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Cultural shift necessary in low back pain beliefs
Expert offers evidence that a shift is possible, discusses guidelines to push return to work.
Low back pain and the related time lost from work remain a huge problem in Europe and throughout the world. As some European projects now suggest, however, guidelines and media campaigns that encourage patients to remain active can lead to a more rapid return to work.
One fundamental way to address the overall problem of back-pain-related work loss: have the medical community lead a cultural shift and present low back pain as a common health problem.
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“Common health problems share a number of features [with low back pain]. They have a high prevalence rate in the normal population and, by and large, we can’t determine any permanent impairment,” said Kim Burton, PhD, DO, director of the Spinal Research Unit at the University of Huddersfield, England.
By presenting low back pain to the public in the same spirit as any common health problem, surgeons may be encouraging back-pain patients to return to work sooner. “Most people with [other] common health problems actually … don’t take time off work, and those that do return quite rapidly,” Burton added.
Although evidence exists that preventing many of the consequences of low back pain is feasible, it is somewhat limited, Burton said during the Volvo Lecture at the International Society for the Study of the Lumbar Spine annual meeting. “Even for those interventions that do have some acceptable evidence, the effects are quite modest.”
But now, recent evidence shows that some delivery mechanisms and updated comprehensive guidelines are effective for low back pain management and creating that cultural shift.
Recent evidence
In Victoria, Australia, researchers implemented a population-based public health educational campaign through media advertisements, guidelines and a provision on evidence-based information and advice.
Scotland recently began a similar campaign. Both countries achieved a positive shift in back pain beliefs, and patients and doctors sustained these beliefs after the campaigns ended, Burton said. In Australia, researchers even saw a decline in the number of Workers’ Compensation claims.
In Ireland, researchers implemented health and clinical guidelines in a social security setting, where medical assessors were trained in diagnostic triage and workplace issues to determine whether a patient was fit to return to work.
“Upon receipt of the invitation to come in early for an assessment, 62% of the claimants came off benefits and went straight back to work,” Burton said. “Of those who did come in for their assessments, 64% of them were assessed as being fit for work, whereas previously there was only considered 20% to be fit for work.”
Irish researchers also saw a decrease in the number of filed appeals, as well as the number of successful appeals.
New controlled trial
In the United Kingdom, researchers recently began a controlled trial comparing typical management to an experimental setting. In the experimental setting, occupational health nurses made early contact with workers and invited them into the workplace for a psychosocial assessment.
During the assessment, the nurses identified patients’ recovery obstacles and tried to overcome them using cognitive behavioral theory (CBT) principles and evidence-based information and advice. Most importantly, the nurses worked with family doctors and team leaders during the assessment, Burton said.
Patients who received the intervention package had 40% less return-to-work time and 50% lower risk for future work loss compared to those in the control group.
All of these studies used messages and advice from an evidence-based patient educational booklet called The Back Book, Burton said.
This evidence proves that a cultural shift is possible, but what is necessary for achieving the cultural shift? Burton said all players – including health care professionals, employers and patients – need to follow an established set of strategies, such as the COST (European Cooperation in the Field of Scientific and Technical Research) Action B13 guidelines, to overcome some common obstacles.
Although most people with low back pain recover, some patients have perceptions of themselves and the workplace that keep them from returning to work. Social and occupational perceptions also serve as obstacles, he said.
Patients may have conflicting attitudes, beliefs and expectations about pain and disability, anxiety, fear and avoidance, psychological distress, negative coping strategies or lack of motivation – all of which can stand in the way of recovery.
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Workplace perceptions include “undue stress from the work, the attribution of the problem to the work, doubting one’s ability to return to work, job dissatisfaction and also low social support at work,” Burton said.
Finally, social and occupational obstacles exist – such as benefit entitlement, certification and even obstacles at the company level. For example, some organizations may only allow a patient to return to work when completely pain-free.
COST Action B13 guidelines
Implementing established guidelines is one way to overcome these obstacles. From September 1999 to December 2004, 40 European scientists developed guidelines for managing and preventing low back pain.
“The European [COST Action B13] guidelines are the most comprehensive and the most up-to-date summary of the evidence in this field,” Burton said.
To develop these guidelines, the scientists searched, reviewed and synthesized evidence to provide recommendations in three separate working groups: prevention in low back pain, acute back pain and chronic back pain.
Overall, they came to similar conclusions: physical exercise could reduce sick leave time, occurrence and duration of future episodes. They also found that providing information and education promoting activity and improving coping could also encourage a positive shift in beliefs on low back pain, Burton said.
Treatment recommendations
The working group on acute low back pain developed recommendations for treatment, which encouraged physical activity and discouraged bed rest, medication, muscle relaxants and spinal manipulation.
Similarly, the working group on chronic low back pain found that the most promising approaches revolved around CBT-based approaches that encourage activity and exercise.
“The group considered that surgery [for low back pain] can’t be recommended unless something in excess of 2 years of multidisciplinary approaches have failed to solve the problem,” Burton said.
The scientists also considered ergonomic interventions in the workplace. They recommended temporary modified work to encourage return to work, but noted that ergonomic workplace adaptations alone would not be effective.
Rather, the scientists recommended ergonomics programs that contain both physical and organizational aspects with employee involvement.
“This sort of intervention in a supported network can be effective, but it’s certainly not easy to achieve,” Burton said. “All the players need to be on one side, they need to be talking a common language, believing the same things, coordinating their actions [and] shifting the culture.”
For more information:
- Burton AK. Volvo Lecture – Low back pain: Prevent, cure or manage? Presented at the International Society for the Study of the Lumbar Spine 33rd Annual Meeting. June 14-17, 2006. Bergen, Norway.
- www.backpaineurope.org
- www.balogh.com