The American Family Physician, a peer review journal of the American Academy of Family Physicians, recently published an article entitled Nonspecific Low Back Pain and Return to Work authored by Drs. Nguyen and Randolph on November 15, 2007. This peer reviewed article is designed for family practice physicians treating injured workers with nonspecific low back pain. The article can be found at www.aafp.org.
The article’s objectives are to encourage conservative care in patients with occupational non-specific low back pain; that is, pain occurring predominately in the low back without neurologic involvement or serious pathology. Specifically, the article promotes early return to work while preventing prolonged disability. These are the same objectives expressed by the former and current Medical Advisors of the Texas Department of Insurance, Division of Workers’ Compensation.
The article reviewed the current state of medical literature regarding low back pain in an occupational setting. As epidemologists, the doctors sought an outcome-focused and scientifically valid opinion resulting in a consensus from the newest and best medical literature.
According to the U.S. Bureau of Labor and Statistics, there are 4.2 million non-fatal occupational injuries and illnesses reported by private industries in 2005. This number does not include federal, state, and local governmental agencies. Nationally, workers’ compensation covers 127 million U.S. workers. The estimated annual cost for low back pain can vary from $20 billion to $50 billion. Annual productivity lost from missed work days are estimated to be $28 billion.
The ever increasing cost of back pain in the occupational setting is not a static figure. From 1991 to 2001, individual indemnity and medical costs increased by 39% and 62% respectively. Increased costs are not predicted by the significant decreases in both rates of injuries and number of lost work days. Nationally, there is an increase in medical costs generally. Such an increase in reimbursements to medical providers effects all forms of injuries, whether occupational or not.
Unfortunately, statistics show the workers’ compensation patients experience more office visits, hospital admissions, treating physicians, diagnostic referrals, and therapeutic procedures. Despite the increased medical attention, injured workers receive longer duration of care compared with patients covered by other forms of insurance.
The article identified red flags which include the following: drug or alcohol abuse, fever, genitourinary difficulties, history of malignancy, immunocompromised status, long history of steroid usage, lower extremity weakness or numbness, major trauma, osteoporosis, pain at rest, suspected ankylosis spondylitis, and worsening neurologic symptoms. Strong risk factors include psychosocial variables, such as depression, education level, excessive pain level, fear avoidance, job dissatisfaction, legal representation, somatization disorder, unemployment and workers’ compensation involvement. In fact, strong evidence exists that personal occupational psychosocial variables play a more important role than spinal pathology or the demands of the job. The strongest predictor of future low back pain is a history of such pain.
Ten percent of patients who develop chronic low back pain (lasting more than three months) account for 65% to 85% of the total costs. Therefore, the question for medical providers (and other stakeholders) is proper behavior to encourage early return to work which reduces medical costs and increases functionality of the injured worker.
The article also addresses imaging studies. The authors state, “There is strong clinical evidence that radiography and magnetic resonance imaging (MRI) findings do not correlate with clinical symptoms of nonspecific low back pain or a patient’s ability to work. MRI and other imaging studies should be reserved for patients with radicular symptoms who fail conservative care and those with worsening neurologic findings, objective weakness, uncontrolled pain, or suspected cauda equina syndrome.” An MRI is a useful diagnostic tool. It is a snap shot of the claimant’s spine but does not give any evidence as to whether or not any of the suspected conditions are causing pain or is reflective of an injury. MRIs are often used to justify surgery. Impairment ratings calculated in accordance with the AMA Guides, Fifth Edition, largely rely upon MRIs alone without any context.
The authors review of medical literature predictably recommends analgesic and anti-inflammatory medications, massage, exercise, and patient education. The effectiveness of accupuncture, epidural steroid injections, muscle relaxants, spinal manipulations, transcutaneous electrical nerve stimlulation, trigger point injections, heat therapy, and therapeutic ultrasound are unclear. The authors do not recommend electromyography biofeedback, shortwave diathermy, botox injections, facet injections, prolotherapy, tractions, or lumbar braces and support. Bed rest is limited to two days. Patients are encouraged to remain as active as possible including exercise conducted under the supervision of a therapist three to five times per week as a first-line therapy treatment. Passive modalities should decrease in favor of active modalities with home exercise initiated in the first therapy session. After two weeks or six visits, the patient’s therapy status should be reassessed. If there is no improvement, other factors should be considered. Surgeries for nonspecific low back pain are not recommended.
Return to work is an important component in assessing the medical success of an injured worker. In fact, the authors note, “It is not necessary for the patient to wait until all pain is eliminated before returning to work.” The authors stress that remaining at work or returning to work does not increase the risk of reinjury. Instead, return to work helps decrease missed work days, chronic pain, and disability. Therefore, work absences should be brief and avoided to prevent chronicity.
The authors do recommend a multi-disciplinary rehabilitation for workers who have difficulty returning to the job after four to twelve weeks. The multidisciplinary team consists of a physician, physiotherapist, and a psychologist. Some cognitive behavior therapy has been successful in returning injured workers to work sooner. However, work hardening is ineffective.
Physicians should encourage early return to work for the benefit of the injured worker. There is a 40% chance a worker will miss work for the entire year if the person misses four to twelve weeks of work. It is highly unlikely a worker will ever return to work regardless of treatment if he has not returned to work within two years.
Therefore, stakeholders should utilize all resources to return injured workers to work as quickly as possible in all cases including nonspecific low back pain. It is in everyone’s best interests to carry out effective medical treatment to return injured workers to work as quickly as possible. Modalities should be chosen based upon strong clinical evidence as opposed to the type of treatment given by a doctor/physician provides in the usual course of his or her practice. Employees, employers, health care providers, and carriers should ensure appropriate medical treatment is provided to injured workers to encourage return to work as quickly as possible.