Hello, and welcome to the second installment of the IPRS Health Clinical Blog Series.

Following on from our introductory blog about the ‘industrial athlete’, we are following up this month with a closer look at a hot topic in both Occupational Health and Physiotherapy - chronic lower back pain. In this blog we take a closer look at the impact of back pain on the individual with regards to the work place, how best to manage it and how to achieve the best outcomes for both individuals and employers. I hope you enjoy reading it as much as I have enjoyed writing it….

Let’s begin with some wording taken from the latest NICE guidelines:

‘To promote and facilitate return to work or normal activities of daily living in people with non-specific low back pain with and without sciatica with the use of risk stratification, manual therapy, exercise therapy and psychosocial support’

Does this sound familiar? Based on the guidelines it’s clear that Physiotherapists should be at the forefront of low back pain (LBP) management in the field of Occupational Health. Occupational Health is one of the fastest growing MSK Physiotherapy specialisations, and the term ‘Occupational’ still tends to put off a lot of MSK physiotherapists, however our skills and expertise can reap huge benefits and deliver positive outcomes in the management of MSK disorders in the workplace. Rarely do we have such an opportunity to directly influence the environments where our patients spend the majority of their days.

On a more selfish note, I’ve noticed that Occupational Physiotherapy also saves our thumbs! This is due to the variety of services that we can offer, extending beyond the traditional MSK Physiotherapy, such as ergonomic assessments, functional capacity assessments, job demand analysis, health promotion and functional restoration programmes to name but a few.

Let’s look closer at someepidemiology statistics which give a greater insight into the impact of LBP in the work place.

Did you know that low back pain is the most common and most expensive MSK disorder in industrialised countries? Low Back Pain (LBP) in the USA results in roughly 149 billion days a year lost in the workplace, estimated to cost between $100-200 billion annually. Furthermore, the Health and Safety Executive (HSE) in the UK estimated that 2.9 million working days were lost due to work related LBP in 2014-15, costing the NHS £50 million! I’m sure that you will agree that, unless you have had your head in the sand as a health professional, these statistics aren’t that surprising, but they are shocking in their sheer scale. As MSK Physiotherapists (or MSK health professionals) we all know that LBP is a major burden – not only to our health, but also to our economy – however, do we really have a full understanding of how our knowledge and skills can tackle these daunting statistics?

Is it true that the majority of LBP costs are mainly associated with absenteeism from work? On the contrary, evidence suggests that this is not truly the case. The latest evidence suggests that the new buzzword, ‘presenteeism’, actually has a greater cost implication than absenteeism!

Presenteeism is defined as “the practice of coming to work despite illness, injury, anxiety, etc., often resulting in reduced productivity”. Research in Switzerland revealed that the majority of productivity losses were dominated by the cost of presenteeism. This evidence showed that the losses due to presenteeism were three times more significant than absenteeism. This catapults our profession into a prime position to prevent and improve the employee’s injury and function within their workplace, and as such reduce the effects of both presenteeism and sickness absence due to MSK disorders. As Occupational Physiotherapists, we are the specialists in MSK who can, not only, help the employee, but also be a huge asset to the employer. A greater understanding of both the employee’s injury and his or her  workplace demands, will enable the Physiotherapist to treat the patient effectively and also to provide the right education and advice to keep the employee at work whilst reducing the potential loss of productivity.

However, before we can decide on our recommendations to manage presenteeism and absenteeism, let’s look into the risk factors related to LBP in the workplace.

There are several risk factors associated with LBP which also have significance in the workplace. These are well documented hand range anywhere from age to genetics to weight, however the best evidenced and documented risk factor is a previous history of LBP, and more specifically in Occupational Health, a history of work-related LBP where the employee has had to take time off work or has been placed on long term light duties. This is where the Physiotherapist can play a major role. Providing a combination of reassurance, education, exercise and work-related advice can help reduce the likelihood of the employee needing to go on permanent light duties, or needing to be absent from work. A recent article from the ‘Journal of Occupational Health Rehabilitation’ demonstrated the positive effects of reducing work-related injury costs at a processing plant with the provision of a work-based, onsite Physiotherapy service. Not only will such services keep the employee happier, but it can also help reduce the recurrence of LBP or the burden of LBP-related presenteeism issues that employers are currently facing.

