Michael O'Donnell looks at recent developments in the treatment of back pain and explains why stress could be the new sickness absence epidemic
In the past, lower back pain (LBP) has been addressed either from a 'risk management' perspective in terms of prevention of injury or, alternatively, from a sickness and disability management perspective. Common to both approaches is the assumption of a close relationship between physical abnormality, pain and dysfunction.
However, recent clinical research has shown that LBP disability is explained by psychosocial as well as biomedical factors. Indeed, in terms of work absence, psychosocial factors seem to be more powerful predictors than either biomedical or ergonomic factors. Recently, a shift in focus from identification of abnormality, which gave little attention to patient perception or engagement, to obstacles to recovery has been suggested.
In the workplace, the specific focus on primary prevention has perhaps hindered proper analysis of the mechanisms of recovery from injury. The 'injury model' is not able to explain the wide variation in resultant disability but, nonetheless, many workers perceive their musculoskeletal symptoms to be work-related. As such, it is appropriate to consider the psychosocial aspects of work.
Stress literature has been important in the identification of adverse features of the working environment. Certain characteristics of this environment appear to constitute risk factors in their own right, but it seems that perceptual factors may even be more important than objective characteristics. There is now clear evidence that psychosocial factors influence musculoskeletal symptoms and work.
Some of these perceptual factors related to the work environment include:
• High demand/low control.
• Unhelpful management style.
• Poor social support from colleagues.
• Perceived time pressure.
• Lack of job satisfaction.
These factors or 'flags' are associated with higher rates of symptoms, ill-health and work loss which, in the context of injury, may delay recovery or constitute a major obstacle to it. Individual workers may differ in their perception of the same working environment. So, how should employers, occupational health practitioners and GPs work to reduce the impact of these factors in the case of injury, and avoid chronicity leading to long-term absenteeism?
The rulebook
In a recent clinical review, Main and Williams (2002) recommended guidelines for GPs to reduce the risk of chronicity, which is also appropriate for employees in occupational settings. These are:
• Paying attention to the psychological aspects of symptom presentation.
• Avoiding unnecessary, excessive or inappropriate investigation.
• Avoiding inconsistent care (which may cause patients to become overcautious).
• Giving advice on prevention of recurrence.
Identification of the minority of patients at risk of becoming chronically incapacitated is also suggested. Here, a number of psychological factors associated with chronicity are highlighted. These are:
• The belief that back pain is due to progressive pathology.
• The belief that back pain is harmful or severely disabling.
• The belief that avoidance of activity will help recovery.
• A tendency to low mood and withdrawal from social interaction.
• The expectation that passive treatments rather than active self-management will help.
The effectiveness of these recommendations was demonstrated in a UK study in which a short occupationally-oriented pain management programme was designed for unemployed benefit claimants with back pain as the principal reason for unemployment. Despite the fact the group had been out of work for an average of 44 months and had, on average, had the symptoms for more than eight years, 43% were rehabilitated into work and 71% into useful function.
According to Professor Chris Main, head of behavioural medicine of Salford Royal Hospitals NHS Trust, the most important conceptual shift needed in relation to prevention is to move beyond the traditional concepts of sickness and disability. He also advocates the development of 'work-life balance'. Given that pain is a part of life, the challenge is to enhance individuals' positive or adaptive coping strategies.
For the insurance industry, this shift translates into a need for employers to be more demanding of the service provided by occupational health practitioners as well as GPs. There needs to be a focus on skills rather than just professional accreditation. Clinicians may need to expand their clinically derived concepts of prevention, broaden their skills and develop closer and more effective liaison with other agencies.
Micheal O'Donnel is company medical officer at UnumProvident
COVER notes
• Evidence shows that psychosocial factors can influence musculoskeletal symptoms at work.
• Work stress, such as time pressures and unhelpful managers, has been found to delay recovery of ailments such as back pain.
