Abstract
Objective: To review the diagnostic descriptions and treatment recommendations
for back and neck pain on the new workers compensation medical certificates and
compare these with evidence-based guidelines.Design: Retrospective analysis of
251 medical certificates of workers with compensable neck and back pain held by
a workers compensation insurer.Main outcome measures: Diagnoses given and
treatments prescribed by the nominated treating doctors.
Results: The diagnoses most frequently used were "sprain/strain" and "pain/ache".
Physiotherapy was the most frequently prescribed treatment, followed by rest
and medication. Rest was prescribed for 68 (27%) workers, 87% of whom were
classified as having an acute injury. Activity-based treatments were prescribed
for 45 (18%) workers.Conclusions: Not all doctors used diagnostic terms
consistent with recommended anatomical taxonomy. The drug therapy prescribed
was consistent with current evidence-based treatment guidelines. However, the
prescribing of rest, and the omission, in most cases, of explicit recommendations
to resume normal activities, including work, are not consistent with current
guidelines.
The cost of managing workplace back injuries is increasing. Figures for 1997-98
show that back injuries accounted for 30% of the cost of all workplace injuries
(gross cost, $224 million),1 while comparable figures for 1996-97 were 36%
and $212.5 million.1,2
In an effort to reverse the growing WorkCover Authority (WCA) debt ($1.7
billion at the time of writing),3 the 1997 Grellman Report4 made recommendations
which resulted in the Workplace Injury Management and Workers Compensation
Act 1998 (NSW). A new medical certificate intended to streamline reporting and
management of compensable work-related injuries was introduced, as well as the
concept of the "nominated treating doctor" (NTD) -- a general practitioner
nominated by the injured worker who agrees to provide continuity of care until
a return to work is achieved (Box 1).
In recent years, national and international guidelines and systematic reviews --
some evidence-based -- have established standards for diagnosis and treatment
of people with back or neck pain,5-10 including the most recent National Health
and Medical Research Council (NHMRC) guide to acute pain management11 and
the definitive publication on classification of pain by the International Association
for the Study of Pain (IASP).12
To streamline management and reduce the costs associated with prolonged
disability and time off work, it is important that the NTDs' diagnoses and treatment recommendations conform with evidence-based guidelines. We compared the
diagnoses and treatments given on Part 1 of a sample of medical certificates of
workers (who had work-related back or neck pain) with the taxonomic guidelines
for diagnosis and the emerging guidelines for management.
Methods
We examined retrospectively all the medical certificates related to neck and
back pain of a NSW workers compensation insurer for the period 1 October 1998
- 15 February 1999. Medical certificate entries were de-identified.
Diagnosis and treatment were coded according to the most common wording
used by doctors. Diagnoses were further grouped into those indicating and those
not indicating a specific pathological condition. Treatments were further coded
according to the amount of rest and/or activity prescribed. Active treatments
involved exercise, work conditioning/work hardening, and maintenance of
normal activity (including work).
Diagnoses were then compared with taxonomic guidelines, and treatments
were compared, wherever possible, with evidence-based guidelines for the
management of spinal pain.
According to the time between the date of injury on the certificates and the date
of the medical certificate, the worker's condition was classified as acute (< 6 weeks),
subacute (6-12 weeks) or chronic (> 12 weeks).
Ethical approval: Approval for the study was obtained from the Human Ethics
Committee, The University of Sydney.
Results
Diagnosis
On 227 of 251 certificates examined (90%), doctors did not specify a patho-
anatomical diagnosis: on 92 certificates (37%) the diagnosis was sprain/strain;
on 68 (27%) ache/pain; and on 67 (26%) injury (mechanical, lumbago,
dysfunction, whiplash, discopathy, myalgia).
The location of the pain was lumbar spine (131; 52%), back (42; 17%),
cervical spine (39; 16%), and other (39; 16%).
Thirty-four doctors (14%) used at least two diagnostic descriptors, and, of
these, six used at least three. Examples included "back pain due to low back
strain", "thoracolumbar spinal pain, right sciatica", and "lumbar disc
degeneration, right low back pain, and right sciatica pain".
Treatment
The most frequently prescribed treatments (Box 2) were physiotherapy
(116; 46%); rest (68; 27%); non-steroidal anti-inflammatory drugs (NSAIDs)
(64; 25%); and analgesia, analgesics or "painkillers" (56; 22%). Specific active
management advice, such as exercise, a return to work, suitable duties, work
conditioning, hydrotherapy or work rehabilitation, was recommended for 45
(18%) workers. Many had more than one treatment prescribed, with the total
sample of 251 being prescribed 455 treatments.