Employees carrying out tasks involving a repetitive heavy load and ‘blue collar’ workers have also been identified as higher risk for LBP in the workplace, however some would contend that keeping active and moving is better than having sedentary job roles. Therefore it is argued that the lift:rest ratio, lack of ergonomic support and/or lifting aids, poor understanding of diet, fitness and well-being, lack of manual handling knowledge and postural awareness, as well as lack of job satisfaction, are the main reasons behind this ‘blue collar’ risk factor. As previously mentioned, this puts the Occupational Physiotherapist in a fantastic position to, not only treat the problem, but to contribute towards preventing recurrence. 

If you have ever done a Workplace Assessment, I’m sure that you will have heard some of the reasons employees give to justify the need for a new chair. Examples from my experience include ‘The chair is crushing my low back discs’ or ‘This chair back has caused a complete block of blood to my arms’! Although these statements can be frustrating at times, it should be remembered they are not the employees’ fault. More often than not, these statements will stem from faulty belief systems that have been imposed upon them by colleagues, family members or even (most worryingly) other health professionals! Therefore understanding the evidence, and providing the right information based on that evidence, is imperative to assessing the workplace.

Contrary to belief, sedentary roles requiring prolonged periods of sitting are not solely responsible for LBP in the workplace. It is the combinations of prolonged sitting for over 50% of the working day combined with awkward postures and/or exposure to vibration which have been identified as the prominent risk factors for LBP. Other factors include combinations of both blue and yellow flags. Examples may include persistent work or home stress (anxiety has been closely linked to persistent pain), low mood and depression, along with other well-known psychosocial triggers such as fear avoidance, catastrophisation, self-reported impairment and poor family support. Many Physiotherapists skim over the assessment of blue flags, however evidence has revealed poor work outcomes for employees with LBP who do not feel supported in the workplace, where there is poor manager/employee relationship or a lack of autonomy in the job role. Workplace assessments can be carried out by any person, medical or otherwise, who has had the appropriate training and, although I believe that the addition of an ergonomic champion in the workplace is a positive step forward, it seems all too common from my experience that many workplace assessments are simply prescribing new chairs without addressing all of the other factors influencing the employees low back pain, whereas the evidence is inconclusive that ergonomics and posture alone will reduce or prevent LBP in the sedentary role.

Occupational Physiotherapists have the skills and experience to assess the workplace from a more holistic stand point, taking into account all of the risk factors during the assessment process, therefore access to an Occupational Physiotherapist to address both physical and psychosocial risk factors for LBP is a powerful tool for employees with either a history of, or a current presentation of LBP. These assessments can provide, not only the ergonomic recommendations, but also advice for both the employer and the employee on such aspects as regular breaks, exercise, fitness and well-being, employer/employee communication and employee support as well as providing the employee with advice and reassurance about his or her injury and information about other services such as a GP or Physiotherapy referral, or treatment such as CBT.

Within the workplace there are two other evidenced-based risk factors that can also be used as prognostic factors for LBP recurrence. The first is the employee’s self-reported impairment, which combines the employee’s perceived levels of pain combined with other psychosocial measures. The second is the match of the patient’s physical capacity to his or her job demands. One example of this self-reported impairment is:

Question: ‘Can you please grade your pain at present on the visual analogue scale (VAS) scale, where 10 indicates unimaginable pain where you could go unconscious soon and will require immediate medical care?’.  Answer: ‘I have a very high pain threshold however today my pain is 10/10’.

I know there are many physio’s who feel like pulling their hair out when they get this kind of answer from patients, however, take the opportunity to consider this issue from a deeper perspective. Once we have cleared any red flag issues, it’s essential to find out why patients are grading their pain so high. Are they afraid of returning to work in case it makes their backs worse? Are they harbouring other psychosocial issues such as stress or anxiety? Do they simply not want to return to work because they are being bullied in the workplace by their managers or colleagues, or simply feel unsupported or dissatisfied? Are there other complex factors affecting their perceptions, such as litigation issues.? The point is that if, whatever the reason, the patient has a very high perception of his or her impairment, and therefore it is highly likely that the LBP will reoccur in the future. Thus, by addressing any underlying psychosocial causes early on, we can increase the chances of a patient successfully returning to work before we have even carried out the physical assessment, let alone any treatment.

