The Management of Back Pain at Work AOHNP (UK) Symposium 13 th May 2004 Carol Coole Occupational Therapist NOTTINGHAM BACK TEAM

Nottingham Back Team GP referrals: back pain > 6 weeks Biopsychosocial assessment Group treatment Interdisciplinary team Community based treatment Cognitive-behavioural model

Main treatment elements Paced activity Graded exercise Relaxation training Medication advice Goal focused treatment Management of physical and emotional stress/strain Use of leisure centre facilities e.g. gym, badminton, squash, tennis Additional individual treatments as required Occupational advice group

The Problem with Back Pain If not well managed - costly to: Employers and business Government The individual – physical health work & financial security hobbies & leisure friends & family mental health

Understanding Pain 1965Gate Control Theory of Pain 1979 International Association for the Study of Pain:- “Pain is an unpleasant sensory and emotional experience, associated with actual or potential tissue damage, or described in terms of such damage” Pain is a mental, not a physical state All pain is real to the sufferer, whether or not a cause can be found The intensity of pain does not equate to the severity of the ‘injury’

Understanding Pain (cont.) Subjective and unique Fear of the pain may be as potent as the pain itself The nervous system becomes oversensitive – pain continues after healing It can be modified by our thoughts, feelings and beliefs Can lead to disability if poorly managed

Clinical Guidelines 1994 Clinical Standards Advisory Group report leading to: 1999 Royal College of General Practitioners’ Guidelines Diagnostic triage (LBP is a diagnosis) (consider differential diagnoses) - Simple backache (common, recurrent) - Nerve root problem (often resolves <5%) - Possible serious spinal pathology (red flags) <2% Routine Xrays/scans not advised for mechanical LBP Assess for psychosocial risk factors (yellow flags) Advise regular pain medication

Clinical Guidelines (cont.) Advise early progressive return to normal activity even if with some pain Refer on if not improving:  Manipulation  Physiotherapy  Rehabilitation Provide written information e.g. ‘The Back Book’ to support advice given

2000 Occupational Health Guidelines Evidence-based recommendations developed by the Faculty of Occupational Medicine: Pre-placement assessment of the worker with back pain Prevention of back pain Assessment of the worker with back pain Managing the worker with back pain in work Managing the worker off sick due to back pain

Obstacles to recovery 1: Red Flags Possible serious spinal pathology e.g. tumour, fracture, infection: A clinical decision based on the following: Age of onset Thoracic pain PMH of cancer, steroid use, HIV Significant recent trauma Non-mechanical pain Systemically unwell Widespread neurological deficits NB Immediate referral for cauda equina syndrome

Obstacles to recovery 2: Yellow Flags Psychosocial factors which may lead to disability e.g. A belief that back pain is harmful or severely disabling A belief that avoidance of activity, or reduced activity levels will help recovery A tendency to low mood and withdrawal from social interaction An expectation that passive treatment(s) will bring about recovery

Obstacles to recovery 3: Physiological factors e.g. De-conditioning: muscle weakness, joint stiffness Shortened scar tissue ‘Activity Cycling’ ‘Learnt’ pain

Obstacles to recovery 4: Occupational psychosocial factors (individual perceptions) e.g. High job demands/low control Time pressures/monotony Low job satisfaction Lack of supervisor/social support A belief that the job is harmful to the back

Obstacles to recovery 5: Organisational occupational factors: e.g. Sickness policies Occupational health management Management style/culture Working conditions Organisational size and structure Physical job demands

Workplace interventions Aim to prevent disability (prevention of back pain is difficult) Educate all workforce in back pain management Help to stay at work/early return to work Ensure policies and procedures reflect occupational health guidelines Optimise take-up of existing NHS services for acute and non-acute back pain (cont.)

Workplace interventions (cont.) Buy-in private treatment(s) or provide in-house treatment (in accordance with clinical guidelines) Provide information/advice/screening clinics for employees: - Reassure (triage?) but take back pain seriously - Advise to remain active but pace activity (home and work) - Advise regular use of pain medication - Refer for further assessment/treatment if required Provide the Back Book to support advice given