Back Pain

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Back Pain Return-to-WorkPerfect Together or
Not?By Mark Werneke MS, PT, Dip.
MDTCentraState Medical Center Rehabilitation
Department
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PurposeEvidence-Based Guidelines

• Managing workers with low back pain
• Implementing best practice case management
  programs to
• enhance quality of treatment
• contain health care costs

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Report CardEpidemic of Low Back Disability
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Disability Rates 1950 - 1970

• Stable LBP prevalence rates
• Disproportional increase

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Back Claims As Of Total Claims (USA)
Bureau of Labor Statistics 12 increase days
from work between 2002 - 2003
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International Disability Rates

• Spine 1995 8.1 million sick days/year in Great
  Britain
• Spine 1998 Sweden 40 fold increase disability
  rates past 2 decades

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Disability Cost Breakdown

• 33 costs direct medical intervention
• 67 costs indirect indemnity costs such as lost
  wages

Webster Spine 1994
75 billion/year USD
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History of Low Back Pain
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Disproportional Disability and Costs Due to Back
Pain

• Multifactorial Problems
• medical
• legal
• financial
• industrial

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Evidence-Based Guidelines

• First International Occupational Health
  Guidelines 2001
• www.facoccmed.au.uk

• European Back Guidelines
• 2004
• www.backpaineurope.org

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International Occupational Health Guidelines

• Back pain, if poorly managed, will have
  devastating effect on return to work
• Rehabilitation plan first week after start of
  LBP episode to prevent chronic problem

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International Occupational Health Guidelines

• Pre-placement assessment
• Prevention
• Examination for worker with back pain
• Management of worker with acute LBP
• Management of worker unable to RTW at normal job
  duties after 4-12 weeks

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Evidence Ratings
The weight of evidence is rated Strong
evidence - multiple high quality studies
Moderate evidence -single acceptable study,
or smaller low quality studies limited or
inconsistent scientific evidence, lack of
acceptable study -- no scientific evidence
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Pre-Placement Screening

• Strong evidence
• single most consistent predictor of future
  LBP/workloss is employees previous low back pain
  history
• prior lumbar surgery
• prior sickness absenteeism due to back pain
• back-function testing machines have no predictive
  value
• X-rays MRI have no predictive value

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Pre-Placement Screening

• Moderate evidence
• physical examination findings height, weight,
  lumbar ROM, and cardiovascular fitness have
  little to no predictive value
• FCE (functional capacity evaluation) matching
  physical ability to job demands are of limited
  value for reducing future LBP

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Prevention at the Worksite

• Strong evidence
• Physical exercise is recommended
• lumbar belts or supports do not reduce
  work-related LBP and workloss
• shoe inserts/orthoses are not recommended
• traditional Back schools based on anatomy and
  injury models are not beneficial

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Prevention at the Worksite

• Moderate evidence
• ergonomic intervention requires employer
  organisational dimension involving worker
• Recent research
• new educational back programs addressing pain
  beliefs and fear avoidance behaviors reduce
  workloss due to LBP
• employer-worker initiatives emphasizing a safety
  culture at work reduces workloss

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Examination Employee with Low Back Pain

• Strong evidence
• MRI and X-ray finding do not correlate with work
  capacity or clinical symptoms
• Screen for yellow flags or psychosocial factors
  to identify workers at high risk for extended
  workloss/disability

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Examination Employee with Low Back Pain

• Yellow Flags
• belief that back pain is harmful and results from
  serious spinal pathology
• elevated fear of physical activity
• expects passive treatment and expresses little
  confidence in ability to RTW

Werneke Hart Spine 2001 and JRM 2005
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Examination Employee with Low Back Pain

• limited evidence yet strong consensus among
  international experts
• perform diagnostic triage and screen for red
  flags to exclude serious spinal pathology and
  true nerve root problems

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Examination Employee with Low Back Pain

• Diagnostic Triage
• Serious Spinal Pathology
• Nerve Root Pain
• Nonspecific Back Pain

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Serious Spinal Pathology Red Flags

• Violent trauma, fracture
• age lt20 gt50 years
• PMH carcinoma, steroids, drug abuse
• unwell, weight loss, fever
• widespread neurology (S4 syndrome)
• Thoracic pain, structural deformity

Prevalence 1-2
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physician fears of making a significant
diagnostic error without imaging tests can be
allayed if clinicians stay alert for red flags
Borkan Spine 2002 McGuirk Spine
2001
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Nerve Root Pain

