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Risk factors associated with the development of long-term back pain and the appropriate interventions

At a glance:
In some cases, back pain can lead to a long-term disability. Many of the treatments for back pain reduce the risk of this happening. Identifying specific risk factors for an individual with back pain and customising their treatment might reduce their risk of disability.
Back pain has two main consequences. It causes pain, and it limits function, or causes “disability.'

Medical treatment can reduce pain, but other factors play a greater role in the level of function a person can maintain.

In the early stages of back pain, muscle spasm and intense pain may occur. In these circumstances people can have difficulty with basic movements. This is called a medically necessary disability. With time, the acute
A condition develops quickly and is often of short duration. The opposite of acute is chronic, which refers to a long term problem continuing for months to years.
 muscle spasm improves, but people can be worried about their back and keep on avoiding activity. This is understandable, however, it results in a less successful recovery. This is called medically unnecessary disability.

The authors of this paper suggest that we should help people manage their fear and concerns and become more active. Being overcautious can lead to a “vicious cycle' of avoidance, fear, reduced fitness and limited activity.

If you don't fully understand your condition, or you worry that doing certain activities will cause damage, talk to your treating practitioner. Make sure you have a clear picture about activity and back pain, and how fear can affect the situation.

There has been a revolution in the way back pain is managed during the last 20 years. Talk to your doctor and make sure you can get the best information about your problem.
A range of factors influence the return to work of a person with back pain. When they are distressed and have serious concerns about activity it can produce negative outcomes.

Although many activities cause back soreness, they do not usually do harm. Help your employee get the best information. Interventions found to improve return to work outcomes are:

Early contact between the workplace and the treating practitioner
Supervisor training and support
Communication between employee and employer
Exercise programs

Employers can sometimes be frustrated at the slowness of recovery from back problems. However this study shows employers can make a major difference to the time off work by implementing a system that fosters communication and partnership, particularly through a supervisor with adequate return to work training.

Job modifications and examining the workplace ergonomics can also help a person return to work.
Treaters deal frequently with patients' emotions, fears, and concerns. Returning to work with back problems can be impeded by mistaken beliefs and misunderstandings about the condition. Some studies suggest that treating practitioners
treating practitioner
A health professional that treats patients. In return to work this may include doctors, physiotherapists, chiropractors, osteopaths, psychologists, masseurs, etc.
 are “fear avoidant'.

Treating practitioners no longer recommend rest, but people are often told to avoid certain activities. In contrast, avoiding activity altogether can cause long-term problems. A person may ultimately lose their job and suffer financial consequences, placing strain
Injury to a muscle in which the muscle fibres tear or become irritated as a result of overstretching or wrenching
 on the rest of the family and the individual's psychological
Refers to a person's perceptions, thought processes, emotions, personality and behaviour. Psychologists can treat mental health problems.

Positive and up-to-date information can make a difference. It can reduce the level of fear, activity avoidance, and improve function.
This review looked at risk factors for the development of long-term back pain, and the interventions that are commonly used to prevent it.

Educating people about staying active, and improving their problem-solving and coping skills, reduces the risk that they will develop a long-term problem.

It is worth talking to the individual about their back problem and understanding their risk factors. These may include their level of employer support, the availability of modified duties, and the individual's fears and worries about their back problem. Interventions to deal with these specific risk factors are encouraged.

The workplace also plays a significant role in return to work outcomes. Encourage employers to communicate early with the employee, and to ensure supervisors are trained in return to work management. A simple phone call that enquires about the person's well being can make a significant difference to the outcome.
Original Article, Authors & Publication Details:
W. S. Shaw1,2, S. J. Linton3 and G. Pransky1,2 (2006).

Reducing sickness absence from work due to low back pain: How well do intervention
A treatment or management program. Interventions often combine several approaches. In this field approaches include training in problem solving, adaptation of work duties, graded activity, an exercise and stretching program and pain relief.
 strategies match modifiable risk factors?
Journal of Occupational Rehabilitation; 16:591-605

1Liberty Mutual Research Institute for Safety, Center for Disability Research, 71 Frankland Road, Hopkinton, MA 01748, USA
2Department of Family Medicine & Community Health, University of Massachusetts Medical School, Worcester, MA, USA
3Department of Occupational and Environmental Medicine, Örebro University, Department of Behavioral, Social and Legal Sciences—Psychology & Örebro Medical Center Hospital, Örebro, Sweden
Background, Study Objectives, How It Was Done:
Low back pain is a common cause of suffering and work disability. 85% of workers will have back pain at some point, and 10% experience long-term problems.

The early provision of appropriate treatments helps to prevent low back pain from becoming a long-term problem. This study reviewed what risk factors influence the development of a long-term disability, and which treatments are effective to reduce these risk factors.

A variety of interventions are used to treat back pain and reduce the risk of disability. Some interventions target the workplace, such as reducing the physical demands of the job and increasing support from supervisors and workmates. Some, such as counselling, education or physical training, try to help the individual. Other interventions are aimed at improving medical care.

