At a glance:
Back pain treatment is helped by taking note of how people view their pain
and work environment, and tailoring treatment accordingly.
Most people with back pain recover with little or no treatment.
Around 10% - 15% are at risk for chronic pain and disability.
Simple self assessments of pain and work readiness are useful in choosing
treatment and return to work programs.
Background, Study Objectives, How It Was Done:
There are three stages in non specific back pain:
1 - acute - symptoms ease in days
2 - sub-acute – symptoms remain for weeks
3 - chronic – symptoms persist beyond 6 months
According to the authors it is not well understood why different treatments for
the same injury produce similar results. One possible explanation is that
patients are diverse in their particular needs and expectations so, only a
minority benefit from any one type of intervention.“If patients could be
subdivided into groups based on the nature of physical, psychological.
Psychological :Refers to a person's perceptions, thought processes, emotions,
personality and behaviour. Psychologists can treat mental health problems.
and/or organizational barriers to recovery, matching them to appropriate
interventions may improve outcomes and reduce costs.'
This study included 568 working adults (183 female, 385 male) with acute,
work-related back pain who sought treatment at 8 community-based
occupational health clinics in the New England region of the United States.
Each of the patients completed a questionnaire that asked them about
factors that have previously been shown to affect whether a person will
become disabled from work-related back pain. Many of these factors are
possible to vary, and include the level of pain and distress,
Distress: Severe suffering, pain, anxiety or sorrow job concerns, whether
the workplace was likely to provide modified duties, and whether the person
expected they could return to work within four weeks.
The individuals were followed up one and three months after completing
the questionnaire, and the following were measured:
a. reported level of pain, on a scale from one to ten
b. reported level of function, measured by a specific questionnaire, the Roland-
Morris Disability
Questionnaire: work status (back at full duties, back at normal duties but
working fewer hours due to pain, back at modified tasks, or off work).
The study objective was to identify different groups of patients with work-
related acute
Acute :A condition develops quickly and is often of short duration.
Chronic: which refers to a long term problem continuing
for months to years. back pain by comparing the information from the initial
questionnaire to the follow up results one and three months later.
The researchers were looking to see if different risk groups could be identified
in the early stages, as if so specific treatments could be put in place that were
most useful for that group.
Study Findings:
The patients were grouped according to their responses to questions about their:
Distress
Pain
Fear/avoidance of returning to work
Workplaces inflexibility
Expectation of resuming work
Four groups (the authors use the term clusters)
of patients with acute back pain were identified:
1. Severe pain / fear avoidant
2. Concerns about inflexibility of the workplace
3. Low risk (good expectations and low concern)
4. Emotional distress
The following table shows the outcomes for each of these groups.
The cluster groups average level of pain, function, and work status is shown,
reported one and three months after the initial questionnaire. The table also
lists the recommended interventions.
Cluster Groups
1 – Severe pain / fear avoidance
2 – Concerns about job accommodation
3 – Low Risk
4 – Emotional distress - Members of this group are often low paid young
people in first job with little or no family support.
Characteristic Questionnaire Responses
1 - High pain,Poor expectations,Fear/avoidance of work
2 - High perception of work inflexibility
3 - Low Pain, Distress, Fear/avoidance, Perception of work, inflexibility,
Good expectations
4 - High distress,Average pain and fear/avoidance,Moderately, poor
expectations.
Outcomes and Recommended Intervention;
1 - This group had the poorest return to work outcomes overall.Suggested
interventions:
a. A gradual increase in physical activity to overcome fears about pain and
activity.
b. A behavioural intervention.
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. to improve coping and problem solving
strategies.
c. A workplace intervention to improve accommodation efforts by the
workplace.
2. Improved monitoring of injury related absences.
3. Effective communication between employers, workers and health care
providers about job modifications
a - Both physical work demands and employer policies and practices have
been associated with sickness absence due to back pain.
Suggested interventions:
a. Proactive return to work strategies
b. Improved monitoring of injury related absences.
c. Effective communication between employers, workers and health care
providers about job modifications
3 - This group returns to work as quickly as they can.
Suggested intervention:
Ongoing assessment by health care providers and employers to ensure the
person does not take on too much too early.
4 - Improving supervisor and peer support after the onset of pain may
decrease the risk of disability
Disability - A condition or function that leaves a person unable to do tasks
that most other people can do in this group.
Suggested intervention:
Workplace outreach to:
a. Improve accommodation efforts
b. Develop modified duty options
c. Improve supervisor support
A simple self assessment survey in which patients self rate their pain,
avoidance, distress, recovery expectations and employers supportiveness
between 1 and 10 may help health care providers to recommend the best
treatment for a person's back pain.
Conclusions:
This is one of a number of studies that has researched whether grouping
patients into clusters in the early stages of back pain, to determine which
treatment they will best respond to, will help prevent long term suffering
and disability.
The study identifies a range of factors that can impact the
longer term outcomes of back pain. Supporting previous research in this
area, the authors found that distress, fear and concerns that the workplace
wouldn't/couldn't accommodate the injury can be barriers to a person's recovery.
The authors recommend the best treatment option for each patient “cluster'.
Further research should be done to test the effectiveness of the interventions
recommended for each of the high risk groups (1, 2 and 4 above) in helping
people to recover from low back pain, as this has not yet been done. In the
meantime, people who are distressed, or fearful of their pain or situation,
should be helped to overcome these negative feelings.The researchers also
siad that a simple patient self assessment survey may be useful, as the brief
questionnaire used in this study could predict how likely a person was to
return to work.
References:
Original Article, Authors & Publication Details:
W. S. Shaw1,2, G. Pransky1,2, W. Patterson3,4, S. Linton5 and T. Winters6
(2006).Patient clusters in acute, work-related back pain based on patterns
of disability risk factors. Journal of Occupational and Environmental Medicine;
48(11):1173-11801Liberty Mutual Research Institute for Safety, Center for
Disability Research, Hopkinton, Massachusetts 2University of Massachusetts
Medical School, Department of Family Medicine & Community Health, Worcester, Massachusetts3Concentra Health Services, Burlington, Massachusetts4Boston
University, School of Public Health, Boston, Massachusetts5Orebro University,
Department of Behavioral, Social and Legal Sciences—Psychology & Orebro
Medical Center Hospital, Department of Occupational and Environmental
Medicine, Orebro, Sweden6Occupational and Environmental Health Network,
Waltham, Massachusetts
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