Spinal problems come in many guises and can cause agony for sufferers - and many lost working days for their employers, writes Joanne Knight
Back pain is an extremely common complaint, affecting approximately 17.3 million people in the UK - over a third of the adult population.
Every year, around 3.5 million people experience back pain for the first time and 3.1 million will suffer from it throughout the year. It affects men and women equally.
It is also one of the main reasons for sickness absence. Close to 120 million working days a year are lost to back pain and one in eight unemployed people says back pain is the reason they are not working.
Fortunately, most occurrences of low back pain go away within a few days. Others take much longer to resolve or lead to more serious conditions.
Acute or short-term low back pain generally lasts from a few days to a few weeks. Most acute back pain is mechanical in nature - the result of trauma to the lower back which may be caused by a sports injury, work around the house or in the garden, or a sudden jolt such as a car accident or other stress on spinal bones and tissues.
Symptoms include muscle ache, shooting or stabbing pain, limited flexibility and range of motion, and an inability to stand straight. Occasionally, pain felt in one part of the body may "radiate" from a disorder or injury elsewhere in the body. Some acute pain syndromes can become more serious if left untreated.
Chronic back pain is measured by duration - pain that persists for more than three months is considered chronic. It is often progressive and the cause can be difficult to determine.
The spine is made up of small bones called vertebrae. These are separated by discs, which allow the spine to bend (see illustration overleaf). This structure of vertebrae and discs is supported along the length of the spine by muscles and ligaments.
The spinal cord threads through the centre of each vertebra, carrying nerves from the brain to the rest of the body.
Over 90% of back disorders are considered mechanical. Precipitating factors for mechanical low back pain include heavy physical work, back twisting and motor vehicle driving (possibly due to vibration). Back injuries are aggravated by obesity, weak muscles and poor posture. Mechanical back injuries include:
Bulging disc (also called protruding, herniated, or ruptured disc). This occurs when the intervertebral discs are under constant pressure. As discs degenerate and weaken, cartilage can bulge or be pushed into the space containing the spinal cord or a nerve root, causing pain. Studies have shown that most herniated discs occur in the lower, lumbar portion of the spinal column.
Cauda equina syndrome: A much more serious complication of a ruptured disc which occurs when disc material is pushed into the spinal canal and compresses the bundle of lumbar and sacral nerve roots. Permanent neurological damage may result if this syndrome is left untreated.
Sciatica: A condition in which a herniated or ruptured disc presses on the sciatic nerve, the large nerve that extends down the spinal column to its exit point in the pelvis and carries nerve fibres to the leg. This compression causes shock-like or burning low back pain combined with pain through the buttocks and down one leg to below the knee, occasionally reaching the foot. In the most extreme cases, when the nerve is pinched between the disc and an adjacent bone, the symptoms involve not pain but numbness and some loss of motor control over the leg due to interruption of nerve signalling. The condition may also be caused by a tumour, cyst, metastatic disease or degeneration of the sciatic nerve root.
Spinal degeneration: Caused by disc wear and tear, it can lead to a narrowing of the spinal canal. A person with spinal degeneration may experience stiffness in the back upon awakening or may feel pain after walking or standing for a long time.
Spinal stenosis: Related to congenital narrowing of the bony canal, it predisposes some people to pain related to disc disease.
Skeletal irregularities: Produce strain on the vertebrae and supporting muscles, tendons, ligaments, and tissues supported by the spinal column. These irregularities include scoliosis, a curving of the spine to the side; kyphosis, in which the normal curve of the upper back is severely rounded; lordosis, an abnormally accentuated arch in the lower back; back extension, a bending backward of the spine; and back flexion, in which the spine bends forward.
Fibromyalgia: A chronic disorder characterized by widespread musculoskeletal pain, fatigue, and multiple "tender points", particularly in the neck, spine, shoulders, and hips. Additional symptoms may include disturbed sleep, morning stiffness and anxiety.
Fewer than 10% of back disorders are non-mechanical. These include:
- Spinal fractures: May or may not include damage to the spinal cord or nerve roots.
- Spondyloarthritism: Include ankylosing spondylitis and reactive spondyloarthritis.
- Spinal infections and Spinal tumours: Malignancies in the spine, whether benign or malignant, have usually spread from a primary cancer elsewhere in the body.
These disorders are characterised by the presence of clinical abnormalities including sensory, motor and reflex impairments. Warning signs include fever, weight loss and impairment of bowel and bladder control. They are more common in people aged over 50.
The back is vulnerable to numerous diseases giving rise to morbidity, which may be prolonged. Back pain is a symptom which may restrict movement and function. However, it is very common and the factors which determine presentation to a doctor are complex. Psychosocial aspects are important, as is the severity of the underlying back disorder.
Joanne Knight is a life and disability underwriter at Scottish Equitable Protect
UNDERWRITING IMPLICATIONS
When assessing an application the underwriter will assess:
- The nature of the underlying disorder (if known).
- The severity and duration of back pain.
- How much time the applicant has had off work.
- Occupation details, particularly any manual work.
The underwriter would also take into consideration how the disorder affects the ability to carry out occupational duties and whether the occupation itself contributes to the problem.
For example, if the job entails any prolonged standing, sitting or driving or if any psychological stresses may be caused by the nature of the work.
The philosophy of the life office is generally based on its own claims experience and can vary from office to office.
There are circumstances in which life and critical illness cover may attract a rating, usually due to an underlying disorder or severe disability but these are the exception rather than the rule.
For the majority of proposals the sickness-related benefits are the only benefits affected by back pain. The options available are:
- Standard rates if the risk is considered minimal, such as acute problems fully resolved and historic.
- Apply an exclusion such as "any disease or disorder of, or any injury to, the spine, its intervertebral discs, joints, nerve roots, spinal cord or supporting musculature and ligaments and any neurological complications".
- Offer full cover - without the exclusion - but with an extra premium to reflect the additional risk of a claim.
- Amend the definition of disability attached to the benefit, for example from "own occupation" to "any occupation/any suited occupation" or even to "activities of daily work/living".
- In some circumstances cover may be declined.
When an exclusion has been applied, underwriters are often asked how their life offices would view a claim relating to the back if the disability did not relate to the pre-existing condition and the existing condition had no bearing on the recovery time, for example, a serious road accident.
Some life offices feel it would be unfair to enforce the exclusion in these circumstances and would pay the claim as the exclusion is designed to only protect the life office from the pre-existing condition. Perhaps it would be helpful to contact the relevant life office direct for their view on this.
Back pain is a complex area to underwrite as it is specific to the individual involved and symptoms can vary dramatically.
If an adviser has an applicant with a history of back pain it may be useful to contact an underwriting helpline operated by some life offices for an indication of terms likely to be offered. However, this is only an indication and terms would be confirmed following receipt of all the necessary evidence.
SOURCES:
www.ninds.nih.gov/disorders/backpain
www.backcare.org.uk
www.hcd2.bupa.co.uk
www.hse.gove.uk/betterbacks/
Swiss Re Underwriting Manual - SURE.