Most workers were seen by their doctors in the acute phase of injury (208; 83%),
with the remainder in the subacute (18; 7%) or chronic (21; 8%) categories. Of the
workers prescribed rest, 87% were classified as having an acute injury.
Fifty-six workers (22%) were certified fit for suitable duties, 24 of these (43%)
on their initial visit to their NTD. Ninety-two workers (37%) were deemed unfit
for work. This information was not included on the remaining certificates. Of
the 92 workers deemed unfit for work, 59 (64%) were on their first visit to their
doctor, 13 (14%) were being issued with a progress medical certificate, and 8 (9%)
were making their final visit. The remaining 20 (22%) certificates did not have
this information.
The treatments prescribed on the medical certificates and available evidence for
their efficacy are summarised in Box 3. Wherever possible, the evidence is
presented according to the NHMRC level-of-evidence ratings.
Discussion
We found that doctors completing medical certificates for workers with back
and neck pain generally did not indicate a specific pathoanatomical diagnosis.
This is consistent with epidemiological evidence:6,7 in 85%-90% of back
complaints, a pathoanatomical diagnosis can not be made from the history,
examination or even medical imaging. One of the primary aims of the initial
assessment is to exclude "red flag" conditions such as tumours, fractures,
disc prolapses, herniations, or infections. According to the NHMRC,11 this
exclusion is the key to managing acute spinal pain, and for this purpose the
history is the most valid tool.13 The diagnoses given on medical certificates
for back and neck pain should explicitly reflect the exclusion of "red flag"
conditions, and the presence of a benign, self-limiting condition which generally
resolves within four weeks of onset of pain.14
The certificates showed that the doctors used a variety of (implicit) taxonomic
systems to describe "non red flag pain"; for example, anatomical (eg, "back
pain", "thoracolumbar spinal pain"), aetiological or mechanical (eg, "mechanical
back pain", "injury"), or descriptive pathological (eg, "sprain", "tear",
"degeneration"). Only anatomical classification is consistent with the IASP
classification.12 However, the precise terminology used to describe pain of
this type is contentious. Terms such as "non-specific back pain",6,15 "simple
back pain",14 or "back pain of unknown or uncertain origin"12 have been proposed.
NSAIDs and analgesics were the most frequently prescribed medical therapy.
Their use for spinal pain is consistent with current evidence-based practice,9
but support for the use of NSAIDs is limited and applies only in the short term.9,11
Although physiotherapy, either alone or in combination with other treatments,
was the most frequently prescribed treatment, the NTD generally did not specify
the exact nature of the physiotherapy intervention. While scientific evidence for
the efficacy of specific physiotherapy treatments for neck and back pain has been published,8,9,16 there is great variability in treatments among physiotherapists,
17,18 and the extent to which they adhere to evidence-based practice has not
been studied.
The Australian Physiotherapy Association has made a concerted effort to educate
and inform its members by producing position statements on neck pain and back
pain. These as yet unpublished statements are based on randomised controlled
trials and systematic reviews (some by the Cochrane Collaboration).
A Physiotherapy Evidence Database has also been created (PEDro).19 When
reviewing their patients, doctors need to consider the evidence for the efficacy
of the specific physiotherapy treatment received.
"Rest" was the second most common word included in treatment recommendations
(27% of cases), and most workers for whom rest was prescribed were in the acute
phase of their injury. In contrast, activity-based treatments were recommended in
only 18% of cases. Both in terms of what was prescribed and what was omitted, this
is contrary to current evidence. There is now Level I evidence that bed rest should
not be prescribed for acute back pain;20 and Level II evidence that advising patients
to return to normal activity (including work),21-24 providing reassurance, and
discouraging fear of activity and illness behaviour, are effective for managing acute
and subacute spinal pain.
It is acknowledged that the use of the word "rest" may not necessarily mean "bed
rest". However, even when used in combination with an activity-based treatment,
the word "rest" may be construed to mean a cessation of all, most, or some of a
person's normal functional and work activities.
Recommendations
As a result of our study, we recommend that:
The new workers compensation medical certificates should be changed to assist
nominated treating doctors (NTDs) to indicate that "red flag" conditions have been
excluded.
The use of the word "rest" on medical certificates should be restricted and the
resumption of normal functional and work activities should be explicitly included.
There should be a taxonomic standard for describing neck and back pain which
clearly communicates that the condition is benign and has a good prognosis. This
should reduce fear-avoidance and illness behaviours in workers,25 and assist
employers to provide suitable temporary duties for workers.
The medical profession and other appropriate authorities need to encourage
dissemination and use of evidence-based guidelines and best practice in the
management of compensable spinal pain.
Acknowledgements
We thank HIH Insurance (Injury Management Department) for providing
access to workers compensation medical certificates, and Dr C Maher and Dr J
Latimer, from the School of Physiotherapy, Faculty of Health Sciences, The
University of Sydney, for their support and helpful comments.