The authors of this study reviewed recent research into the risk factors for disability
A condition or function that leaves a person unable to do tasks that most other people can do.
 due to back pain, and the interventions that help people return to work. They then evaluated whether or not the different treatments specifically addressed the risk factors. They examined the results of 17 other studies that had reviewed and summarised research papers on disability risk factors and interventions. All of those reviews were published between 2000 and 2005.
Study Findings:
The authors looked at whether risk factor and interventions that made a difference were found consistently across the studies.

The consistent risk factors associated with development of long-term lower back pain are:

Workplace factors

a) Physical demands

i. Fast work pace
ii. Heavy physical work

b) Social and management factors

i. Low social support
ii. Lack of control
iii. Short-term/temporary work
iv. Lack of modified tasks to do, to adjust for the injury
v. Delays in reporting the injury

c) Patient's perceptions of work

i. Job dissatisfaction
ii. Repetitive work
iii. Job stress
iv. Belief that work is dangerous
v. Emotional effort of work

d) Individual factors

e) Behaviour

i. The patient believing that they have a disability
ii. Fear/avoidance of activities that might cause pain
iii. Pain behaviour

f) Mental factors

i. Pain intensity
ii. Conversion of anxiety into physical symptoms (“somatisation')
iii. Making pain into a catastrophe (“catastrophising')
iv. Low expectations of returning to work
v. Poor rating of general health

g) Emotion

i. Distress
ii. Depressed mood
iii. Anxious mood

The interventions that are effective in preventing disability from low back pain are:

1. Personal interventions

a) Physiotherapy together with cognitive
relating to the mental processes of perception, memory, judgment, and reasoning
 behavioural therapy
b) Cognitive behavioural therapy
c) Physical exercise
d) Strength training
e) Light activity
f) Gradually increasing activity
g) Reassurance from a health care provider
h) Advice on self-management
i) Problem solving
j) Coping skills
k) Changing the way the patient thinks about their injury
l) Education about the injury
m) Relaxation training
n) Stress management

Gradually reintroducing activity, improving coping skills and reducing fear decreases mental and behavioural risk factors (such as perceived disability, catastrophising the problem and avoiding pain.)

2. Workplace interventions

a) Having a return to work co-ordinator
b) Early contact between doctor and employer
c) Early discussion between worker and employer
d) Supervisor training and support
e) Public information
f) Workplace exercise programs

Improved communication and training reduces workplace social and management risk factors (such as low social support and lack of control at work).

3. Technical, engineering or ergonomic
Designing activities and the workplace in a way to minimize discomfort. i.e. Adapting work tasks, hours, or workstation to accommodate people. An ergonomic computer workstation allows the person to work in the best position to relieve load on the muscles of the neck and arms.

a) Accommodation of injury within the workplace
b) Modified work duties
c) Good design of the workspace to minimise strain/injury

Changing the layout or procedures in the workplace reduces the physical risk factors for disability.

Most interventions try to help the individual reduce distress,
Severe suffering, pain, anxiety or sorrow
 increase physical activity and manage their own pain.

Although emotional risk factors increase the risk of disability, few interventions are aimed at improving mood symptoms (distress, depression
A symptom of mood disorder characterized by intense feelings of loss, sadness, hopelessness, failure, and rejection. Major depression is likely to interfere significantly with everyday activity, with symptoms including insomnia, irritability, weight loss, and a lack of interest in outside events. The disorder may last several months or longer and may recur, but it is generally reversible in the short run.
 and anxiety.)

Lack of medical understanding may also be a risk factor. Educational programs may help by providing social support, encouraging self-management or teaching coping skills.
Back pain can lead to long-term disability. There are a number of risk factors that increase the likelihood of this happening.

Interventions and treatments for back pain can reduce some of these risk factors. For example, gradually introducing exercise after an injury reduces risk factors like inactivity, avoiding pain and believing that one has a disability.

One way to reduce the risk of disability could be to identify the risk-factors that a person has, and then choose treatments that address these risks. This approach has not been tested yet.

The study's authors suggest that screening for risk factors could divide patients with back pain into three groups, with different interventions for each group:

Risk factor category Characteristics of people in this category Possible interventions to reduce the risk of long-term disability for these people
Patients who are immobilised Patients who:

- Show fear and avoid pain

- Make pain a catastrophe

- Are not able to function well physically

- Have poor expectations about recovery

- Graded activity

- Exercise

- Physiotherapy

- Changing belief about pain
Patients with problems at work Patients who have:

- High physical job demands

- Poor employer support

- No modified duties

- A short-term contract or temporary position

- Increase workplace support

- Assess the worksite for possible changes in the layout or procedures

- Modify work duties
Patients who are overwhelmed Patients with:

- Mood symptoms (distress, anxiety, depression)

- Work stress

- Fears and worries

- Training in problem solving and coping skills

- Stress management

- Cognitive behaviour therapy
PubMed Abstract
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