests for a computer workspace there are four things to look at regarding the chair to prevent low back pain. These four suggestions are backrest, seat, armrest and the base. The back rest should have a lumbar support. Chairs without lumbar support can use a rolled up towel or a removable back support to provide the natural curve of the spine. The seat should be adjusted to where your feet are flat on the ground and slightly higher than the seat of the chair. A stool can be used as a footrest to provide a stable support for the feet. Armrest position should support the lower arm and elbow to allow the upper arm to be close to the torso, if the armrest is not adjustable, remove them. The base of the chair needs to have a strong, five-legged base. Chairs with four or few legs provide insufficient support and prone to tipping. Makhsous et al confirmed that sitting with decreased ischial support and back support reduced peak pressure under the tuberosities, reduced muscular activity, maintained proper lordosis, increased intervertebral disc heights, which could potentially reduce low back pain.
Key Research[edit | edit source]
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IN PROGRESS:
http://www.osha.gov/
http://www.bls.gov/iif/
Resources
[edit | edit source]
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Clinical Bottom Line[edit | edit source]
Occupational related LBP can be prevented and managed approriately if a multidisciplinary approach is utilized and can address an individuals' impairments, pain, disability and psychosocial factors. By addressing these factors, workers' compensation claims can be reduced, as well as days absent from work. Treatment targeting workplace functional concerns, activity avoidance, and adherence to an appropriate intervention, including educational and physical factors, are key to improving an individuals' return-to-work goals (Shaw, 2011).
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References[edit | edit source]
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