Competing interests: No conflict of interest exists and the study received no
funding.
References
WorkCover NSW. Statistical bulletin. NSW workers compensation. Sydney:
WorkCover NSW, 1997-1998.
WorkCover NSW. Back injuries statistical profile, 1996/1997.
WorkCover NSW, 1997/98 Annual Report. Sydney: WorkCover NSW, 1998.
Grellman RJ. Inquiry into workers compensation system in NSW. Sydney:
KPMG, 1997.
Agency for Health Care Policy and Research (AHCPR). Clinical Practice
Guidelines Number 14. Acute low back problems in adults. Rockville, Md:
AHCPR, 1994.
Fordyce WE, editor. Back pain in the workplace. Management of disability
in nonspecific conditions. International Association for the Study of Pain.
Seattle, Wash: IASP Press, 1995.
Victorian WorkCover Authority. Guidelines for the management of employees
with compensable low back pain. Melbourne: Victorian WorkCover Authority, 1996.
Gross A, Aker P, Goldsmith CH, Peloso P. Conservative management of
mechanical neck pain: systematic overview and meta-analysis. BMJ 1996; 313:
1291-1296.
Van Tulder MW, Koes BW, Bouter LM. Conservative treatment of acute and
chronic nonspecific low back pain. A systemic review of randomized controlled
trials of the most common interventions. Spine 1997; 22: 2128-2156.
Waddell G, Feder G, McIntosh A, et al. Low back pain evidence review. London:
Royal College of General Practitioners, 1998.
National Health and Medical Research Council. Acute pain management: scientific
evidence. Canberra: NHMRC, 1999.
Merskey H, Bogduk N, editors. Classification of chronic pain. International
Association for the Study of Pain. Seattle, Wash: IASP Press, 1994.
Deyo RA, Rainville J, Kent DL. What can the history and physical examination
tell us about low back pain? JAMA 1992; 268: 760-765.
Croft PR, Macfarlane GJ, Papageorgiou AC, et al. Outcome of low back pain in
general practice: a prospective study. BMJ 1998; 316: 1356-1359.
Cedraschi C, Nordin M, Nachemson AL, Vischer TL. Health care providers should
use a common language in relation to low back pain patients. Baillieres Clin
Rheumatol 1998; 12: 1-15.
Gross A, Aker P, Goldsmith C, Peloso P. Physical medicine modalities for
mechanical neck disorders (Cochrane Review). Cochrane Library; Issue 1, 2000.
Van der Valk RWA, Dekker J, van Baar ME. Physical therapy for patients with
back pain. Physiotherapy 1995; 81: 345-351.
Jette AM, Smith K, Haley SM, Davis KD. Physical therapy episodes of care for
patients with low back pain. Phys Ther 1994; 74: 101-114.
The Physiotherapy Evidence Database (PEDro). May 2000.
Koes BW, van den Hoogen HMM. Efficacy of bed rest and orthoses of low back
pain. A review of randomized clinical trials. Eur J Phys Med Rehabil 1994; 4: 96-99.
Malmivaara A, Hakkinen U, Aro T, et al. The treatment of acute low back pain --
bed rest, exercise or ordinary activity? N Engl J Med 1995; 332: 351-355.
Indahl A, Velund L, Reikeraas O. Good prognosis for low back pain when left
untampered. A randomized clinical trial. Spine 1995; 20: 473-477.
Lindstrom I, Ohlund C, Eek C, et al. Mobility, strength, and fitness after a
graded activity program for patients with subacute low back pain. A randomized
prospective clinical study with a behavioural therapy approach. Spine 1992; 17:
641-652.
Lindstrom I, Ohlund C, Eek C, et al. The effect of graded activity on patients
with subacute low back pain: a randomized prospective clinical study with an
operant-conditioning behavioural approach. Phys Ther 1992; 72: 279-293.
Loeser JD, Sullivan M. Doctors, diagnosis and disability: a disastrous diversion.
Clin Orthop Rel Res 1997; 336: 61-66.
(Received 3 Sep 1999, accepted 31 Jul 2000)
Authors' details
Faculty of Health Sciences, The University of Sydney, Sydney, NSW. Eva
Schönstein, BAppSc(Phty), MHPEd, Lecturer, School of Physiotherapy. Dianna
T Kenny, PhD, MAPsS, Associate Professor of Psychology.
Reprints will not be available from the authors.Correspondence: Ms Eva
Schönstein, School of Physiotherapy, Faculty of Health Sciences, University of
Sydney, PO Box 170, Lidcombe 1825. E.SchonsteinATcchs.usyd.edu.au
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