This is the part of my job as an Occupational Physiotherapist that I find the most challenging, but also the most rewarding; the ability to identify the triggers that may be causing these flawed health beliefs about LBP, and then working with the patient to find the solutions.  

The following quote sums up this point, and my opinion, perfectly;

‘There are many problems, but I think there is a solution to all these problems; it's just one, and it's education’

(Malala Yousafzai).

We know that an early return to work in non-specific low back pain aids in the prevention of the condition becoming persistent but we also know that returning to work with LBP can often limit our functional capacity to some degree. Are we putting our patients at risk if we always recommend light duties as an alternative to sickness absence? As Occupational Physiotherapists, one of our roles is to attempt to mitigate the negative effect of presenteeism, but our primary concern must be the safety and well-being of the employee. A systematic review in 2016 for LBP prognostic factors identified that those employees who did not have the provision of short-term modified duties had a higher LBP recurrence rate. However, there was no supporting evidence that long-term modified duties prevents recurrence.

As a physiotherapist who has also worked in sports, I compare this to the players I worked with in football. We would not expect a player to wait until he or she is 100% improved and then just let him or her return to a full match. We would gradually phase the player into training and playing part matches, before returning to playing full matches. This should be no different from an Occupational Health perspective. LBP can be incapacitating and the employee is likely to benefit from this kind of support to allow for a gradual reintegration into his or her normal work demands. This is especially true if the employee has been absent for a longer period of time, where conditioning and fitness have almost certainly been affected. However, light duties are not always required. If the patient was assessed and treated early, work absence was minimal and the patient appears confident and capable of safely returning to work, then there is no indication for the recommendation of light or modified duties. Within my own practice, if I am unsure whether the patient is fit for full duties, or if the patient presentation is bit more complex, I complete a full return to work assessment which will incorporate a functional capacity evaluation (FCE).

The systematic review that I mentioned previously also identified that there was moderate evidence supporting the association of FCE’s with return to work. A FCE is a set of objective tests, practices and observations that are combined to determine the ability of the employee to function in employment. As this assessment is fundamentally objective, combination with a thorough subjective screening to determines all red, yellow, blue, orange and black flags is also essential. This high bank of information will provide a clearer justification for return to work recommendations, and therefore matching the employee’s capacity to the job demands with our recommendations can soundly help prevent recurrence of LBP in the long term.

As an overview it is obvious that early access Physiotherapy services can significantly help both the employee and the employer. The skills and expertise delivered  provide both the employer and the employee with services that not only aim to treat injuries, but also aspire to prevent further recurrence through trend-specific and innovative provisions such as health promotion, job demands analysis/risk assessment, functional restoration programmes and ergonomic assessments.

Today’s Occupational Health physiotherapist has become the expert in MSK management in the workforce, and as such IPRS Health are driving the field with continuous and effective evidence-based practice combined with innovation in service delivery. The use of technology such as the IPRS Health app to deliver home exercise programmes, provide information on MSK injuries and complete visual triage assessments is an example of this innovation. Recent evidence, along with the NICE guidelines for LBP, have highlighted the importance of using a return to normal activities of daily living and work as an outcome measure. In my experience, and in light of the current evidence, I believe that it’s clear that we are the experts in this, and therefore physiotherapists should be pioneering this exciting area.   

To keep up to date with all relevant clinical physiotherapy information and IPRS Health job opportunities, follow us on twitter at @iprshealth and visit our website at www.iprshealth.com. All of our blogs will be held here as well as plenty of other useful clinical ‘gems’ such as clinical discussions and access to physiotherapy research papers.

Please feel free to pass on our patient information sheet to relevant patients and there will also be a useful infograph summarising this blog on Twitter.

Thanks for taking the time to read this and keep your eyes peeled for future installments!

Paul Scallan

MCSP MACPOHE BSc (Hons) Physiotherapy, Dip Sports Therapy

IPRS Health Clinical Lead of Occupational Health Physiotherapy Services.

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