• Unilateral leg pain gt back pain
• Radiates to foot or toes
• Numbness/paraesthesia in same distribution
• Localized neurological signs
• Positive SLR (lt45) reproduces pain or
  paraesthesia below knee

Prevalence 5
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disc prolapse is a diagnosis that is overused,
misused, and abused by patients and physicians
and should be restricted for disc pathology
with clear signs of nerve involvement
Waddell Back Pain Revolution
2001
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Nonspecific Low Back Pain

• Mechanical back pain with or without leg symptoms

Prevalence 85 - 93
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Examination Employee with Low Back Pain

• Moderate evidence
• traditional physical findings height, weight,
  lumbar ROM are of limited value
• New Research Classification
• treatment-based classification systems
• Fritz Spine 2003 Long Spine 2004
• clinical prediction rules
• Childs Ann Int Med 2004 Hicks Arch Phys Med
  Rehabil
• centralization
• (Werneke and Hart Spine 1999- 2003, Phys Ther
  04, JRM 05)

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Management for Worker with Recent Low Back Pain

• Strong evidence
• most workers are able to RTW within days to 1-2
  weeks despite residual and recurrent symptoms, do
  not wait until pain free
• advise return to usual activities despite pain
  and avoid advise to rest and let pain be your
  guide

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Management for Worker with Recent Low Back Pain

• Moderate evidence
• early intervention designed to overcome fear
  avoidance beliefs, encourage self- care for back,
  and support early RTW,
• communication cooperation between occupational
  health team, supervisors, employers, and
  employees to achieve successful treatment outcome

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Management for Worker with Back Pain after 4-12
Weeks

• Strong evidence
• Longer off work greater the chances of ever
  returning to work
• Off work 4-12 wks 10-40 off work at 1 year
• Off work 1 year 5 likelihood to ever RTW
• Off work 1 year - subsequent clinical
  interventions are ineffective

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Management for Worker with Back Pain after 4-12
Weeks

• Moderate evidence
• Combination of clinical management,
  rehabilitation program, and organizational
  intervention produces faster RTW, less sickness
  absence, and less chronic disability,
• Management designed to overcome fear avoidance
  beliefs and promote self-care,
• Temporary light duty ergonomic workplace
  adaptations facilitates RTW

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Occupational Low Back PainModerate- Strong
Evidence

• Private Insurance W/C data
• Decreasing length of disability days and costs
• Improved management strategies following
  evidence-based guidelines
• Employers increased involvement in managing back
  problems via early injury reporting policies and
  transitional duty programs

• Primary Challenge
• integrate and apply guidelines at the local
  medical and industrial communities
• dialogue relationship building between all
  stakeholders
• guidelines structure the dialogue and provide the
  criteria to support interventions

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Case Management

• Payor strategies
• capitation
• utilization reviews
• pre-authorization procedures

• Provider strategy
• Pay for Performance program (P4P)

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Landmark Report

• Institute of Medicine
• CMS private payors
• MedPac 2005

Crossing the Quality Chasm A New Health System
for the 21st Century
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Rehabilitation Services

• Offers a unique opportunity for paying on the
  basis of outcomes
• Reliable, valid, and responsive functional status
  measures exist to facilitate meaningful P4P
  processes

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High Quality Rehabilitation Providers

• Value of Service
• treatment efficiency
• treatment effectiveness
• patient satisfaction

In God we trust, everyone else bring data
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CentraStates Rehabilitation Services

• FOTO
• national medical rehabilitation data management
  company
• 1,500 customers participating nationwide e.g.
  hospital or private outpatient clinics
• by providing external risk-adjusted database,
  can measure value against other providers

• Strongly positioned to prove the value of our
  rehabilitation services

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CentraStates RehabilitationTreatment Efficiency

• Efficiency
• Number of treatment visits/episode 5 (38 lt
  national average)
• Duration of treatment episode 23 days (30 lt
  national average)

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Treatment Effectiveness

• Effectiveness is determined by achieving
  high quality functional outcomes while
  maintaining high patient satisfaction

• FOTO effectiveness outcome measure
• US Dept of Health Human Services
• National Quality Measures Clearinghouse
• Institute of Medicine

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CentraStates RehabilitationTreatment
Effectiveness

• Effectiveness
• functional improvement /episode 50 gtnational
  average
• Patient satisfaction 97

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High-Quality Providers Rehabilitation Services

• Active in case management
• Prove the quality of services to both payors and
  employers by demonstrating efficient effective
  data

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Report CardEpidemic of Low Back Disability
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21st Century Challenge
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Evidence-Based Practice

• Back pain and return to work are perfect together

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